***HURST REVIEW NCLEX-RN Readiness Exam 1***, Hurst Practice Exam 2, Hurst Review Test # 3, Hurst Review Test #2, Hurst Readiness Exam 3, Hurst (Readiness Exam #4), Hurst (Readiness Exam #3), Hurst 1, HESI 8, HESI 7, HESI Exit 2 leigh_love_life

Which statement made by a client post-thyroidectomy would require further investigation by the nurse? 1. "I have a tingling feeling of my fingers." 2. "It hurts when I move my head." 3. "I feel pressure in my arm when you take my blood pressure." 4. "My legs are weak."

1

Cardiac output decreases with dysrhythmias.

Dopamine increases BP

Thorazine, Haldol (antipsychotic) can lead to

EPS (extrapyramidal side effects)

Itching under cast area

Treat with cool air via a blow dryer, ice pack for 10-15 minutes. NEVER use a QTip or anything to scratch the area.

Theophylline (Aminophylline)

Treatment for asthma or COPD; therapeutic level is 10-20

Which statements should a nurse make when educating a client about advance directives? 1. Used as guidelines for client treatment should the client's family deem them necessary. 2. Legally binding document. 3. Should be documented in the client's medical record as to whether or not the client has an advance directive. 4. Specifies a client's wishes for healthcare treatment should the client become incapacitated. 5. Allows the client's spouse to make end-of-life decisions.

2,3,4

What interventions should the nurse initiate to keep the airway free of secretions in a client with pneumonia? 1. Evaluate results of ABG's and report abnormal findings. 2. Increase oral intake to at least 2000 mL/day. 3. Administer a cough suppressant medication. 4. Educate client on incentive spirometry. 5. Perform percussion to affected area.

2,4,5

Dilantin level

(10-20). Can cause gingival hyperplasia

Tagamet with food

(H2; messes with elderly ppl be careful ! Interacts with a lot of things)

Cushing's syndrome

(have extra "cushion" of hormones)

While performing a vaginal examination on a client in labor, the nurse feels soft, squishy tissue instead of a head. What conclusion should the nurse make based on this assessment finding? 1. Breech presentation 2. Edema of cervix 3. Closed cervix 4. Bulging membranes

1

perform amniocentesis before

20 weeks gestation to check for cardiac and pulmonary abnormalities.

Gastric ulcer pain occurs

30 minutes to 90 minutes after eating, not at night, and doesn't go away with food

Birth weight doubles by

6 month and triple by 1 year of age.

vastus lateralis is IM administration site for

6 month infants

TIdal volume

7-10 ml/kg

Med of choice for CHF

ACE Inhibitor (-pril)

Age 4-5 y/o child needs

DPT/MMR/OPV

for meningitis check for

Kernig's/ Brudzinski's signs.

glomerulonephritis

Take V/S q 4 hours and attain daily weights

physiological jaundice occurs

after 24 hours

a newly diagnosed hypertension patient should have BP assessed in

both arms

cognitive therapy

counseling

placenta previa

there is no pain, there is bleeding

asthma

wheezing on expiration

Hypocalcemia

CATS Convulsions, Arrythmias, Tetany, spasms and stridor

Med of choice for Status Epilepticus

Diazepam (Valium)

No Pee, No K

Do not give potassium without adequate urine output

Safety over Nutrition with a

severely depressed client

Best way to warm a newborn

skin to skin contact covered with a blanket on mom

Myxedema/ hypothyroidism

slowed physical and mental function, sensitivity to cold, dry skin and hair.

Uremic fetor

smell urine on the breath

Acetaminophen

10-20

The nurse is caring for a client admitted to the skilled nursing unit approximately 3 months ago. Since admission, the client has lost 8 pounds. There have been no documented changes in the client's physical health. Which strategy may help to improve caloric intake for this client? 1. Encourage the client to eat meals in the room. 2. Take the client to the dining room for all meals. 3. Provide a high protein supplement 30 minutes before meals. 4. Ask the unlicensed assistive personnel to feed the client at each meal.

2

first sign of cystic fibrosis may be meconium ileus at birth.

Baby is inconsolable, do not eat, not passing meconium.

GERD

Barretts esophagus (erosion of the lower portion of the esophageal mucosa)

Give Carafate (GI med):

Before meals to coat the stomach

Prednisone toxicity (cushing's syndrome):

Buffalo hump, moon face, hyperglycemia, hypertension

Respiratory problems are the chief concern with

CF

COAL (cane walking)

Cane Opposite Affected Leg

In early septic shock states, what is the primary cause of hypotension? A. Cardiac failure B. A vagal response C. Peripheral vasoconstriction D. Peripheral vasodilation

D. Peripheral vasodilation

700. In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement? a- Document the extend of the bruising in the medical record b- Call the lab to obtain a stat APTT and prothrombin time c- Assign a UAP to take vital sig measurements q 1h. d- Advise the client that anticoagulant therapy may be needed.

Document the extend of the bruising in the medical record.

An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding? a- Immediately apply a pressure dressing b- Document the ongoing wound healing. c- Irrigate the wound with sterile saline d- Obtain a capillary INR, measurement

Document the ongoing wound healing. Rationale: Appearance of granulation tissue is the best indicator of increased venous retuns and ongoing wound healing

637. Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscul...Which finding warrants immediate intervention by the nurse? a. Extremity muscle weakness b. Bilateral eyelid drooping c. Inability to swallow pills d. Evidence of hypoventilation

Evidence of hypoventilation.

Signs of a fractured hip

External rotation, shortening, adduction

Peptic ulcers caused by H. pylori are treated with:

Flagyl, Prilosec and Biaxin. This treatment kills bacteria and stops production of stomach acid, but does not heal ulcer.

EleVate Veins; dAngle Arteries

For better perfusion

684. A male client who was admitted with an acute myocardial infarction receives a cardiac diet with sodium restriction and complains that his hamburger is flavorless. Which condiment should the nurse offer?

Fresh horseradish.

Theophylline causes

GI upset, give with food

shock

HYPOtension TACHYpnea TACHYcardia

infectious mononucleosis

Hallmark: sore throat, cervical lymph adenopathy, fever

730. During discharge teaching, an overweight client heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? (Select all that apply) A. Canned fruit in heavy syrup. B. Plain, air-popped popcorn. C. Cheddar cheese cubes. D. Natural whole almonds. E. Lightly salted potato chips

Plain, air-popped popcorn. Natural whole almonds.

A guy loses his house in a fire.

Priority is using community resources to find shelter, before assisting with feelings about the tremendous loss.

Gout Meds

Probenecid (Benemid), Colchicine, Allopurinol (Zyloprim)

The nurse recognizes that treatment has been successful in resolving fluid volume excess based on which assessment findings? You answered this question Correctly 1. Continued lethargy 2. Heart rate 112/min 3. Decreasing shortness of breath 4. BP 114/78 5. Increased thirst

RationaleStrategies 3. & 4. Correct: Urinary output should increase with decreasing shortness of breath as hydration is corrected, and BP should be normal. 1. Incorrect: Level of consciousness (LOC) should improve with perfusion to the brain. 2. Incorrect: Heart rate should decrease if hydration is corrected. 5. Incorrect: Thirst level should be decreased if hydration is corrected.

Hypernatremia (greater than 145)

S (Skin flushed) A (agitation) L (low grade fever ) T (thirst)

The MMR vaccine is given

SQ not IM

INH (Isoniazid) can cause peripheral neuritis

Take vitamin B6 to prevent. Hepatotoxic

CRIES pain scale

The CRIES scale is used with neonates and infants. Crying- characteristic of pain Requires O2 for SaO2 ,95% Increased Vital signs Expression Sleepless

If the baby is breech,

The sounds are HIGH up in the FUNDUS near the UMBILICUS.

If the baby is vertex,

The sounds are SLIGHTLY ABOVE the SYMPHYSIS PUBIS.

A client diagnosed with pancreatitis becomes increasingly restless, confused and has pulled out the NG tube and IV catheter. HR-128/min, BP 96/62. Oxygen saturation = 90%. Skin is cool and clammy to touch. Prioritize the actions that the nurse should take. Initiate oxygen. Insert another IV line. Obtain blood sugar level. Insert NG tube. Repeat vital sign checks

This is the correct order

703. A client with hyperthyroidism is admitted to the postoperative after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse? a- Thyroxine 12 ug/dl b- Total calcium 5.0 mg/dl c- T3 uptake at 50% d- Glucose 150 mg/dl

Total calcium 5.0 mg/dl.

Carafate (sucralfate)

Treatment for duodenal ulcers (coats the ulcers); client should take before meals

667. A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile, which assessment finding warrants immediate intervention by the nurse? A. Uncontrollable drooling B.Inability to raise voice C. Tingling of extremities D. Eyelid drooling

Uncontrollable drooling.

738. Immediately after extubation, a client who has been mechanically ventilated is placed on a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately? A. Blood tinged sputum B. Expiratory wheezing C. Upper airway stridor D. Oxygen saturations 90%

Upper airway stridor.

616. A client who is at 36 weeks gestations is admitted with severe preclampsia. After a 6 gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?

Urine output 20 ml/hour. Rational: urinary output of less than 30 ml/hour indicates that the kidneys are being affected by the high level of magnesium, which is excreted through kidneys.

694. While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? A. Ask the mother what she usually uses on the child's lips and nose B. Apply a petroleum jelly (Vaseline) to the child's nose and lips C. Use a topical lidocaine (Zylocaine viscous) analgesic for cracked lips D. Use a water soluble lubricant on affected oral and nasal mucosa

Use a water soluble lubricant on affected oral and nasal mucosa.

783. The nurse is preparing to mix two medications from two different multidose vials, A and B. In which order should these actions be implemented when drawing the solutions from the vials? (Arrange from first on top to last on the bottom)

Verify the drug and dose with the label on the vial. Inject the volume of air to be aspirated from each vial. Aspirate the desired volume from vial A. Aspirate the desired volume from vial B.

797. After multiple attempts to stop drinking, an adult male is admitted to the medical intensive care unit (MICU) with delirium tremens. He is tachycardic, diaphoretic, restless, and disoriented. Which finding indicates a life- threatening condition? A. CIWA-Ar for alcohol withdrawal score of 30 B.. Acute onset of unrelenting chest pain C. Widening QRS complexes and flat waves D. Intense tremor and involuntary muscle activity

Widening QRS complexes and flat waves.

Iron injections should be given

Z-track so they don't leak into SQ tissues.

Prolonged hypoxemia is

a likely cause of cardiac arrest in a child

Munchausen Syndrome

a psychological disorder that causes an individual to self-inflict injury or illness or to fabricate symptoms of physical or mental illness, in order to receive medical care or hospitalization. In a variation of the disorder, Munchausen by proxy (MSBP), an individual, typically a mother, intentionally causes or fabricates illness in a child or other person under her care

728. The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? a- Recommend weigh bearing physical activity b- Reduce intake of foods high in vitamin D c- Decrease intake of foods high in fat d- Minimize heavy lifting and bending.

a- Recommend weigh bearing physical activity Rationale: Active weight-bearing exercise is a primary preventive measure for osteoporosis. C is indicated for client with cardiac and liver diseases. D may decrease injuries but is not directed toward slowing bone loss and promoting bone formation.

Exacerbation

acute, distress

Antacids

after meals

zoloft s/e

agitation, sleep disturb, and dry mouth

Give synthroid on

an empty stomach

a patient with a vertical c-section surgery will more likely have

another c-section

Bactrim

antibiotic .dont take if allergic to sulfa drugs...diarrhea common side effect...drink plenty of fluids

Lasix can cause a patient to lose his

appetite (anorexia) due to reduced potassium

650. The nurse assesses a female client with obstructive sleep apnea syndrome (OSAS) who is 5 feet tall (152 cm) and weighs 155 pounds (70 kg), the client's 24 hour diet history includes: no breakfast, cheeseburger and fries for lunch; lasagna, chocolate ice cream and a cola drink for dinner, and 2 glasses of wine in the evening before going to bed for a total caloric intake of 3500 calories. What instructions should the nurse provide? (Select all that apply) A. Maintain current caloric intake B. Avoid use of alcohol as a sleep aide at bedtime C. Reduce intake of dairy products D. Start a weight loss program E. Set a goal of increasing BMI (Body Mass Index)

b-Avoid use of alcohol as a sleep aide at bedtime. d-Start a weight loss program.

emphysema

barrel chest

Ottorhea (drainage exiting ear) s/s of

basilar fracture

avoid salt substitutes when taken dig and k-supplements

because many are potassium based

a patient with leukemia may have epistaxis

because of low platelets

Shock

bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg)

Carafate (sucralfate) (mucosal barrier; constipation)

before meals

With glomerulonephritis you should consider

blood pressure to be your most important assessment parameter. Dietary restrictions you can expect include fluids, protein, sodium, and potassium.

when phenylalanine increases, __________ occurs.

brain problems occur

cystitis

burning on urination

SLE (systemic lupus erythematosus)

butterfly rash

Calan (verapamil)

calcium channel blocker: tx of HTN, angina...assess for constipation

Phenobarbital (Luminal)

can be taken during pregnancy but Dilantin is contraindicated

Botox (botulinum toxin)

can be used with strabismus also to relax vocal cords in spasmodic dysphonia

Diamox, used for glaucoma

can cause hypokalemia

during Continuous Bladder Irrigation (CBI)

catheter is taped to thigh so leg should be kept straight. No other positioning restrictions.

Most spinal cord injuries are at the

cervical or lumbar regions

Digoxin (Lanoxin)

check pulse, less than 60 hold, check dig levels and potassium levels.

aspirin can cause Reye's syndrome (encephalopathy) when given to

children

bryant's traction

children <3 y <35 lbs with femur fx

bulimia

chipmunk face

other than initially to test tolerance, G tube and J tube feedings are usually given as

continuous feedings

For knee replacement use

continuous passive motion machine

Magnesium sulfate (used to halt preterm labor) is

contraindicated if deep tendon reflexes are ineffective. if patient experiences seizure during magnesium administration. Get the baby out stat (emergency)

Kawasaki disease causes

coronary artery aneurysms d/t the inflammation of blood vessels

weight is the best indicator of

dehydration

stomas

dusky means poor blood supply, protruding means prolapsed, sharp pain + rigidity means peritonitis, mucus in ileal conduit is expected.

Iron deficiency anemia

easily fatigued

Cullen's sign

ecchymosis in umbilical area, seen with pancreatitis

nephrotic syndrome s/s

edema + hypotension. Turn and reposition (risk for impaired skin integrity)

Turner's sign

flank grayish blue (turn around to see your flanks) pancreatitis

Wilm's tumor is usually encapsulated above the kidneys causing

flank pain

Ask for allergy to eggs before

flu shot

With flecainide (Tambocor) an antiarrhymic, limit

fluids and sodium intake, because sodium increases water retention which could lead to heart failure

Duchenne's muscular dystrophy (DMD)

gower's sign (use of hands to push one's self from the floor)

no nasotracheal suctioning with

head injury or skull fracture.

CSF in meningitis will have

high protein and low glucose

To remember blood sugar

hot and dry-sugar high (hyperglycemia) cold and clammy-need some candy (hypoglycemia)

Pheochromocytoma

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

Addison's

hypoNa, hyperK, hypoglycemia, dark pigmentation, decreased resistance to stress, fractures, alopecia, weight loss, GI distress

The beta cells of the pancreas produce

insulin

Heroin withdrawal neonate

irritable, poor sucking

Reaction formation

is behaving in a way that is exactly opposite of one's true feelings. (defense mechanism)

TPN (total parenteral nutrition)

is given in subclavian line

Second voided urine most accurate when testing for

ketones and glucose

BSA is considered the most accurate method for medication dosing with

kids

buck's traction

knee immobility

Prolapsed Cord

knee-chest position or Trendelenburg

DKA

kussmal's breathing (deep rapid RR)

MMR and varicella immunization come when

later around 15 months

Ethambutol

messes with your eyes

From the a** (diarrhea)

metabolic acidosis

From the mouth (vomitus)

metabolic alkalosis

Lyme disease is found

mostly in Connecticut

Hypokalemia

muscle weakness, dysrhythmias, increase K (raisins bananas apricots, oranges, beans, potatoes, carrots, celery)

Hypercalcemia

muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, sedative effect on CNS

Kids with RSV

no contact lenses or pregnant nurses in rooms where ribavirin is being administered by hoot, tent, etc.

diverticulitis (inflammation of the diverticulum in the colon)

pain is around LLQ

placenta abruption

pain, but no bleeding

Priapism

painful erection lasting longer than 6 hours

glaucoma

painful vision loss, tunnel/gun barrel/ halo vision (peripheral vision loss)

Always select a

patient focused answer

When you see coffee brown emesis, think

peptic ulcer

WBC shift to the left in a patient with

pyelonephritis. Neutrophils kick in to fight infection.

appendicitis

rebound tenderness

typhoid

rose spots on abdomen

FIVE INTERVENTIONS FOR PSYCH PATIENTS

safety setting limits establish trusting relationship meds least restrictive methods/environment

Ativan is the treatment of choice for

status epilepticus

Zocar (Simvastatin) for hyperlipidemia

take on empty stomach to enhance absorption, report any unexplained muscle pain, especially if fever

It is essential to maintain nasal patency with children < 1 year, because

they are obligatory nasal breathers

Easy Way to Remember MAOIs

thinks PANAMA PA-parnate NA-nardil MA-marplan metallic bitter taste

place apparatus first then place the weight when putting _________.

traction

placenta should be in

upper part of uterus

Myasthenia Gravis

worsens with exercise and improves with rest

The nurse is caring for a client in the emergency department. The primary healthcare provider prescribed 1000 mL of D5 ½ NS. The IV is infusing at 25 gtts/min. (Drop factor is 60 gtts/mL). What is the infusion time in hours? Round your answer to the nearest whole number.

x = 2400 min. divide by 60 = 40 hours

To Prevent Dumping Syndrome

(post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. (also restrict fluids during meals, low CHO and fiber diet. small, frequent meals.)

Greek heritage

- they put an amulet or any other use of protective charms around their baby's neck to avoid "evil eye" or envy of others

A client with Crohn's disease develops a fever and symptoms of an infection. The nurse recognizes this complication may occur as a result of which finding? 1. Perianal irritation from frequent diarrhea 2. Fistula formation with an abscess 3. Stricture formation 4. Impaired immunologic response to infectious microorganisms

2

A client with chronic alcoholism has been admitted to the intensive care unit after overdosing on alcohol. Which medication should the nurse prepare to administer? 1. Disulfiram 250 mg po daily 2. Thiamine 100 mg IV twice a day 3. Naloxone 0.4 mg IV prn 4. Clonidine TTS patch 2.5 mg per week

2

The emergency department nurse is assessing a client who presents with severe epigastric pain. The client reports that three rolls of calcium carbonate were consumed in the past eight hours to treat the indigestion. Which blood gas report does the nurse associate with this situation? 1. pH - 7.49, pCO2 - 40, HCO3 - 30 2. pH - 7.32, pCO2 - 48, HCO3 - 20 3. pH - 7.38, pCO2 - 52, HCO3 - 32 4. pH - 7.29, pCO2 - 54, HCO3 - 26

1

A client, hospitalized with possible acute pancreatitis secondary to chronic cholecystitis, has severe abdominal pain and nausea. The client is kept NPO, an NG tube is inserted, and IV fluids are being administered. What is the rationale for the client being NPO with an NG tube to low suction? 1. Relieve nausea 2. Reduce pancreatic secretions 3. Control fluid and electrolyte imbalance 4. Remove the precipitating irritants

2

The nurse evaluates the effectiveness of discharge teaching for a client with type I diabetes mellitus. Which statement by the client would indicate to the nurse that teaching has been effective? 1. "Exercising regularly will decrease my insulin need." 2. "I will need to decrease my insulin dose when I develop an infection." 3. "I need to lose weight since obesity decreases insulin resistance." 4. "Increased stress levels will cause the glucose level in my blood to go down."

1

Ampho B causes

*hypokalemia (amongst many other things..gotta premedicate before giving. Pts will most likely get a fever)

The nurse is providing discharge education to a client after a concussion. What should the nurse emphasize to report to the primary healthcare provider? 1. Difficulty waking up 2. Headache (3/10 on the pain scale) 3. Blurry vision 4. Achy feeling all over 5. Vomiting

1,3,5

A nurse has responded to the scene of a natural disaster to triage clients. Which client should the nurse triage with a black disaster tag? 1. Traumatic amputation to the left lower leg. 2. 2nd and 3rd degree burns over 75 % of the body. 3. Fracture of the humerus. 4. Blood pressure of 90/40 and lethargic.

2

anterior fontanelle closes by...posterior by..

18 months, 6-8 weeks

Kidney glucose threshold

180

A low income family with children lives in an old, run-down apartment building situated close to a salvage yard in a poor neighborhood. Which area of assessment would be most important for the home health nurse? 1. Immunization status 2. School-related problems 3. Lead poisoning 4. Signs of child abuse

3

The nurse is providing care to a client who has a large abdominal dressing. Which intervention is most likely to reduce the risk of skin irritation due to frequent dressing changes? 1. Use a paper tape for adhering the dressing. 2. Use tape sparingly. 3. Secure the dressing with Montgomery straps. 4. Change the dressing only if it becomes saturated with drainage.

3

A client has returned to the burn unit after an escharotomy of the forearm. What is the priority nursing intervention? 1. Roll sterile q-tip over the wound 2. Elevate the affected arm 3. Ask the client to rate pain level 4. Assess bilateral radial pulses

4

A client has sustained a major head injury as a result of a motor vehicle accident. The emergency department nurse is assessing the client's neurological status every 15 minutes. Which sign would the nurse recognize as an early indicator of an increased intracranial pressure (ICP)? 1. Dilated and unresponsive pupils 2. Cheyne-Stokes respirations 3. Cushing's triad 4. Change in level of consciousness (LOC)

4

A client, admitted in Sickle Cell Crisis, is started on oxygen at 2L/NC and given a narcotic analgesic for pain control. What additional prescription is a priority for the nurse to initiate? 1. A high protein, low fat diet 2. Administration of a thrombolytic, such as streptokinase 3. Implementation of bleeding precautions 4. Administration of IV fluids for hydration

4

The nurse is working with the parents of a preschooler to help promote healthy sleep patterns of approximately 8-12 hours per night. Which intervention should assist the parents to achieve adequate sleep for their preschooler? 1. Offer a time of exercise prior to bedtime. 2. Follow a bedtime routine at least three or four nights per week. 3. Spend about 30 minutes with the preschooler prior to bedtime for stories, prayers, etc. 4. Do not encourage your preschooler to take a toy to bed.

3. Correct: Rituals help the preschooler to feel secure. Quiet time to read, tell stories, and say prayers prepares the child for sleep. 1. Incorrect: Stimulation of activity before bedtime impedes sleep.2. Incorrect: The routine should be maintained each night if at all possible. Only through routine does the child feel secure in preparation for bedtime.4. Incorrect: A special toy helps the child to feel secure and adds to the nighttime routine.

The nurse is caring for a client who has taken an acetaminophen overdose. Which symptom is the client most likely to exhibit? 1. Expectorating pink frothy sputum 2. Sudden onset of mid-sternal chest pain 3. Jaundiced conjunctiva 4. Diaphoresis and fever

3. Correct: This is a sign of liver damage, which is caused by an overdose of acetaminophen. 1. Incorrect: This is a symptom of pulmonary edema, not liver damage. 2. Incorrect: This is a symptom of myocardial ischemia, not liver damage. 4. Incorrect: Acetaminophen would decrease fever, and fever could cause diaphoresis so neither of these are expected with acetaminophen overdose.

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.

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.

Which client could the charge nurse assign to an LPN/VN? 1. Eight year old in diabetic ketoacidosis (DKA) 2. Six year old in sickle cell crisis 3. Two month old with dehydration 4. Five year old in skeletal traction

4

epiglotitis

3Ds' Drooling, Dysphonia, Dysphagia

Also for ventilator alarms

HOLD High Alarm - Obstruction due to increased secretions, kink, pt coughs, gags or bites Low Alarm - Disconnection or leak in ventilator or in pt airway cuff, pt stops spontaneously breathing

Thyroid storm is

HOT (hyperthermia)

When doing an epidural anesthesia

HYDRATION is a PRIORITY INTERVENTION prior to the procedure.

increase ICP

HYPERTENSION, BRADYpnea, BRADYcardia (cushings triad)!

atropine overdose

Hot as a Hare (Temp), Mad as a Hatter (LOC), Red as a Beet (flushed face) and Dry as a Bone (Thirsty)

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

MRI

claustrophobia, no metal, assess pacemaker

A small community has experienced a severe tornado that hit a shopping mall and caused extreme damage and suspected mass casualties and injuries. Which intervention takes priority?

Activate the community emergency response team.

Mineral corticoids are given in

Addison's disease

NO Vitamin C with

Allopurinol

658. A male Korean-American client looks away when asked by the nurse to describe his problem. What is the best initial nursing action? A. Allow several minutes for the client to respond B. Ask social services to find a Korean interpreter C. Repeat the question slowly and distinctly D. Establish direct eye contact with the client

Allow several minutes for the client to respond.

Trendelenburg test

for varicose veins. If they fill proximally = varicosity.

A nurse is preparing a lecture about suicide. Which target audience would be most appropriate?

Among those who commit suicide, young men between the ages of 15-24 are more likely to commit suicide than young girls and women. The best line of defense is to teach about the warning signs of suicide to high school teachers, students, and parents of teens and young adults, particularly male.

Hypo-parathyroid

CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet

Myxedema coma is

COLD (hypothermia)

retino blastoma

Cat's eye reflex (grayish discoloration of pupils)

Cholinergic Crisis

Caused by excessive medication ---stop giving Tensilon...will make it worse.

Decerebrate positioning in response to pain

Cerebellar, brain stem involvement

724. A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication? a- Chest pain and dysrhythmia b- Vasodilation of the extremities c- Hypotension and tachycardia d- Decreasing GI cramping and nausea.

Chest pain and dysrhythmia. Rationale: In large doses, vasopressin may produce increased blood pressure, coronary insufficiency, myocardial ischemia or infarction and dysrhythmias.

682. After diagnosis and initial treatment of a 3 year old with Cystic fibrosis, the nurse provides home care instructions to the mother, which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions?

Chest physiotherapy should be performed twice a day before a meal.

hypocalcemia

Chvostek's and Trousseau's signs.

Obsession is to thought

Compulsion is to action

740. While the nurse is preparing a scheduled intravenous (IV) medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement? A. Apply ice first, then a warm compress to the IV site B. Discontinue the painful IV after a new IV is inserted C. Review the medical record for the date of insertion D. Document that the medication was not administered

Discontinue the painful IV after a new IV is inserted.

750. A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? A. Avoid exposure to large crowds B. Do not take any over-the-counter medications C. Call the crisis hot line if feeling lonely D. Eat a high carbohydrate, low fat, low protein diet

Do not take any over-the-counter medications.

fibrin hyalin

Expiratory Grunt

Rule of NINES for burns

Head and Neck= 9% Each upper ext= 9% Each lower ext= 18% Front trunk= 18% Back trunk= 18% Genitalia= 1%

633. The mother of a one-month-old boy born at home brings the infant to his first well...was born two weeks after his due date, and that he is a "good, quiet baby" who almost...hypothyroidism, what question is most important for the nurse to ask the mother? a. Has your son had any immunizations yet? b. Is your son sleepy and difficult to feed? c. Are you breastfeeding or bottle feeding your son? d. Were any relatives born with birth defects?

Is your son sleepy and difficult to feed?

Hypotension / Bradypnea/bradycardia

Major risks and emergencies

617. What is the nurse's priority goal when providing care for a 2-year-old child experience... A. Stop the seizure activity B. Decrease the temperature C. Manage the airway D. Protect the body from injury

Manage the airway.

cushing's syndrome

Moon face appearance and buffalo hump

hemophilia is x linked

Mother passes disease to son.

625. The nurse teaches an adolescent male client how to use a metered dose inhaler. Seen in the picture. What instruction should the nurse provide? A. Move the device one to two inches away from the mouth B. Secure the mouthpiece under the tongue C. Press down on the device after breathing in fully D. Breathe out slowly and deeply while compressing the device

Move the device one to two inches away from the mouth.

when asking patients' questions

NEVER use "why" questions. Eliminate all why answers

763. Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement? A. No action is required since postoperative bleeding can be expected B. Lower the client's head while assessing for symptoms of shock C. Call the health care provider and prepare to take the client back to the operating room D. Outline the area with ink and check it every 15 minutes to see if the area has increased

Outline the area with ink and check it every 15 minutes to see if the area has increased.

No phenylalanine with a kid positive for

PKU (no meat, no dairy, no aspartame)

686. A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room?

Place the ID bands on the infant and mother.

Pain is usually the highest priority with

RA (rheumatoid arthritis)

Hydroxyurea for sickle cell

Report GI symptoms immediately; could be a sign of toxicity

to access role relationship pattern focus on

image and relationships with others

droplet precautions

Sepsis, scarlet fever, streptococcal pharyngitis, parovirus B19, pneumonia, pertusis, influenza, diptheria, epiglottis, rubella, mumps, meningitis, mycoplama and adenovirus. Door open, 3 ft distance, private room or cohort, mask

A position PPD confirms

infection, not just exposure. A sputum test will confirm active disease.

The nurse receives new healthcare provider prescriptions on a client diagnosed with Addison's disease. Which prescriptions should the nurse recognize as being inappropriately written and requiring clarification from the prescriber?

Use "daily" or "every day". QD is an unapproved abbreviation. T.I.W. stands for three times a week; however, it is an unapproved abbreviation. Use "three times a week".

Fat soluble vitamins

Vitamins A, D, E, K

Watch out for questions suggesting a child drinks more than 3-4oz of milk, milk can reduce the intake of other essential nutrients, especially iron.

Watch for anemia with milk-aholics. And don't let the mother put anything but water in that kid's bottle during naps/over-night. Juice or milk will rot the kid's teeth.

782. In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider? A. Watery diarrhea B. Yellow-tinged sputum C. Increased fatigue D. Nausea and headache

Watery diarrhea.

The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice for the nurse to place the client in until full consciousness is regained?

When someone is very sedated and not fully conscious, we want them on their side so the airway remains open and the secretions can drain.

Myesthenia gravis is caused by

a disorder in the transmission of impulses from nerve to muscle cell.

Hirschsprung's diagnosed with rectal biopsy looking for

absence of ganglionic cells. Cardinal sign in infants is failure to pass meconium, and later the classic ribbon-like and foul smelling stools

School age children (5 and up) are old enough and should have ______________ of what will happen a week before surgery such as a tonsillectomy.

an explanation

dystocia

baby cannot make it down to vaginal canal

small frequent feedings are

better than larger ones.

Assessment, teaching, meds, evaluation, unstable patient

cannot be delegated to a UAP

High potassium is expected with

carbon dioxide narcosis (hydrogen floods the cell forcing potassium out). Carbon dioxide narcosis causes increased intracranial pressure.

Hepatitis

ends in a VOWEL, comes from the BOWEL (Hep A) Hepatitis B=Blood and Bodily fluids Hepatitis C is just like B

Med of choice for anaphylactic shock

epinephrine

Diabetes Insipidus (decreased ADH)

excessive urine output and thirst, dehydration, weakness, administer Pitressin

hyperthyroidism/grave's disease

exopthalmus

Hyper-parathyroid

fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet

after endoscopy check

gag reflex

Depression often manifests itself

in somatic ways, such as psychomotor retardation, GI complaints, and pain.

Anhedonia

inability to experience pleasure...in clinical depression

Non-dairy sources of Calcium:

include RHUBARB, SARDINES, COLLARD GREENS

Dumping syndrome

increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink

coarctication of the aorta causes

increased blood flow and bounding pulses in the arms

Congenital cardiac defects result in hypoxia which the body attempts to compensate for (influx of immature RBCs). Labs supporting this would show

increased hematocrit, hemoglobin and RBC count

The first sign of ARDS is

increased respirations. Later comes dyspnea, retractions, air hunger, cyanosis

Allen's test

occlude both ulnar and radial artery until hand blanches then release ulnar. If the hand pinks up, ulnar artery is good and you can carry on with ABG/radial stick as planned. ABGS must be put on ice and whisked to the lab.

Cranial Nerves

olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, vestibulocochlear, glossopharyngeal, vagus, accessory, hypoglossal some say marry money but my brother says big books matter more

Never give potassium if the patient is

oliguric or anuric

pyloric stenosis

olive like mass

During Internal Radiation

on bedrest while implant in place

Epispadias

opening of the urethra on the dorsal (front) surface of the penis

with lower amputations patient position

placed in prone position

heparin prevents

platelet aggregation

If you have never heard of it....

please don't pick it!

Chest tubes are placed in the

pleural space

Crackles suggest

pneumonia, which is likely to be accompanied by hypoxia, which would manifest itself as mental confusion, etc.

Complications of mechanical ventilation

pneumothorax, ulcers

down syndrome

protruding tongue

Insomnia is a side effect of

thyroid hormones.

753. The nurse applies a blood pressure cuff around a client's left thigh. To measure the client's blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the location on one of the images.)

"On left thigh with arrow pointing to inner thigh".

tetany

- hypocalcemia (+) Trousseau's sign/carpopedal spasm; Chvostek sign (facial spasm).

Digoxin

0.5-2

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.

A client who has been on a psychiatric unit because of several attempted suicides states, "I am happy to be going home today." What is the nurse's best analysis of this statement? 1. No longer has depression. 2. Has developed appropriate coping mechanisms. 3. May have decided on another suicide plan. 4. Is happy to go home and see family.

3

A hospice nurse is assessing a client reporting chronic pain (5/10 on the pain scale). In addition to the primary healthcare provider and the nurse, what member of the care team will assist in providing comfort therapies for this client? 1. Physical therapist 2. Nutritionist 3. Massage therapist 4. Occupational therapist

3

Assessing extraocular eye movements check cranial nerves ____

3, 4 and 6

Rule of nines

9 = head, 18 = arms, 36 = torso, 36 =legs, and 1= perineum = 100%

change in color is

ALWAYS a LATE sign

use Cold for acute pain (eg. Sprain ankle) and Heat for chronic (rheumatoid arthritis)

Acute (cold) vs chronic pain (heat)

Mucomyst (acetylcysteine)

Antedote for Tylenol OD and is given PO

What should the nurse include when providing education to a client receiving tetracycline?

Antibiotic: for skin infections Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Tetracycline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun. Take tetracycline on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective. Tetracycline can make birth control pills less effective. Use a second method of birth control while you are taking this medicine to keep from getting pregnant. Throw away any unused tetracycline when it expires or when it is no longer needed. Do not take this medicine after the expiration date on the label has passed. Expired tetracycline can cause a dangerous syndrome resulting in damage to the kidneys.

Ranitidine

Antihistamine and Antacid treats: heartburn.,stomach ulcers, gastroesophageal reflux disease (GERD), and conditions that cause too much stomach acid. Ranitidine can cause confusion in the elderly as well as agitation.

Don't fall for 'reestablishing a normal bowel pattern' as a priority with small bowel obstruction.

Because the patient can't take in oral fluids 'maintaining fluid balance' comes first.

681. An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. What action should the nurse take first?

Begin manual ventilation immediately.

An older male client with a history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first? A. Record pain evaluation B. Assess blood glucose C. Identify pills in the bag D. Obtain a medical history

C. Identify pills in the bag

The client in the manic phase of bipolar disorder begins climbing onto a table in the dayroom and shouts, "I can fly! I can fly! Watch me fly!" What should be the initial intervention by the nurse?

Call for personnel to escort the client out of the day room.

MS

Charcot's Triad (IAN) (scanning speech, intention tremor, nystagmus)

MRSA

Contact precaution... ONLY!

Decorticate positioning in response to pain

Cortex involvement

MI

Crushing stubbing pain which radiates to left shoulder, neck, arms, unrelieved by nitro

pancreatitis

Cullen's sign (ecchymosis of umbilicus); (+) Grey turners spots

A client is scheduled for plateletpheresis. When taking the client's history, which information is most significant?

Date last donated Platelet donors can have plateletpheresis as often as every 14 days.

Hypermagnesemia

Depresses the CNS, hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations (this is a medical emergency)

671. The nurse is caring for four clients...postoperative hemoglobin of 8.7 mg/dl; client C, newly admitted with potassium...an appendectomy who has a white blood cell count of 15,000mm3. What intervention... A. Determine the availability of two units of packed cells in the blood bank for client B B.Increase the oxygen flow rate to 4 liters/minute per face mask for client A C. Remove any foods, such as banana or orange juice, for the breakfast tray for client C D. Inform client D that surgery is likely to be delayed until the infection responds to antibiotics

Determine the availability of two units of packed cells in the blood bank for client B.

775. A client is admitted to the surgical unit with symptoms of a possible intestinal obstruction. When preparing to insert a nasogastric (NG) tube, which intervention should the nurse implement? A. Elevate the head of the bed 60 to 90 degrees B. Measure from corner of mouth to angle of jaw C. Administer a PRN analgesic D. Assess for a gag reflex

Elevate the head of the bed 60 to 90 degrees.

Position prone with HOB elevated with

GERD. In almost every other case, though, you better lay the kid on his back. (Back to Sleep - SIDS)

never get pregnant with a German (rubella)

German measles (rubella) is dangerous when pregnant

An example of when you would implement before going through a bunch of assessments is when someone is experiencing anaphylaxis.

Get the ordered epinephrine in them stat, especially if the stem clearly states the s/s (difficulty breathing, increasing anxiety, etc)

718. A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply) a- Headache and tremors b- Irregular heart rate c- Skin hyperpigmentation d- Postural hypotension e- Pallor and diaphoresis

Headache and tremors. Postural hypotension. Pallor and diaphoresis. Irregular heart beat.

if HR is <100 (children)

Hold Digoxin

Cultures are obtained before starting

IV antibiotics

Can't cough

Ineffective airway clearance

Iron via IM

Inferon via Ztrack

672. A client with a new diagnosis of Raynaud's disease lives alone. Which instruction should the nurse include in the client's discharged teaching plan?

Keep room temperature 80.

Weighted NI (naso intestinal tubes)

Must float from stomach to intestine. Don't tape right away after placement. May leave coiled next to pt on HOB. Position pt on RIGHT to facilitate movement through pyloris

Myelogram

NPO for 4-6 hours. allergy hx phenothiazines, cns depressants and stimulants withheld 48 hours prior. Table moved to various positions during test. Post--neuro assessment q2-4 hours, water soluble HOB UP. oil soluble HOB down. oralanalgesics for HA. No po fluids. assess for distended bladder. Inspect site

737. After an elderly female client receives treatment for drug toxicity, the HCP prescribes a 24- hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3mg/dl. What action should the nurse implement? A. Initiate the urine collection as prescribed. B. Notify the HCP of the results. C. Evaluate the client's serum BUN level. D. Assess the client for signs of hypokalemia.

Notify the HCP of the results.

Hypotension and vasoconstricting meds may alter the accuracy of

O2 sats

Prior to a liver biopsy it's important to be aware of the lab result for ______________.

Prothrombin Time

Orange tag in triage is non emergent

Psych

The nurse is caring for a client admitted to the emergency department with a history of asthma. Which assessment findings would the nurse anticipate? You answered this question Incorrectly 1. Coughing 2. Chest tightness 3. 3 + pitting edema to ankles 4. Kussmaul respirations 5. Increased respiratory rate

RationaleStrategies 1., 2., & 5. Correct: The client with asthma has a pattern of dyspnea (shortness of breath), chest tightness, coughing, wheezing, and increased respiratory rate. 3. Incorrect: There should be no dependent edema with asthma. 4. Incorrect: This respiration classification relates to metabolic acidosis and is seen in DKA.

Normal PCWP (pulm capillary wedge pressure) is 8-13.

Readings of 18-20 are considered high.

629. The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider? A. Rebound tenderness in the upper quadrants B. Hypoactive bowel sounds in the lower quadrants C. Tympany with percussion of the abdomen D. Light colored gastric aspirate via the nasogastric tube

Rebound tenderness in the upper quadrants.

questions about a halo?

Remember safety first, have a screwdriver nearby.

627. A client with hypertension receives a prescription for enalapril, an angiotensin...instruction should the nurse include in the medication teaching plan? A. Increase intake of potassium-rich foods B. Report increased bruising of bleeding C. Stop medication if a cough develops D. Limit intake of leafy green vegetables

Report increased bruising of bleeding.

A client, who is having difficulty falling asleep, asks the nurse for a sleeping aid. What is the first action the nurse should provide to the client?

Research indicates that back massage can enhance client comfort, relaxation, and sleep. This is the least invasive option and should be done first.

Autonomic Dysreflexia/Hyperreflexia

S/S pounding headache, profuse sweating, nasal congestion, goose flesh (chills), bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST!

intussusception

Sausage shaped mass , Dance sign (empty portion of RLQ)

778. The nurse is preparing to administer an IV dose of ciprofloxacin to a client with urinary tract infection. Which client data requires the most immediate intervention by the nurse? A. Urine culture positive for MRSA B. Serum sodium of 145 mEq/L (145 mmol/L SI) C. Serum creatinine of 4.5 mg/dl (398 mcmol/L SI) D. White blood cell count of of 12,000 mm3 (12 x 109/L SI)

Serum creatinine of 4.5 mg/dl (398 mcmol/L SI).

thoracentesis prep

Take V/S, shave area around needle insertion site, position client with arms on pillow/over bed table/lying on side, no more than 1000 cc at one time. Post: Listen for bilateral breath sounds, V/S, check leakage, and apply a sterile dressing.

The nurse is teaching a diabetic client who has been prescribed Lispro insulin about avoiding hypoglycemia. What administration teaching is priority?

Take it with meals. Lispro is a rapid-acting insulin that should only be taken with food or within 15 minutes of a meal.

762. The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement? A. Inquire about food allergies and food likes and dislikes B. Talk directly to the adolescent while providing care C. Initiate open communication with the teen's parents D. Monitor vital signs and neuro status every 2 hours

Talk directly to the adolescent while providing care.

Radioactive iodine

The key word here is flush. Flush substance out of body w/3-4 liters/day for 2 days, and flush the toilet twice after using for 2 days. Limit contact w/patient to 30 minutes/day. No pregnant visitors/nurses, and no kids.

The clinical specialist is teaching a group of new staff nurses about therapeutic communication. Which statement by one of the staff nurses indicates to the clinical specialist that further teaching is needed?

Therapeutic communication does not include the use of gestures. Gestures are a type of nonverbal communication which can provide assistance in communicating therapeutically with a client. Other forms of nonverbal communication include facial expression, touch, mannerisms, posture, position, and personal space.

Diaphragm must stay in place 6 hours after intercourse.

They are also fitted so must be refitted if you lose or gain a significant amount of weight.

787. An adult male who fell from a roof and fractures his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse? A. Onset of mild confusion B. Pain score 8 out of 10 C. Pale, diaphoretic skin D. Weak palpable distal pulses

Weak palpable distal pulses.

clozapine s/e

agranulocytosis, tachycardia and siezures

Med of choice for Aystole (no heart beat) (when electrical activity is brought back)

atropine

Long term use of amphojel

binds to phosphates, increases Ca, robs the bones..leads to increased Ca resorption from bones and WEAK BONES)

placental abruptio

bleeding with pain, don't forget to monitor volume status (I&O)

A patient with low hemoglobin and/or hematocrit should be evaluated for signs of

bleeding, such as dark stools

Amniotic fluid is alkaline and turns nitrazine paper

blue. Urine and normal vaginal discharge are acidic, and turn it pink.

Hypervolemia

bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's

REVERSE AGENTS FOR TOXICITY

heparin = protamine sulfate coumadin = vitamin K ammonia = lactulose acetaminophen = n-Acetylcysteine Iron = deferoxamine Digitoxin, digoxin = digibind Alcohol withdrawal = Chlordiazepoxide

Don't use Kayexalate if patient has

hypoactive bowel sounds

Hypernatremia

increased temp, weakness, disorientation/ delusions, hypotension, tachycardia. give hypotonic solution.

take Vermox with high fat diet

increases absorption

Theophylline

increases the risk of digoxin toxicity and decreases the effects of lithium and Dilantin

Nonfat milk reduces reflux by

increasing lower esophageal sphincter pressure

Tensilon is used in

myesthenia gravis to confirm the diagnosis

Addison's disease

need to "add" hormone

bladder cancer

painless hematuria

cataract

painless vision loss, opacity of the lens, blurring of vision

Isoniazid causes

peripheral neuritis

DM

polyuria, polydipsia, polyphagia

cerebral palsy

poor muscle control due to birth injuries and/or decrease oxygen to brain tissues

Infant with cleft lip

position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position.

crisis intervention

short term

A person shouldn't have cantaloupe before an occult stool test because cantaloupe is high in

vitamin C and vitamin C causes a false positive for occult blood

the parathyroid gland relies on the presence of

vitamin D to work

Following surgery, a client refuses to ambulate as prescribed. What action should the nurse take?

The nurse should educate the client about complications that can be prevented with ambulation, such as constipation, pneumonia, or deep vein thrombosis (DVT).

If the baby is a posterior presentation

The sounds are heard at the SIDES.

Which task should the nurse perform first? 1. Suctioning the tracheostomy. 2. Changing a colostomy bag that is leaking. 3. Performing an admission assessment on a client. 4. Administering pain medication to a postoperative client.

The tracheostomy tube must be suctioned to keep the client's airway open. Suctioning the tracheostomy should take priority. Remember, airway first.

In COPD patients the baroreceptors that detect the CO2 level are destroyed.

Therefore, O2 level must be low because high O2 concentration blows the patient's stimulus for breathing

Bleeding is part of the 'circulation' assessment of the ABCD's in an emergent situation.

Therefore, if airway and breathing are accounted for, a compound fracture requires assessment before Glasgow coma scale and a neuro check (D=disability, or neuro check)

When assessing a client, the nurse finds that in response to painful stimuli the upper extremities exhibit flexion of the arm, wrist, and fingers with adduction of the limb, while the lower extremity exhibits extension, internal rotation, and plantar flexion. How would the nurse accurately document this finding?

This describes decorticate posturing because they are moving towards the core of the body.

A client has been prescribed vancomycin 1 gram IV every 12 hours for the treatment of methicillin-resistant staphylococcus aureus (MRSA). Which action by a new nurse when administering this medication would require intervention by the charge nurse?

This dose of medication should be delivered over at least 60 minutes to prevent hypotension and ototoxicity.

What should the nurse document after a client has died?

Time of death Who pronounced the death Disposition of personal articles Destination of body Time body left facility

Test child for lead poisoning at:

around 12 months of age

Guillain-Barre syndrome - GBS

ascending muscle weakness. watch for respiratory failure.

Guillain-Barre syndrome

ascending paralysis. Keep eye on respiratory system.

portal hypotension + albuminemia=

ascites

Test for hypersensitivity before the administration of

asparginase

CT

assess allergies

Pyelogram

assess allergies

Latex allergies

assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes and peaches

Coughing without other s/s is suggestive of

asthma. Watch out when the wheezer stops wheezing. It could mean he is worsening.

Toddlers need to express

autonomy (independence)

Nitroglycerine is administered up to 3 times (every 5 minutes).

if chest pain does not stop, go to the hospital. do not give when BP <90/60.

decreased acetylcholine

is related to senile dementia

CVA (Cerbrovascular Accident)

is with dead brain tissue

No aspirin with kids because

it is associated with Reye's syndrome. Also no NSAIDS such as ibuprofen. Give Tylenol.

Atropine blocks acetylcholine

it reduces secretions

The vital sign you should check first with high potassium is

pulse (due to dysrhythmias)

Brachial pulse

pulse area CPR on an infant.

Pancreatitis patients

put them in fetal position, NPO, gut rest, prepare antecubital site for PICC because they'll probably be getting TPN/Lipids

when patient is in distress, medication administration is

rarely a good choice

dilantin s/e

rash (stop med), gingival hyperplasia (good hygiene) toxicity-->poor gait + coordination, slurred speech, nausea, lethargy, and diplopia

During Epidural Puncture

side lying

dunlap traction

skeletal or skin

You can petal the rough edges of a plaster cast with tape to avoid .

skin irritation

Which client will the charge nurse intervene on behalf when making rounds? 1. The client turned to left side 1 ½ hour ago. 2. Client who has been sitting in a chair for 2 ½ hours. 3. Client who is day one postop from hip replacement with abduction pillow in place. 4. The client who is in buck's traction with foot boots.

2

Which finding should a nurse expect when assessing a healthy 65 year old client? 1. Anomia 2. Presbyopia 3. BP 156/88 4. Apraxia

2

Which signs and symptoms would the nurse expect to see in a client who has taken prednisone for two months? 1. Weight loss 2. Decreased wound healing 3. Hypertension 4. Decreased facial hair 5. Moon face

2,3,5

A client's last two central venous pressure (CVP) readings were 13 cm of water. The nurse would expect the client to manifest which associated signs and symptoms? 1. Dry oral mucus membranes 2. Tachypnea 3. Orthostatic hypotension 4. Rales in the posterior chest 5. Jugular vein distention 6. Weight gain

2,4,5,6

Don't pick cough over tachycardia for signs of _____ in an infant

CHF

Laparoscopy

CO2 used to enhance visual. general anesthesia. foley. Post--ambulate to decrease CO2 buildup

Remember the phrase "step up" when picturing a person going up stairs with crutches.

The good leg goes up first, followed by the crutches and the bad leg. The opposite happens going down. The crutches go first, followed by the good leg.

The nurse is caring for a client suffering from major depression. The client spends all day in bed. Which nursing action is appropriate? 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. Question the client about reason for not getting out of the bed.

1

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy to determine equipment needs upon discharge to home for hospice care. Which equipment should the case manager obtain for this client? 1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen

1,2,4,5

The nurse is caring for an adolescent client diagnosed with depression. The client is prescribed fluoxetine. What is the best response by the nurse when the client says, "What will this medicine do to me?" 1. It will increase the level of serotonin in the brain. 2. It will decrease the production of noradrenaline. 3. It will lower your level of the brain hormone norepinephrine. 4. It will balance blood glucose and dopamine levels in your head.

1

The nurse observes a client at a follow-up appointment using correct cane walking technique but losing balance each time the quad cane is lifted off of the floor. The client reports a history of recent falls. What is the best action for the nurse to take? 1. Inform the primary healthcare provider of the observations made regarding quad cane use, and imbalance assessment. 2. Inform client that there are only a few assistive devices available to help with ambulation. 3. Instruct the client on proper quad cane use. 4. Notify the primary healthcare provider after consulting with the neighbor.

1

The unit charge nurse is responsible for reporting all healthcare associated infections. Which client condition needs to be reported? 1. A client diagnosed with Clostridium Difficile while receiving intravenous (IV) antibiotics. 2. A client admitted with Methicillin-Resistant Staphylococcus aureus (MRSA) in a wound. 3. A client with ulcerative colitis exhibiting diarrhea. 4. A client with a fever of 99.1º F (37.2° C) two days post gastrectomy.

1

Which prescriptions would the nurse recognize as being appropriate for the client with shingles? 1. Private room 2. Negative pressure airflow 3. Respirator mask 4. Face Shield 5. Positive pressure room

1,2,3

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.

Which home routines help reduce the risk of skin damage in a client with impaired sensation? 1. Using a hot water bottle to help warm up when first going to bed. 2. Hot water heater set at a temperature of 140 °F (60 °C) 3. Open flame heaters in the living areas of the home. 4. Testing the water with the back of the wrist and forearm before getting in the shower. 5. Check condition of all equipment used in the home.

4,5

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 receives new healthcare provider prescriptions on a client diagnosed with Addison's disease. Which prescriptions should the nurse recognize as being inappropriately written and requiring clarification from the prescriber? Select all that apply 1. Weigh QD 2. IV of normal saline at 125 mL/hr 3. MRI of pituitary gland 4. Fludrocortisone acetate 0.1 mg by mouth T.I.W. 5. Dehydroepiandrosterone DHEA sulfate 5 mg by mouth every other day

1. & 4. Correct: Use "daily" or "every day". QD is an unapproved abbreviation. T.I.W. stands for three times a week; however, it is an unapproved abbreviation. Use "three times a week". 2. Incorrect: This is a correct action and is written properly. 3. Incorrect: The primary healthcare provider may suggest an MRI scan of the pituitary gland if testing indicates the client might have secondary adrenal insufficiency. This is an approved abbreviation. 5. Incorrect: This is written correctly and may be given to women to treat androgen deficiency.

Which assessment findings would be of concern to the nurse who is caring for a client who has an arterial line to the radial artery?

1. Capillary refill: Left hand-2 seconds; Right hand- 4 seconds. 2. Blue tinged color to finger tips of right hand. 4. Left radial pulse-88/min; Right radial pulse-82/min 5. Blanching to right hand. These are all signs of poor circulation to the right hand. The arterial line could be occluding circulation and needs to be removed.

The nurse is caring for a client who has a history of sleep apnea. The client is scheduled for a colon resection the following morning and asks if the sleep apnea machine should be brought to the hospital. What is the nurse's best response? 1. Yes, bring the sleep apnea machine. 2. No, do not bring the sleep apnea machine. 3. It is your choice. 4. Call your primary healthcare provider.

1. Correct: A client with sleep apnea is at risk for cardiac and respiratory complications postop due to decreasing oxygenation. So yes, the client needs to use the CPAP machine. Remember this client will also be receiving narcotics for pain and have a decreased activity level as well. All of these things can decrease oxygenation. 2. Incorrect: The client will need to have the machine after surgery. 3. Incorrect: The best response is for the nurse to recommend that the client bring the CPAP machine. 4. Incorrect: The nurse can answer this question.The primary healthcare provider does not need to be called.

Following surgery, a client is placed on methylprednisolone. What additional drug therapy would the nurse expect to be prescribed for this client to prevent an adverse reaction related to methylprednisolone? 1. Pantoprazole 2. Phenytoin 3. Imipramine HCI 4. Aminocaproic acid

1. Correct: A potential side effect of methylprednisolone is a peptic ulcer. The primary healthcare provider will prescribe a proton pump inhibitor or H2 blocker to prevent this side effect. 2. Incorrect: Phenytoin is an anticonvulsant. Seizures are not a side effect of methylprednisolone. 3. Incorrect: Imipramine HCI is an antidepressant which is not routinely given with methylprednisolone (Although mood changes can occur with steroid administration, anti-depressants are not routinely given). 4. Incorrect: Aminocaproic acid is given when clients are bleeding. Bleeding is not a side effect of methylprednisolone.

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.

Which nursing task would be appropriate for the LPN/VN to complete? 1. Obtain a wound culture from a client. 2. Administer regular insulin IV to a client in diabetic ketoacidosis. 3. Update plan of care for a client. 4. Initiate client teaching on ostomy care.

1. Correct: The LPN/VN has the knowledge and skill to obtain a wound culture. This is within the scope of practice for the LPN/VN. 2. Incorrect: The LPN/VN cannot administer IV medications to an unstable client. This client needs the RN for close monitoring. 3. Incorrect: The LPN/VN cannot develop or update a plan of care for a client. This is an RN task. The PN can contribute to the development and update, however. 4. Incorrect: Initiating teaching is the task of an RN. LPN/VN's can collect data, observe, monitor the client, and reinforce teaching.

Which nursing task would be appropriate to delegate to an LPN/VN? 1. Obtain a wound culture from a client. 2. Administer regular insulin IV to a client in diabetic ketoacidosis. 3. Monitor a client's closed drainage unit (CDU) for tidaling. 4. Assess a client for tactile fremitus.

1. Correct: The LPN/VN has the knowledge and skill to obtain a wound culture. This is within the scope of practice for the LPN/VN. 2. Incorrect: The LPN/VN cannot administer IV medications to an unstable client. This client needs the RN for close monitoring. 3. Incorrect: The LPN/VN can monitor a chest tube and closed drainage unit, however we don't know whether the client is unstable or not. The LPN can definitely obtain a wound culture. 4. Incorrect: Assessment is the task of an RN. LPN/VN's can collect data, observe, and monitor the client.

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.

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.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Totaling I & O records on five clients at the end of the shift. 2. Assessing VS on a client who was admitted 30 minutes ago. 3. Administering nasogastric (NG) tube feeding. 4. Changing an abdominal surgical dressing on a client that is 3 days post op.

1. Correct: Totaling I & O is an appropriate task for a UAP to be assigned. This is within the scope of practice for the UAP. 2. Incorrect: New clients should be assessed by an RN; however, it is acceptable for the RN to get assistance with some of the information. The RN must verify all information. The client is a new admit, and is considered unstable; therefore, the RN should get the baseline vitals. 3. Incorrect: Administering a NG tube feeding is not within scope of practice for the UAP. 4. Incorrect: Changing a surgical dressing is not within the scope of practice for the UAP.

The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client?

1. Document the client's statement in the client's own words. 2. Provide information on advance directives to the client. 3. Inform the client that personnel are available to assist with completing an advance directive.

Which prescriptions are appropriate for the nursery nurse to initiate on a newborn prior to discharge home? SATA 1. Hepatitis B vaccine 2. Erythromycin Ointment 3. Vitamin K 4. Lanolin 5. PKU Screening

1. Hepatitis B vaccine 2. Erythromycin Ointment 3. Vitamin K 5. PKU Screening This vaccine is recommended at birth to decrease the incidence of hepatits B virus. Mandatory prophylactic agent is applied in newborn's eyes as precaution against ophthalmia neonatorium. Vitamin K (Aquamephyton) routine injection to prevent hemorrhagic disease of newborn. PKU-Screening for phenylketonuria is not reliable until the newborn has ingested an ample amount of the amino acid, phenylalanine, a constituent of both human and cow's milk. Nurse must document initial ingestion of milk and perform test at least 24 hours after that time. This test is thus done just prior to discharge.

A nurse is teaching a group of small farm owners how to prevent pesticide exposure for field workers. What points should the nurse include?

1. Importance of hand washing before eating. 3. Removing clothing and shoes worn in the field before entering the home. 4. Washing fruit and vegetables prior to eating.

733. When washing soiled hands, the nurse first wets the hands and applies soap. The nurse should complete additional actions in which sequence? (Arrange from first action on top last action on bottom.)

1. Rub hands palm to palm. 2. Interlace the fingers. 3. Dry hands with paper towel. 4. Turn off the water faucet.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which clients should the charge nurse assign to the medical-surgical nurse? SATA 1. Total abdominal hysterectomy 2. Breast reduction 3. Vaginal delivery with fetal demise 4. 32 week gestation with lymphoma 5. Post-partal with HELLP syndrome

1. Total abdominal hysterectomy 2. Breast reduction

Following a total hip replacement, the nurse provides discharge teaching to the client. The nurse knows that teaching was effective when the client states which activities are safe to perform? SATA 1. Using an abduction pillow while sleeping 2. Crossing the legs 3. Using a toilet extender 4. Showering rather than taking a bath 5. Tying shoes

1. Using an abduction pillow while sleeping 3. Using a toilet extender 4. Showering rather than taking a bath 1. use an abduction pillow to keep hip in proper alignment and prevent hip dislocation . 2. A toilet extender keeps the hip in proper alignment and prevents hip dislocation. 3. Showering rather than sitting in a tub will prevent flexion of the hip.2. Incorrect: Crossing the leg can pop the hip out of place and prevent total healing and success with the replacement. 5. Incorrect: To tie shoes, the client has to bend over which can pop the hip out of place. The client would need to have shoes that do not require tying or have someone do it for them.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which clients should the charge nurse assign to the medical-surgical nurse? Select all that apply 1. Total abdominal hysterectomy 2. Breast reduction 3. Vaginal delivery with fetal demise 4. 32 week gestation with lymphoma 5. Post-partal with HELLP syndrome

1., & 2. Correct: Though the clients are females, their postoperative care has similarities to the standard postoperative clients. 3. Incorrect: This client needs specialized care. This postpartum client had a vaginal delivery. A nurse who has experience caring for a client who delivered a stillborn should be assigned to this client. 4. Incorrect: This client needs specialized care. The client is at 32 weeks gestation. A nurse with obstetrical experience, should be assigned to this client. 5. Incorrect: No, the monitoring is too specific for the medical-surgical nurse. Hemolysis Elevated Liver enzymes Low Platelet count (HELLP) syndrome is a form of preeclampsia with severe liver damage. The medical-surgical nurse should not be assigned to this client.

Which prescriptions would the nurse recognize as being appropriate for the client with shingles? 1. Private room 2. Negative pressure airflow 3. Respirator mask 4. Face Shield 5. Positive pressure room

1., 2. & 3. Correct: According to the current standards of Standard Precautions per the CDC, the client with shingles should be placed on airborne precautions which require the use of a private room with negative pressure airflow and a N-95 respirator mask. 4. Incorrect: A face shield is used when there is risk of splashing or spraying of blood or body fluids. This is not required for airborne precautions. 5. Incorrect: Negative pressure is required in order to prevent the airborne infection from spreading outside of the room. Positive pressure is used only in protective environments such as when immunocompromised clients require protection from potential infectious agents outside of the room.

Which assessment finding would indicate to a nurse that a client receiving chemotherapy may have difficulty maintaining proper nutrition? 1. Fatigue 2. Mucositis 3. Neutropenia 4. Diarrhea

2

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).

The nurse notes that a client has impaired swallowing as a result of a cerebrovascular accident (CVA). Which interventions are appropriate for the nurse to include in the plan of care? Select all that apply 1. Sit the client up at a 90° angle during meals. 2. Assist the client to hyperextend the head when preparing to swallow. 3. Encourage the client to sit up for 30 minutes after eating. 4. Educate a family member on the Heimlich maneuver. 5. Start the client on a thin liquid diet.

1., 3. & 4. Correct: This is the optimal position for chewing and swallowing without aspirating. Sitting up 30 minutes after completing a meal will prevent regurgitation of food. In case of choking, family members should know how to perform emergency measures such as the Heimlich maneuver. 2. Incorrect: The client should position the head in forward flexion in preparation for swallowing, called the "chin tuck". Hyperextension would cause aspiration.5. Incorrect: The client should be started on thick liquid or pureed diet. Thickened or pureed foods are easier to swallow than thin liquids and prevent aspiration.

The nurse is advising the family of a client receiving palliative care on alternative methods for pain control to be used in conjunction with pain medications. Which method should the nurse include? 1. Providing a back massage 2. Administering pain medication when pain is rated at 5 out of 10 3. Distracting with music 4. Exercise 5. Prayer

1., 3., & 5. Correct: These are types of alternative pain control that could be used in conjunction with traditional pain management. They can be used to provide relaxation and comfort; mind-body therapies such as meditation, guided imagery and hypnosis may be effective. Other measures may include: acupuncture, therapeutic touch, music therapy and spiritual practices such as prayer. These have been found to be effective in helping to reduce pain. 2. Incorrect: Pain medication is traditional, not alternative pain control. Also, pain medication should be provided prior to a rate of 5/10. 4. Incorrect: The client is likely not going to be able to exercise. Movement during pain may increase pain.

The nurse, caring for a client diagnosed with Alzheimer's disease (AD), notices the client becoming agitated. What nursing intervention would be appropriate for the nurse to initiate? (SATA) 1. Provide a snack for the client. 2. Tell the client to stop the unwanted behavior. 3. Take client for a walk. 4. Ask the client to sweep the floor. 5. Inform the client that restraints will be used if behavior continues. 6. Turn on the client's favorite music.

1., 3., 4., & 6. Correct: Nursing interventions that address difficult behavior include redirection, distraction, and reassurance as provided by these correct interventions. 2. Incorrect: These behaviors are often unpredictable and not intentional. Do not challenge the client. Use redirection, distraction, and reassurance. 5. Incorrect: When dealing with a difficult client, do not threaten to restrain the client or call the primary healthcare provider.

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).

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.

The nurse is caring for a client on the surgical unit. The primary healthcare provider prescribed morphine sulfate 20 mg IM one time dose. The nurse has available: morphine sulfate in a 20 mL vial, labeled 15 mg per mL. How many mL should the nurse administer? Record answer using one decimal place.

1.3 mL

Which statement, made by a client scheduled for a total laryngectomy, indicates to the nurse a need for further preoperative teaching? 1. After the surgery, I will breathe only through a hole in my neck. 2. My wife will have to get a hearing aid because I will not be able to talk above a whisper. 3. I must have smoke detectors installed at home since I may not be able to smell after surgery. 4. After surgery, I will have a tube going through my nose to my stomach for feeding.

2

A group of women ask a community health nurse how to prevent stress incontinence. What points should the nurse teach these women? 1. Limit alkaline foods. 2. Avoid caffeine. 3. Maintain a healthy weight. 4. Eat less fiber. 5. Perform high-impact exercise.

2,3

A nurse is planning a health education seminar for a group of females who are age 45-54. What should the nurse recommend be done annually? 1. Chest xray 2. Mammography 3. Influenza vaccine 4. Tuberculous (TB) skin test 5. Colonoscopy

2,3

Post thyroidectomy, the nurse assesses the client for complications by performing which assessment? 1. Perform blood glucose monitoring every 6 hours 2. Check for a positive Chvostek's 3. Assess swallowing reflex 4. Monitor neck dressings for change in fit and comfort 5. Administer desmopressin per nasal spray for urinary output (UOP) greater than 200 mL/hr

2,3,4

Which factors should the nurse include when teaching a parent about risk factors for otitis media? 1. Breast-feeding 2. Contact with siblings 3. Day care attendance 4. Season of the year 5. Age over 5

2,3,4

Which nursing tasks can the RN delegate to an unlicensed assistive personnel (UAP)? 1. Tell a female client who has recurrent urinary tract infections how to wipe after urinating. 2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 3. Collects a urine specimen from an indwelling catheter tubing. 4. Document the intake and output of a client in acute renal failure. 5. Irrigate the foley catheter of a client who has had transurethral resection of the prostate (TURP). 6. Perform perineal care of a client who has urinary incontinence.

2,4,6

Developmental

2-3 months: turns head side to side 4-5 months: grasps, switch and roll 6-7 months: sit at 6 and waves bye bye 8-9 months: stands straight at 8 10-11 months: belly to butt 12-13 months: 12 and up, drink from a cup

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.

639. The nurse determines that a client's pupils constricts as they change focus from a far object. What documentation should the nurse enter about this finding? a. Pupils reactive to accommodation b. Nystagmus present with pupillary focus. c. Peripheral vision intact d. Consensual pupillary constriction present

Pupils reactive to accommodation.

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.

A client was admitted to the psychiatric unit with delusions and a history of auditory hallucinations. The client reports, "The FBI has been watching my house and are going to raid it and arrest me." What is the nurse's best response? 1. The FBI would not be watching you unless there was a good reason. 2. I don't think that the FBI is watching your house. 3. I believe that your thoughts are very disturbing to you. 4. Tell me more about your thoughts.

3

The RN is caring for a client diagnosed with an abdominal aortic aneurysm. Which prescription can the RN delegate to the LPN? 1. Obtain vital signs every 15 minutes. 2. Insert a urinary catheter for hourly urinary outputs. 3. Place a PICC line for fluid management. 4. Provide morphine 1 mg per PCA pump at a 10 minute lockout.

2. Correct. Inserting a urinary catheter is within the scope of practice for the LPN. This task does not include further assessment of the urinary output, which the RN will perform. 1. Incorrect. The UAP can do this task as well as the LPN. In order to be most effective with the nurse's time, this task can be delegated to the UAP. 3. Incorrect. The RN with special training can insert a PICC line. The LPN cannot complete this task. 4. Incorrect. The RN must complete this task. The LPN should not initiate PCA morphine.

What precautions should be taken with computer monitors that display client health information to ensure client's confidentiality? 1. Orient the screen facing the client rooms so that healthcare personnel can access the information easily. 2. Have the screen placed facing away from any visitor or client care area where information could be viewed by unauthorized persons. 3. Turn the computer monitors off when the computer is not in use. 4. The computer should be kept in a secured, locked area.

2. Correct: Computer monitors that display client health information should be positioned away from the view of any visitors or unauthorized persons. Even a well-guarded computer monitor, with an authorized employee sitting in front of it, could be a potential breach of confidentiality, depending on the angle of the monitor screen and who was attempting to view the information on it. The responsibility for keeping health information safe is on every member of the healthcare team. 1. Incorrect: No, this would be easily viewed by unauthorized individuals. 3. Incorrect: Not necessary to turn off if proper precautions are taken. 4. Incorrect: Not necessary to keep in secured area if proper precautions are taken.

A primary healthcare provider prescribed KCL 40 mEq in 100 mL NS to infuse over 30 minutes. What action should the nurse take? 1. Administer the KCL through the lowest IV line port. 2. Clarify the prescription with the primary healthcare provider. 3. Mix KCL 40 mEq into the present infusing bag of NS when it reaches 100 mL. 4. Set the infusion pump to 100 mL / hour.

2. Correct: Potassium chloride should be diluted and administered to infuse no faster than 40 mEq per hour. So this prescription would infuse too quickly and may lead to life threatening arrhythmias. 1. Incorrect: This prescription should not be administered as written. The rate of infusion over 30 minutes is too fast. 3. Incorrect: This is dangerous. Nurses should not add KCL to an existing bag of infusing fluid. This prescription should not be administered as written. 4. Incorrect: The nurse should verify the rate prior to initiating the infusion. The rate of administration should be clarified with the primary healthcare provider.

A client, who is having difficulty falling asleep, asks the nurse for a sleeping aid. What is the first action the nurse should provide to the client? 1. Assist client to take a cool bath. 2. Provide a back massage. 3. Administer prescribed triazolam. 4. Give client a crossword puzzle to work.

2. Correct: Research indicates that back massage can enhance client comfort, relaxation, and sleep. This is the least invasive option and should be done first. 1. Incorrect: A cool bath would wake a client, whereas, a warm bath would increase relaxation. 3. Incorrect: Triazolam is a short acting benzodiazepine. Do not go to the sleeping pill first. 4. Incorrect: Distraction is a good strategy for drawing a client's attention away from pain but may increase thinking, thus keeping the client awake.

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 school nurse educates a group of teachers how to extinguish a fire involving a child whose clothes are on fire. Which statement by the teachers would indicate to the school nurse that the teachers understand what should be done first? 1. "Someone should be assigned to call 911." 2. "Lay child flat and roll in a blanket." 3. "A blanket should be thrown over the child's head and body." 4. "Use a fire extinguisher to put out the flames."

2. Correct: The flames should be extinguished first. The best way to accomplish this it to lay the child flat and roll in a blanket. This is referred to as the drop and roll method, when a blanket is available. 1. Incorrect: 911 should be called but the most important thing to do is to extinguish the flames first. 3. Incorrect: Throwing a blanket over the child's head can trap smoke. This may lead to smoke inhalation and does not extinguish the fire. 4. Incorrect: The fastest and most effective way to extinguish the flames is by using the drop and roll method.

A client has been taught guided imagery as a method to relieve pain. How should the nurse first assess for pain relief after completion of guided imagery by the client? 1. Assess vital signs 2. Use of pain intensity scale 3. Ask client to describe the pain 4. Observe ability to perform activities of daily living

2. Correct: The use of pain intensity scales is an easy and reliable method of determining the client's pain intensity. 1. Incorrect: Although respiratory and heart rate may decrease with guided imagery and pain reduction, the most objective measure is to ask the client to rate the pain. 3. Incorrect: First, ask the client if pain is present. If present, the client should be asked to rate the pain. Once pain has been rated, the client should be asked to describe the pain. 4. Incorrect: The client may be able to perform activities of daily living and still have pain. Therefore, this would not be an accurate means of assessing pain relief.

What precautions should be taken with computer monitors that display client health information to ensure client's confidentiality?

2. Have the screen placed facing away from any visitor or client care area where information could be viewed by unauthorized persons.

A client is diagnosed with new onset grand mal seizures. Which nursing interventions should the nurse implement for this client?

2. Pad the side rails with blankets. 3. Place the bed in low position. 5. Instruct client to call for help when ambulating.

The primary healthcare provider suspects the client has tuberculosis (TB) and prescribes a Mantoux test. What precautions should the nurse take when administering the Mantoux test? 1. Don sterile gloves. 2. Place the client on reverse isolation. 3. Wear a particulate respirator 4. Obtain a consent form. 5. Initiate airborne precautions.

3,5

A nurse is caring for a client in an outpatient clinic. The client lost her husband of 51 years three months ago. Which findings support that the client is experiencing normal grief reactions rather than clinical depression? SATA 1. The client is experiencing anhedonia. 2. The client states, "I have good and bad days." 3. The client smiles at the nurse while talking about her grandchild. 4. The client has a persistent state of dysphoria. 5. The client states, "I am having fewer crying spells."

2. The client states, "I have good and bad days." 3. The client smiles at the nurse while talking about her grandchild. 5. The client states, "I am having fewer crying spells."

A group of women ask a community health nurse how to prevent stress incontinence. What points should the nurse teach these women? 1. Limit alkaline foods. 2. Avoid caffeine. 3. Maintain a healthy weight. 4. Eat less fiber. 5. Perform high-impact exercise.

2., & 3. Correct: Fluids containing caffeine, carbonation, alcohol or artificial sweeteners act as irritants to the bladder wall and should be avoided. Acidic foods, such as citrus fruits, are also irritants. Obesity can cause increased pressure on the bladder, leading to incontinence. 1. Incorrect: Acidic foods, not alkaline, are bladder irritants and should be avoided. 4. Incorrect: The client should eat more fiber (not less) to prevent constipation, which can put pressure on the bladder and be a cause of urinary incontinence. 5. Incorrect: High-impact exercise puts pressure on the pelvic floor muscles and can increase leakage. Try Pilates, a gentle method of stretching and strengthening core muscles, which has become a more popular treatment for stress incontinence.

A client with dementia has been admitted to the medical floor. The family informs the nurse that the client tends to wander at night. When planning client safety goals, which action by the nurse would take priority? 1. Place client with a roommate who is able to notify staff when client wanders. 2. Discuss safety goals with family, encouraging them to spend time with client. 3. Designate an unlicensed assistive personnel (UAP) to sit with the client through the night. 4. Reorient the client every shift regarding floor policies and safety procedures.

3

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).

Which factors should the nurse include when teaching a parent about risk factors for otitis media? 1. Breastfeeding 2. Contact with siblings 3. Day care attendance 4. Season of the year 5. Age over 5

2., 3. & 4. Correct: Contact with siblings, day care attendance, and season of the year all increase a child's risk of developing otitis media. Otitis media usually follows or accompanies an upper respiratory infection or the common cold. The exposure to upper respiratory infections is increased when other siblings are in the home and when the child attends daycare. More upper respiratory infections occur during times when the climate changes and during the winter months. 1. Incorrect: Breastfeeding decreases the incidence of otitis media. Ear infections are more common in children who drink from bottles or sippy cups, especially when lying on their back. 5. Incorrect: Age under 5 is a risk factor. The Eustachian tube is shorter, narrower, and more vulnerable to blockage in the younger children. It also lies more horizontal and does not drain as well as older children and adults. This, along with immature immune systems, puts the younger child at higher risks for otitis media.

The nurse is teaching a client about foods containing tyramine which should be avoided while taking a monoamine oxidase inhibitor (MAOI). Which meal selection by the client would indicate understanding of an acceptable food to eat? 1. Smoked turkey and dressing, sweet peas and carrots and milk. 2. Baked chicken over pasta with parmesan sauce, baked potato and tea. 3. Fried catfish, French fries, coleslaw and apple juice. 4. Liver smothered in gravy and onions, rice, squash and water.

3

The primary healthcare provider prescribes a combination of pyrazinamide and isoniazid to treat a client with tuberculosis. The client asks the nurse, "Why am I taking two drugs?" Which explanation should the nurse give the client? 1. One diminishes the side effects of the other. 2. Hepatoxicity is reduced. 3. Bacterial resistance is decreased. 4. One kills the live bacteria, and the other the spores.

3

The triage nurse in the emergency department (ED) assesses 4 clients. Which client is in need of emergent care? 1. A 52 year old who has a partially amputated finger. 2. A 9 month old with temperature of 103°F (39.4°C). 3. A two year old with excessive drooling and a weak cough. 4. A 28 year old experiencing a migraine headache for three days.

3

What assignment would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Teaching the client perineal care. 2. Changing a colostomy bag on a client. 3. Serving the diet tray for a diabetic client. 4. Taking the initial vital signs on a client who is to receive blood.

3

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.

The nurse is working in a long term care facility. What actions by the nurse are appropriate when taking a telephone prescription from a primary healthcare provider? 1. Document the prescription prior to the end of the shift. 2. Explain to the primary healthcare provider that nurses cannot take telephone prescriptions. 3. Repeat the prescription back to the primary healthcare provider prior to hanging up. 4. Transcribe the prescription in the client's record. 5. Ask the primary healthcare provider to wait and write the prescription during rounds.

3. & 4. Correct: Whenever a verbal or telephone prescription is given, the nurse is to transcribe the prescription, and then read it back to the prescribing primary healthcare provider at the time the prescription is given for validation of accuracy of the prescription received. Otherwise an error may occur. 1. Incorrect: Errors are more likely to be made if documentation is not made at the time the prescription is received. 2. Incorrect: Nurses can take telephone prescriptions; however, safety measures include writing down the prescriptions immediately and repeating the prescriptions to the primary healthcare provider. 5. Incorrect: Asking the primary healthcare provider to wait until rounds is not appropriate, as nurses can take telephone prescriptions with appropriate safety measures to ensure accuracy.

The nurse is preparing a client for a renal biopsy. Which data is most important to gather prior to this procedure? (SATA) 1. BUN 2. NPO status 3. Prothrombin time (PT) 4. Serum potassium 5. Activated partial thromboplastin time (aPTT)

3. & 5. Correct: Yes, before you insert a needle into an organ for a biopsy it would be best to know their bleeding time and coagulation studies. Prothrombin is a protein produced by the liver. The PT test measures how well and how long it takes for blood to clot. Normally this is 20-30 seconds. aPTT also measures the time it takes for blood to clot. 1. Incorrect: Although BUN is related to renal function, it does not impact the procedure itself. This is not essential for the procedure. 2. Incorrect: Although this is carried out, it does not take priority over the risk of bleeding. Always think what could be life threatening. 4. Incorrect: Although serum potassium is related to renal function, it does not impact the procedure itself. This is not essential for the procedure.

What should the nurse do first when caring for a client who is being admitted with a diagnosis of meningococcal meningitis? 1. Perform neurological checks. 2. Collect data for health history. 3. Institute droplet precautions. 4. Orient client to the room and procedures.

3. Correct: Although all the options are appropriate, you should first place the client on droplet precaution to prevent the spread of meningococcal meningitis. 1. Incorrect: Placing client in isolation should be done first (actually prior to arriving to room) since the client has a diagnosis of meningococcal meningitis. Neurological checks can be completed after the client is placed in isolation. 2. Incorrect: Collecting data for the health history can be obtained after placing the client on droplet precautions. 4. Incorrect: Orientation can occur after the initiation of droplet precautions.

Which client must the nurse assign to a private room? 1. Primiparous client who delivered twins at 28 weeks gestation two days ago 2. Postpartum client on IV Ampicillin and Gentamicin for chorioamnionitis 3. Postpartum client whose 2 hour old infant is being worked up for sepsis 4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C)

4

A new admit arrives to the nursing unit with one thousand dollars in cash. What would be the best action by the nurse to safeguard the client's money? 1. Insist the money go home with the client's visitor. 2. Place the money in the client's bedside table drawer. 3. Put itemized cash in envelope and place in hospital safe. 4. Lock money up in narcotic cabinet with client's identity and room number.

3. Correct: It is best to have two witnesses (preferably hospital staff) sign the inventory list. The best action by the nurse would be to itemize the valuables, place in an envelope with the record of the inventory, and have it put in the hospital safe. If you fail to properly safeguard the client's property, the trust of the healthcare team for medical care can also be lost. Liability waivers should be signed if for whatever reason, the valuables must remain at the hospital. 1. Incorrect: This is not the best option. The visitor may not be the best person to send the money with. The client also has the right to refuse. Sending the money home with someone else does not safeguard the client's valuables and puts the nursing unit at risk for liability if a liability waiver has not been signed. 2. Incorrect: This is not a safe option. Anyone could retrieve the money. This would be considered careless actions by the nurse and could cause a lack of trust in the entire healthcare team. 4. Incorrect: This is not a safe option. Anyone with access could retrieve the money. Although it is in a locked area, it does not need to be placed with narcotics where the cabinet would be accessed by multiple people. This would still be considered a failure to properly safeguard the client's valuables.

What assignment would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Teaching the client perineal care. 2. Changing a colostomy bag on a client. 3. Serving the diet tray for a diabetic client. 4. Taking the initial vital signs on a client who is to receive blood.

3. Correct: The most appropriate task for a non-licensed person would be serving the diet tray for a client. This does not require experience for a particular skill nor does it require higher level skills that would require a licensed person to perform. 1. Incorrect: Teaching is the responsibility of the RN and cannot be delegated to a LPN nor a non-licensed personnel. 2. Incorrect: Changing the colostomy bag on a client will need someone with the experience/skill of performing this task. Although some agencies allow UAP's to change colostomy bags, there may be further assessment needed associated with the ostomy, such as skin condition around the ostomy. This would not be the best option to assign to the UAP. 4. Incorrect: UAPs can take VS, but they must be very cautious in order to note changes and the client receiving blood should be assessed for any s/s of reaction. Therefore, it would be best for the licensed personnel to obtain the initial v/s prior to blood administration to assess the client's status and have a baseline for evaluating the client's response to the blood administration.

After shift report, which client should the nurse see first? 1. Eight year old that is in skeletal traction. 2. Six year old who is 5 hours postop appendectomy. 3. Unattended two year old admitted for a sleep study. 4. Four year old cerebral palsy child with a urinary tract infection (UTI).

3. Correct: The unattended child should be checked first to make sure he/she is safe and having no complications. A child this age is entirely dependent on someone else. Safety is priority here. 1. Incorrect: An eight year old in skeletal traction does not take priority over unattended 2 year old.. 2. Incorrect: A six year old who is 5 hr post appendectomy should be seen, but not as immediate as an unattended 2 year old. 4. Incorrect: This client has a UTI and is not acutely ill at this time. The major clues in the question are age and unattended. The unattended two year old child's safety is the reason for that child being the priority over this child.

The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice for the nurse to place the client in until full consciousness is regained? 1. Supine 2. Fowler's 3. Lateral 4. High Fowler's

3. Correct: When someone is very sedated and not fully conscious, we want them on their side so the airway remains open and the secretions can drain. 1. Incorrect: No, the jaw will fall back, the tongue will block the airway, and the client will have airway obstruction, either partial or maybe even life-threatening. 2. Incorrect: No, if you sit a client up who is not fully conscious, the client's head tips forward and blocks the airway. 4. Incorrect: Again, head may fall forward and block airway.

A small community has experienced a severe tornado that hit a shopping mall and caused extreme damage and suspected mass casualties and injuries. Which intervention takes priority? 1. Triage victims and tag according to injury. 2. Assess the immediate area for electrical wires on the ground and in vicinity of victims. 3. Activate the community emergency response team. 4. Begin attending to injuries as they are encountered.

3. Correct: With mass casualties, community response teams are needed. 1. Incorrect: This would be the third step. 2. Incorrect: This would be the second step so that further injuries are not encountered. 4. Incorrect: Triage must occur before treatment of anyone so that an accurate assessment of level of injuries can be made. With mass casualties, a color tag system is usually implemented.

The nurse is working with the parents of a preschooler to help promote healthy sleep patterns of approximately 8-12 hours per night. Which intervention should assist the parents to achieve adequate sleep for their preschooler?

3. Spend about 30 minutes with the preschooler prior to bedtime for stories, prayers, etc.

A client had an abnormal maternal serum alfa fetoprotein (MSAFP) at 18 weeks gestation. She is now 22 weeks gestation, and an amniocentesis has just been completed for genetic analysis. Which nursing action has priority? 1. Monitor the needle entry site for signs of infection. 2. Encourage the client to express her feelings. 3. Assess the maternal blood pressure for hypertension. 4. Monitor fetal heart tones and uterine activity.

4

In what position should the nurse place a client post liver biopsy? 1. Left Sims' 2. Reverse Trendelenburg 3. Semi-Fowler's 4. Right Lateral Decubitus

4

A client was admitted to the medical unit with pneumonia 2 days ago. There is a history of drinking 5-6 martinis every night for the past 2 years. Today, the nurse notes that the client is disoriented to time and place and is seeing imaginary spiders on the ceiling. The nurse cannot understand what the client is saying. What is this client most likely experiencing? 1. Wernicke's Encephalopathy 2. Korsakoff's Psychosis 3. Alcohol Withdrawal 4. Alcohol Withdrawal Delirium

4. Correct: Alcohol Withdrawal Delirium usually occurs on the second or third day following cessation of or reduction in prolonged, heavy alcohol use. Symptoms are the same as for delirium: Difficulty sustaining and shifting attention. Extremely distractible; disorganized thinking; rambling, irrelevant, pressured, and incoherent speech; impaired reasoning ability; disoriented to time and place; impairment of recent memory; delusions and hallucinations. 1. Incorrect: Wernicke's Encephalopathy represents the most severe form of thiamine deficiency in alcoholics. Symptoms include paralysis of the ocular muscles, diplopia, ataxia, confusion, somnolence, and stupor. If thiamine replacement therapy is not given, death will ensue. 2. Incorrect: Korsakoff's Psychosis is identified by a syndrome of confusion, personality changes, loss of recent memory, and confabulation (filling in some memory gaps with different life events or created thoughts). It is frequently encountered in clients recovering from Wernicke's encephalopathy. Coordination may be affected, so the client may have difficulty maintaining balance. Treatment is parenteral or oral thiamine replacement. 3. Incorrect: Alcohol withdrawal typically begins 4-12 hours after cessation of or reduction in heavy and prolonged alcohol use. Symptoms include: coarse tremor of hands, tongue, or eyelids; nausea and vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood or irritability; transient hallucinations or delusions; headache; and insomnia.

A client with gestational diabetes delivers an infant with macrosomia. What is the most vital component of the infant's assessment for the nurse to perform? 1. Evaluation of the infant for cephalhematoma. 2. Determining if the infant sustained a clavicle fracture. 3. Observing for arm movement to evaluate for facial palsy. 4. Frequent blood glucose monitoring to ensure stable values.

4. Correct: Infants of diabetic mothers are at risk for hypoglycemia following birth. Hypoglycemia can trigger seizures and cognitive deficits. 1. Incorrect: Assessing for cephalhematoma is important in macrosomia infants, but not as vital as ensuring stable glucose levels. 2. Incorrect: Assessing for clavicle fracture is important in macrosomia infants, but not as vital as ensuring stable glucose levels. 3. Incorrect: Assessing for facial palsy is important in macrosomia infants, but not as vital as ensuring stable glucose levels.

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 client had an abnormal maternal serum alpha fetoprotein (MSAFP) at 18 weeks gestation. She is now 22 weeks gestation, and an amniocentesis has just been completed for genetic analysis. Which nursing action has priority? 1. Monitor the needle entry site for signs of infection. 2. Encourage the client to express her feelings. 3. Assess the maternal blood pressure for hypertension. 4. Monitor fetal heart tones and uterine activity.

4. Correct: There is a risk for pregnancy loss after amniocentesis. The priority nursing intervention is to monitor for fetal heart tones and uterine contractions. 1. Incorrect: There would not be signs of infection so soon after the procedure. 2. Incorrect: The physiological needs have priority over psychological/self-esteem needs (Maslow's hierarchy). The fetal status should be the priority to be monitored. The client's feelings are important and would be assessed, but would not take priority over the fetal status. 3. Incorrect: Hypotension is a more likely side-effect of the procedure. Since the procedure involved entering the amniotic sac, fetal status should be a priority assessment.

A client experiencing chest pain is prescribed an intravenous infusion of nitroglycerin. After the infusion is initiated, the occurrence of which symptom would prompt the nurse to discontinue the nitroglycerin? 1. Frontal headache 2. Orthostatic hypotension 3. Decrease in intensity of chest pain 4. Cool, clammy skin

4. Correct: This assessment finding of cool, clammy skin is an indication of decreased cardiac output that could be the result of too much vasodilatation. Cardiac output could continue to decrease if the nitroglycerin is not discontinued. 1. Incorrect: A headache is an expected common side effect of nitroglycerin administration. The headache is treated with medication. 2. Incorrect: A decrease in blood pressure when rising from a supine or sitting position is a common effect of the vasodilatation that occurs with the administration of nitroglycerin. The client should be advised to change positions slowly. 3. Incorrect: The decrease in the intensity of the client's chest pain is the desired outcome of the nitroglycerin administration.

The nurse is caring for a client with possible hepatic failure. The nurse asks the client to sign a permit for a procedure. The nurse recalls the client's admission signature as legible, but, now observes a jerky, illegible signature. What should the nurse suspect is the cause of this handwriting change? 1. Fetor 2. Ataxia 3. Apraxia 4. Asterixis

4. Correct: Yes, the liver flap, which is an abnormal muscle tremor, is usually found in clients with diseases of the liver. This is an indication that the hepatic failure is worsening and needs to be documented. 1. Incorrect: This is an offensive odor of the client's breath often associated with liver failure.2. Incorrect: This is uncoordinated movement that is associated with many different neuromuscular disorders.3. Incorrect: This is a term to describe not using items for their intended purpose and is associated with neurological disorders and damage to the brain.

Which foods should the nurse teach a client to avoid when prescribed a diet limiting purine rich foods? Select all that apply 1. Peanut butter 2. Potatoes 3. Apples 4. Venison 5. Scallops

4., & 5. Correct: Meats such as liver, bacon, veal, and venison are high in purine and should be avoided. Seafood such as sardines, mussels, codfish, scallops, trout, and haddock are high in purine and should be avoided. 1., 2., & 3. Incorrect: The client can enjoy peanut butter, potatoes, fruits and fruit juices, vegetables.

Based on the Parkland formula, the primary healthcare provider has determined that a burn victim needs 9,250 mL of LR intravenously over the first 24 hours. How many milliliters of LR should the nurse administer over the first eight hours? Round answer to the nearest whole number.

4625

In a five year old, breathe once for every _____ compressions during CPR

5

Angiotensin II in the lungs

= potent vasodialator. Aldosterone attracts sodium

749. The nurse suspect may be hemorrhaging internally. Which findings of an orthostatic test may indicate to the nurse of major bleed?

A decrease in the systolic b/p of 10mm/hg with a corresponding increase of heart rate of 20.

770. A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply). A. A bedside commode is positioned near the bed B. A saline lock is present in the right forearm C. A full pitcher of water is on the bedside table D. The client is lying in a supine position in bed E. A low sodium diet tray was brought to the room

A full pitcher of water is on the bedside table. The client is lying in a supine position in bed.

The charge nurse was notified that a client with 2nd degree burns is being admitted to the floor. Which nurse should be assigned this client? 1. A nurse caring for clients with spina bifida and acute gastroenteritis. 2. The new nurse, out of orientation for 2 months, caring for clients diagnosed with tonsillitis and anorexia nervosa. 3. The pregnant nurse caring for clients with cystic fibrosis and staph infection. 4. A nurse caring for clients with irritable bowel syndrome and post op appendectomy.

A nurse caring for clients with irritable bowel syndrome and post op appendectomy. it would be best to assign the client to this nurse because the clients this nurse is caring for do not have anything contagious, which will decrease the risk of the burn client becoming infected.

Disseminated Herpes Zoster is AIRBORNE PRECAUTIONS, as Localized Herpes Zoster is CONTACT PRECAUTIONS.

A nurse with a localized herpes zoster CAN care for patients as long as the patients are NOT immunosuppressed and the lesions must be covered

636. After checking the fingerstick glucose at 1630, what action should the nurse implement? a. Notify the healthcare provider b. Administer 8 units of insulin aspart SubQ c. Gives an IV bolus of Dextrose 50% 50 ml d. Perform quality control on the glucometer.

Administer 8 units of insulin aspart SubQ.

Aminoglycocide (__Mycin ; except erythromycine)

Adverse Effects are bean shaped - Nephrotoxic to Kidneys and Ototoxic to Ears

SARS (severe acute respiratory syndrome)

Airborne and Contact precautions (same as varicella)

634. In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)? a- An older client who fell yesterday and is now complaining of diplopia b- An adult newly diagnosed with type 1 diabetes and high cholesterol c- A client with pancreatic cancer who is experience intractable pain. d- An older client post-stroke who is aphasic with right-sided hemiplegia

An older client post-stroke who is aphasic with right-sided hemiplegia.

748. An antacid is prescribed for a client with gastroesophageal (GERD). The client asks the nurse, "How does this help my GERD?" What is the best response by the nurse? A. This medication will coat the lining of your esophagus B. Antacids will neutralize the acid in your stomach C. It will improve the emptying of food through your stomach D. antacids decrease the production of gastric secretions

Antacids will neutralize the acid in your stomach.

Phenytoin

Anticonvulsant

Risperdal (antipsychotic)

Doses over 6 mg can cause tardive dyskinesia (used as the 1st line antipsychotic in children)

622. A male client with cancer, who is receiving antineoplastic drugs, is admitted to the...what findings is most often manifest this condition? A. Ecchymosis and hematemesis B. Weight loss and alopecia C. Weakness and activity intolerance D. Sore throat and fever

Ecchymosis and hematemesis.

An emergency department (ED) nurse working triage has assessed four clients. Which client should receive the highest priority?

Elderly client who moans when the nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds. This client is responding to verbal stimuli by moaning and has an open airway; but any client with an altered level of consciousness is at risk for airway obstruction. The skin assessment indicates a circulation problem.

Two days after a myocardial infarction, a client begins reporting orthopnea and dyspnea. Further assessment reveals bi-basilar crackles, jugular venous distension, an S3 heart sound, a BP of 100/60 mm Hg, and apical pulse of 90 beats per minute. The urine output has steadily declined over the past 12 hours. What should the nurse do first?

Elevate the head of the bed first. The client is reporting inability to breathe. (Orthopnea means the client needs to sit up to breathe better.) With ANY client having difficulty breathing, the first intervention for the nurse is to sit the client up. This client is showing s/s of heart failure.

764. While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate? A. Blood pressure fluctuations means that the condition has become chronic B. Elevated blood pressure must be anticipated and identified quickly C. Hypotension leading to sudden shock can develop at any time D. Sodium intake with meals and snacks affects the blood pressure

Elevated blood pressure must be anticipated and identified quickly.

674. A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse?

Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer.

The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzheimer's disease. What action should the nurse take? a- Explain that memory loss and confusion are common with vitamin B12 deficiency. b- Ask if the client is experiencing any changes in bowel habits c- Determine if the client is taking iron and folic acid supplements d- Encourage the husband to bring the client to the clinic for a complete blood count.

Explain that memory loss and confusion are common with vitamin B12 deficiency Rationale: Pernicious anemia is related to the absence of intricic factor in gastric secretions, leading to malabsorption of vit B12, and commonly causes memory loss, confusion and cognitive problems, and GI manifestations. The nurse should reassure the husband that the client's signs are consistent with the primary disease. Although B, C and D provide additional information about the client's compliance and response to therapy, a quick and dramatic response can occur after 72 hrs. of B12 injections.

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history? a- Genetically inherited disorders of family members b- Length and frequency of the client's tobacco use. c- Ingestion of selfish or fish oil capsules daily. d- Frequency of laxative use for chronic constipation

Frequency of laxative use for chronic constipation

ICP AND SHOCK HAVE OPPOSITE V/S

ICP- Increased BP, decreased pulse, decreased resp Shock--Decreased BP, increased pulse, increased resp

anytime you see fluid retention think

Heart Problems First!

SNS

Increase in BP, HR and RR (dilated bronchioled), dilated pupils (blurred vision), Decreased GUT (urniary retention), GIT (constipation), Constricted blood vessels and Dry mouth.

blood tests for MI

Myoglobin, CK and Troponin

An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? a- Auscultate for renal bruits b- Obtain a clean catch mid-stream specimen c- Use a dipstick to measure for urinary ketone d- Begin to strain the client's urine.

Obtain a clean catch mid-stream specimen

Battles sign and racoons eyes s/s of

Orbital fracture

Best time to take Growth Hormone ____, Steroids ___, Diuretics ___, Aricept ___

PM AM AM AM

Murphy's sign

Pain with palplation of gall bladder (seen with cholecystitis)

With chronic pancreatitis

Pancreatic enzymes are given with meals

morphine is contraindicated in

Pancreatitis (it causes spasm of the Sphincter of Oddi). Therefore Demerol should be given.

The nurse is caring for a client following spinal surgery. The client is placed on methylprednisolone. What additional drug therapy would the nurse expect to be prescribed with methylprednisolone?

Pantoprazole A potential side effect of methylprednisolone is a peptic ulcer. The primary healthcare provider will prescribe a proton pump inhibitor or H2 blocker to prevent this side effect.

Remember compartment syndrome is an emergency situation.

Paresthesias and increased pain are classic symptoms. Neuromuscular damage is irreversible 4-6 hours after onset

BOTOX for strabismus

Patch the GOOD eye so that the weaker eye can get stronger.

712. While assisting a male client who has muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement? a- Administer a PRN dose of pain medication b- Place a portable toilet next to the bed c- Restrict activity to complete bed rest d- Evaluate the client's leg muscular strength.

Place a portable toilet next to the bed. Rationale: Due to the contractures and muscle weakness that progress with MD, the client's awkward movements and clumsiness is an expected sequela. Using assistive devices, such as bedside toilet, should be implement to help limit the client's frustration and ensure client safety, Discomfort is constant and may not always require pain medication (A). Activity should be encouraged (C) as long as the client is capable. (D) should be implemented before mobilizing the client.

739. The nurse is collecting sterile sample for culture and sensitivity from a disposable three chamber water-seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system? A. Stopper port located above the water-seal level B. Plastic tubing located at the chest insertion site C. Rubberized port at the bottom of collection chamber D. Tubbing located on the top of the suction chamber

Plastic tubing located at the chest insertion site.

A new admit arrives to the nursing unit with one thousand dollars in cash. What would be the best action by the nurse to safeguard the client's money?

Put itemized cash in envelope and place in hospital safe.

784. An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping, and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal? A. Bring the client to the team meeting to discuss the treatment plan B. Ask the client to write feeling in a journal and then review it together C. Explain the purpose of each medication the client is currently taking D. Play a board game with the client and begin taking about stressors

Play a board game with the client and begin taking about stressors.

A healthy newborn has just been delivered and placed in the care of the nurse. What nursing actions should the nurse initiate? Place in the correct priority order. Assess newborn's airway and breathing. Bulb suction excessive mucus. Assess newborn's heart rate. Place identification bands on newborn and mom. Administer sterile ophthalmic ointment containing 0.5% erythromycin.

Remember Maslow's hierarchy of needs will guide your assessment. First, Assess newborn's airway and breathing. The most critical change that a newborn must make physiologically is the initiation of breathing. The nurse should assess the newborn's crying. If the cry is weak, it may indicate a respiratory disturbance. Other signs of respiratory compromise may include: stridor, grunting, retractions, apnea or diminished breath sounds. Normal respiration are 30 - 60 breaths a minute. Second, Bulb suction excessive mucus. It is important to assure that the throat and nose are kept clean of secretions to prevent respiratory distress. Third, Assess newborn's heart rate. If there is no respiratory distress, the nurse continues the assessment by checking the heart rate and other vital signs. Fourth, Place identification bands on newborn and mom. These are critical for ensuring babies and moms will be appropriately matched at all times but does not take priority over respiration and circulation. Fifth, Administer sterile ophthalmic ointment containing 0.5% erythromycin. This is a legally required prophylactic eye treatment to prevent Neisseria gonorrhea. However, this would never be a priority over Maslow's hierarchy of needs.

Heart defects

Remember for cyanotic -3T's( Tof, Truncys arteriosus, Transposition of the great vessels). Prevent blood from going to heart. If problem does not fix or cannot be corrected surgically, CHF will occur following by death.

624. The nurse observes an adolescent client prepare to administer a prescribed corticosteroid medication using a metered dose inhaler as seen in the picture. What action should the nurse take? A. Remind the client to hold his breath after inhaling the medication B. Confirm that the client has correctly shaken the inhaler C. Affirm that the client has correctly positioned the inhaler D. Ask the client if he has a spacer to use for this medication

Remind the client to hold his breath after inhaling the medication.

A nurse invites a friend home one evening. On arrival, the friend sees the nurse's large, white, long-haired cat sitting on the couch and begins to experience palpitations, trembling, nausea, shortness of breath, and a feeling of losing control. What should the nurse do first?

Remove the source of the panic attack first, then continue to assess the person for symptoms. Removing the cat "fixes" the problem.

Fluid volume overload caused by IV fluids infusing too quickly and CHF can cause an

S3

668. A client with multiple sclerosis (MS) is admitted to the medical unit. The client reports...which action should the nurse implement to reduce the client's risk for falls?

Schedule frequent rest periods. Provide assistance to bedside commode. Teach to patch one eye when ambulating.

Guthrie test

Tests for PKU. Baby should have eaten protein first

Which nursing task would be appropriate to delegate to an LPN/VN

The LPN/VN has the knowledge and skill to obtain a wound culture. This is within the scope of practice for the LPN/VN.

The nurse is caring for a client who is to receive an IV infusion of heparin. The client's dose is based on a sliding scale prescription. What is the priority lab value to check before initiating the heparin infusion? 1. PT and/or INR 2. aPTT 3. Platelet count 4. WBC count

The activated partial thromboplastin time (aPTT) is a lab value used to assess pathways in the clotting cascade and is used to monitor Heparin therapy in clients. To maintain a therapeutic level of Heparin, the aPTT should be maintained at 1.5-2.5 times the normal range.

619. The husband of a client with advanced ovarian cancer wants his wife to have every treatment available. When the husband leaves, the client tells the nurse that she has had enough chemotherapy and wants to stop all treatments but knows her husband will sign the consent form for more treatment. The nurse's response should include which information? a- The husband cannot sign the consent for the client, her signature is required b- The client's specific wishes should be discussed with her healthcare provider c- Counseling should be sought to resolve the husband's desire to control his wife d- The healthcare team will formulate a plan of care to keep the client comfortable e- The client should seek a second medical opinion before deciding to stop treatment.

The husband cannot sign the consent for the client, her signature is required. The client's specific wishes should be discussed with her healthcare provider. The healthcare team will formulate a plan of care to keep the client comfortable.

The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider?

Weight gain of 5 pounds in one week is a s/s of an adverse effect of ACE inhibitor use. Weight gain is a sign of fluid retention. Angioedema is an adverse effect of ACE inhibitors and can be life threatening. This should be reported immediately to the healthcare provider. The potassium level is too high. Hyperkalemia is an adverse effect of an ACE inhibitor and needs to be reported.

615. The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer? A. What food does your baby usually eat in a normal day? B. What was the baby's weight at the last well-baby clinic visit? C. The baby is below the normal percentile for weight gain D. Your baby is gaining weight right on schedule

What food does your baby usually eat in a normal day?

675. A mother calls the nurse to report that at 0900 she administered a PO dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine, what instruction should the nurse provide to this mother?

Withhold this dose.

epi is always given in

a TB syringe

Diazepam is

a commonly used tranquilzer given to reduce anxiety before operating room

autonomic dysreflexia (life threatening inhibited sympathetic response of nervous system to a noxious stimulus - patients with spinal cord injuries at T7 or above) is usually cause by

a full bladder

Undescended testes or cryptochidism is

a known risk factor for testicular cancer later in life. Start teaching boys testicular self exam around 12, because most cases occur during adolescence.

Myasthenia Crisis

a positive reaction to Tensilon---will improve symptoms

683. A middle-aged woman, diagnosed with Graves' disease, asks the nurse about this condition. Which etiological pathology should the nurse include in the teaching plan about hyperthyroidism? (Select all that apply.) A. Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors. B. T3 and T4 hormone levels are increased C. Large protruding eyeballs are a sign of hyperthyroid function D. Weight gain is a common complaint in hyperthyroidism E. Early treatment includes levothyroxine (Synthroid).

a-Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors. b-T3 and T4 hormone levels are increased. c-Large protruding eyeballs are a sign of hyperthyroid function.

Med of choice for SVT

adenosine or adenocard

DOA

dead on arrival

All psych meds' (except Lithium) side effects are the same as SNS (sympathetic nervous system) but the BP is

decreased

caput succedaneum

diffuse edema of the fetal scalp that crosses the suture lines. reabsorbs within 1 to 3 days

Potassium potentiates

digoxin toxicity

Do vitals before administering

digoxin. Apical pulse for one minute.

LLQ

diverticulitis , low residue, no seeds, nuts, peas

INH, used to treat and prevent TB

do not give with dilantin, can cause phenytonin toxicity, monitor LFTs (liver function tests), give B6 along with, hypotension will occur initially then resolve

After Supratentorial Surgery (incision behind hairline)

elevate HOB 30-45 degrees

Buck's Traction (skin traction)

elevate foot of bed for counter-traction

Above Knee Amputation

elevate for first 24 hours on pillow, position prone daily to provide for hip extension.

A patient with liver cirrhosis and edema may ambulate, then sit with legs

elevated to try to mobilize the edema

COPD is chronic, pneumonia is acute.

emphysema and bronchitis are both COPD

intussusception is common in kids with CF. Obstruction may cause

fecal emesis, currant jelly-like stools (blood and mucus). A barium enema may be used to hydrostatically reduce the telescoping. Resolution is obvious, with onset of bowel movements

russell traction

femur or lower leg

The nurse is providing post-operative care to the craniotomy client. Hourly urinary output increases from 100 mL last hour to 500 mL this hour. What action by the nurse takes priority?

we are "worried" this client is going into SHOCK due to diabetes insipidus. So, you better be checking a BP. This is a time where checking the BP is appropriate. If we "assume the worst" I better check a blood pressure. It could have dropped out the bottom.

Place a wheelchair parallel to the bed on the side of

weakness

Cerebral angio prep

well hydrated, lie flat, site shaved, pulses marked. Post--keep flat for 12-14 hr. check site, pulses, force fluids.

Decerebrate posturing

when the client is stimulated, and teeth clench and the arms are stiffly extended, adducted, and hyperpronated. The legs are stiffly extended with plantar flexion of the feet. Abnormal extension occurs with lesions in the area of the brain stem.

for a CABG operation

when the great saphenous vein is taken it is turned inside out due to the valves that are inside

Sepsis and anaphylaxis (along with the obvious hemorrhaging) reduce circulating volume by way of increased capillary permeability,

which leads to reduced preload (volume in the left ventricle at the end of diastole).

Do not use why or I understand statement when dealing ?

with patients

Serum acetone and serum ketones rise in DKA. As you treat the acidosis and dehydration expect the potassium to drop rapidly, so be ready,

with potassium replacement.

For any kind of bad fetal heart rate pattern

you give O2, often by mask...

Never release traction UNLESS

you have an order from the MD to do so

when drawing an ABG

you need to put the blood in a heparinized tube, make sure there are no bubbles, put on ice immediately after drawing, with a label indicating if the pt was on room air or how many liters of O2. Remember to preform the Allen's Test prior to doing an ABG to check for sufficient blood flow

767. An elderly male client is admitted to the urology unit with acute renal failure due to a post-renal obstruction. Which questions best assists the nurse in obtaining relevant historical data? A. "Have you had a heart attack in the last 6 months" B. "Have you had any difficulty in starting your urinary stream" C. "Have you taken any antibiotics recently" D. "Have you received any blood products in the last year"

"Have you had any difficulty in starting your urinary stream".

626. A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother...During the assessment, the mother asks the nurse why her child is at the 5th percent...response is best for the nurse to provide? A. Does your child seem mentally slower than his peers also? B. "His smaller size is probably due to the heart disease" C. Haven't you been feeding him according to recommended daily allowances for children? D. You should not worry about the growth tables. They are only averages for children

"His smaller size is probably due to the heart disease".

732. An adolescent, whose mother recently died, comes to the school nurse complain headache. Which statement made by the students should warrant further explanation nurse? A. "I've had dreams about Mom since she died." B. "I've been very sad and cry a lot at night." C. "I miss Mom and would like to go see her'". D. " it's hard to concentrate on my homework"

"I miss Mom and would like to go see her'".

680. While the school nurse is teaching a group of 14-year-olds, one of the participants remarks, "You are too young to be our teacher! You're not much older than we are!" How should the nurse respond? A. "How old do you think I am?" B. "We need to stay focused on the topic." C. "I think I am qualified to teach this group." D. "Do you think you can teach it any better?"

"We need to stay focused on the topic."

Autonomic dysreflexia

(potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)

hyper reflexes

(upper motor neuron issue "your reflexes are over the top")

Transesophageal fistula (TEF)

- Esophagus doesn't fully develop and is a surgical emergency - The 3 C's of TEF in the newborn are: Choking, Coughing, Cyanosis

meningitis

- Kernig's sign (leg flex then leg pain on extension), Brudzinski sign (neck flex = lower leg flex).

Neuroleptic Malignant Syndrome (NMS)

- NMS is like S & M - You get hot (hyperpyrexia) - stiff (increased muscle tone) - Sweaty (diaphoresis) - BP, pulse and resp go up - Start to drool

Tardive Dyskinesia

- irreversible - involuntary movements of the tongue, face and extremities, may happen after prolonged use of antipsychotics

Diabetic ketoacidosis (DKA)

- when body is breaking down fat instead of sugar for energy. Fats leave ketones (acids) that cause pH to decrease. - rare in diabetes mellitus type II because there is enough insulin to prevent breakdown of fats.

Amphojel (aluminum hydroxide)

-treatment of GERD and kidney stones -watch for constipation

4 year old kids cannot interpret TIME

. Need to explain time in relationship to a known COMMON EVENT (eg: "Mom will be back after supper").

INtal, an inhaler used to treat allergy induced asthma may cause bronchospasm, think

... INto the asthmatic lung

Lithium

0.5-1.5

A client asked the nurse what could have caused them to develop right sided heart failure? What would be the best response by the nurse? 1. High blood pressure in the lungs. 2. Long term hypertension. 3. The inability of the mitral valve to close properly. 4. Narrowing of the aorta.

1

A client diagnosed with glomerulonephritis presents with generalized malaise, weight gain, generalized edema, and flank pain. The primary healthcare provider prescribes antibiotics and strict bedrest. What is the best explanation to give the client regarding the strict bedrest prescription? 1. Promotes diuresis 2. Prevents injury 3. Promotes rest 4. Stimulates RBC production

1

A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. EGD, colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the symptoms. The client tells the nurse, "The doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad some times that I can't function!" What is the nurse's most appropriate response? 1. "The pain you feel is real." 2. "The primary healthcare provider is right. Your pain is not real." 3. "Let me get you an appointment with the psychiatrist." 4. "Don't worry. Everything will be ok."

1

A client suffers from migraine headaches. What assessment finding would the nurse expect to find during a migraine attack? 1. Unilateral, pulsating pain quality. 2. Bilateral, pressing/tightening pain quality. 3. Ipsilateral nasal congestion and rhinorrhea. 4. Headache occurs after recovering from a headache treated with narcotics.

1

A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first to assure that the client's request is respected? 1. Ensure a do-not-resuscitate prescription has been provided. 2. Report client wishes during the end-of-shift report. 3. Have the client sign an advanced directive. 4. Ask the client who holds the durable power of attorney for health care decisions.

1

A client, who only speaks Spanish, is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure? 1. Use an audiotape made in Spanish to inform the client of the pre-surgical procedure. 2. Draw pictures of what the client can expect prior to surgery. 3. Facial expressions and gestures can be used to let the client know what to expect. 4. Enlist the help of a Spanish speaking family friend to tell the client what to expect prior to surgery.

1

A homebound client lives alone, has a history of poorly controlled diabetes, and has an open wound on the left heel. The home health nurse is concerned about the client's condition and the possible need for a referral. Which intervention should the nurse initiate for this client? 1. Ask the primary healthcare provider to prescribe a diabetes educator consult. 2. Increase home health visits to monitor the healing process of the open wound. 3. Suggest nursing home placement to the family until wound has healed. 4. Suggest that the client's family hire sitters to assist with hygiene care.

1

A new mother brings her infant to the clinic for a well-baby checkup. While at the clinic, the mother asks the nurse if there are any reasons why her infant should not have the measles, mumps, rubella (MMR) vaccine. The nurse's response is based on evidence that the MMR vaccine is contraindicated under which condition? 1. A known allergy to gelatin. 2. A family history of autism. 3. In infants with diarrhea. 4. A known allergy to sulfonamides.

1

A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client should the charge nurse assign to the neonatal nurse? 1. Undergoing surgery for placement of a central venous catheter. 2. Diagnosed with leukemia, hospitalized for induction of high-dose chemotherapy. 3. Receiving IV heparin for left leg thrombosis. 4. Admitted with a cerebrovascular accident.

1

An 82 year old client tells the nurse at the clinic, "I have lived a good, successful life and married my best friend". Which of Erikson's developmental tasks does the nurse recognize that this client has probably accomplished? 1. Ego Integrity versus Despair 2. Generativity versus Stagnation 3. Intimacy versus Isolation 4. Industry versus Inferiority

1

The nurse is planning care for a pediatric client reporting acute pain with sickle cell crisis? What should the nurse identify as an appropriate goal for this client? 1. Client will report a pain level of less than 2 on a Faces scale. 2. The nurse will administer prescribed pain meds around the clock. 3. Client will only take breakthrough pain medication. 4. Client will use distraction instead of pain medication.

1

Two hours after a gastrectomy, a client has pink tinged drainage from the nasogastric (NG) tube, and the tube appears occluded. What is the nurse's initial action at this time? 1. Call the primary healthcare provider. 2. Reposition the client. 3. Increase the suction level. 4. Irrigate the tube.

1

What is the best instruction the nurse should provide when administering acetylsalicylic acid 81 mg to a client experiencing severe, crushing chest pain radiating up the left jaw? 1. Chew the acetylsalicylic acid prior to swallowing. 2. Place the acetylsalicylic acid under the tongue so that it can dissolve. 3. Swallow the acetylsalicylic acid tablet. 4. Insert the acetylsalicylic acid between the cheek and gum for greater absorption.

1

blood transfusion sign of allergies in order

1)Flank pain 2)Frequent swallowing 3)Rashes 4)Fever 5)Chills

An RN on the general pediatric unit has been reassigned to the spinal/neurology unit. What assignment by the charge nurse would be appropriate for this RN? 1. Child with spina bifida with a previous shunt revision 2. Adolescent who is 4 days post op from a spinal fusion 3. Child with a ventriculoperitoneal shunt one day post-op 4. Child with spinal muscle atrophy who is ventilator assisted 5. Child with cerebral palsy who had a tracheostomy performed this AM

1,2

Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection? 1. Cleans perineum from front to back after newborn soils diaper. 2. Makes certain the umbilical cord remains dry with each diaper change. 3. Places the top of the diaper just above the umbilicus. 4. Wraps sterile petroleum gauze around umbilical cord. 5. Submerges newborn in warm water up to the chest for first bath.

1,2

The charge nurse is making assignments for one RN and one LPN/VN on a pediatric unit. Which clients would be most appropriate for the charge nurse to assign to the RN? 1. 2 year old with asthma receiving IV medication. 2. 6 year old with new onset seizures. 3. 12 year old with colitis receiving TPN. 4. 2 month old with urinary tract infection. 5. 10 year old paraplegic needing assistance with bowel training.

1,2,3

The nurse is planning health promotion strategies for a single parent of young children who is trying to increase personal physical activity level but expresses a lack of time. Which interventions would help the client get more regular physical activity into the day? 1. Suggest walking up and down steps at home several times each morning and evening. 2. Suggest parking further away from the grocery store and work. 3. Walk with the children in the evening instead of watching TV with them. 4. Suggest waking one hour earlier in the morning to go to the gym. 5. Suggest walking for 30 minutes with a buddy each afternoon before leaving work.

1,2,3

The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which clients would be appropriate for the nurse to assign to the LPN/VN? 1. In Bucks traction requiring frequent pain medication. 2. 24 hours post appendectomy. 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM. 4. Admitted 6 hours ago in adrenal insufficiency. 5. Client newly diagnosed with Type 2 diabetes.

1,2,3

What information should a nurse include when educating a client regarding buccal administration of a medication? 1. This route allows the medication to get into the blood stream faster than the oral route. 2. Stinging may occur after placing the medication in the cheek. 3. If swallowed, the medication may be inactivated by gastric secretions. 4. The buccal dose of medication will need to be increased from the oral dose. 5. Remove the tablet from buccal area after 15 seconds.

1,2,3

What should the nurse tell the parents of a newborn about a Guthrie test? 1. The purpose of this test is to determine the presence of phenylalanine in the blood. 2. A positive test indicates a metabolic disorder. 3. To conduct this test, a sample of blood is taken from the baby's heel. 4. An increase in protein intake can interfere with the test. 5. This test will be done when your baby is 6 weeks old.

1,2,3

A client arrives at the emergency department after sustaining partial and full-thickness burns over the anterior neck, chest, and right arm. Which interventions will the nurse initiate? 1. Administer oxygen 2. Start two intravenous lines 3. Remove necklace 4. Elevate right arm 5. Debride wounds

1,2,3,4

A nurse is caring for a client admitted with chronic fatigue and weakness. During the physical assessment, the nurse notes jaundiced sclera, abdominal distension, swelling in the legs and ankles, and bruises in various stages of healing throughout the body. What nursing interventions should the nurse initiate? 1. Measure abdomen 2. Monitor intake and output 3. Obtain daily weight 4. Place on fall precautions 5. Provide three meals per day 6. Dangle legs

1,2,3,4

A nurse is planning to provide an education class on preconception health care to a group of young women wishing to become pregnant. What points should the nurse include in this class? 1. Attain a healthy weight. 2. Make sure immunizations are up to date. 3. Avoid drinking alcohol. 4. Learn family health history. 5. Maintain folic acid intake at 200 micrograms/day.

1,2,3,4

A school nurse is teaching a group of preteens with acne how to care for the skin. What points should the nurse include? 1. Wash face with soap and warm water. 2. Avoid using oily creams. 3. Do not use cosmetics that block sebaceous gland ducts. 4. Do not squeeze lesions. 5. Clean face vigorously with a terrycloth.

1,2,3,4

What measures should the unit nurse initiate after admitting a client who had a chest tube inserted for pleural effusion of the right lung? 1. Place in semi-Fowler's position. 2. Connect to oxygen saturation monitor. 3. Assess respiratory status every 2 hours. 4. Prevent dependent loops in closed drainage unit tubing. 5. Maintain closed drainage unit at the level of the client's chest.

1,2,3,4

Which interventions should be included in the plan of care for an adult client with constipation? 1. Allow adequate time for defecation. 2. Provide privacy for bowel elimination. 3. Suggest increasing fluid intake (unless contraindicated). 4. Encourage client to increase fiber in the diet. 5. Encourage the client to delay the urge to defecate until after a meal.

1,2,3,4

Which interventions should the nurse initiate to lessen acid reflux in a client diagnosed with gastroesophagel reflux disease (GERD)? 1. Provide small, frequent meals. 2. Avoid carbonated beverages. 3. Administer omeprazole as prescribed. 4. Assist with smoking cessation. 5. Place in left lateral position for 2 hours after eating.

1,2,3,4

A nurse has just inserted an indwelling urinary catheter in a client scheduled for surgery. What should the nurse document? 1. Perineal skin assessment 2. Client teaching 3. Color of urine 4. Date and time of insertion 5. Type catheter inserted 6. Infusing rate of IV fluid

1,2,3,4,5

A client is preparing to be discharged after a total hip replacement. Which statements, if made by the client, would indicate to the nurse that teaching has been successful regarding prevention of hip prosthesis dislocation? 1. I should not cross my affected leg over my other leg. 2. I should not bend at the waist more than 90 degrees. 3. While lying in bed, I should not turn my affected leg inward. 4. It is necessary to keep my knees together at all times. 5. When I sleep, I should keep a pillow between my legs.

1,2,3,5

A home health nurse inspects the home of a client scheduled to be discharged home after receiving care for a cerebrovascular accident with generalized weakness. What safety interventions should the nurse recommend based on findings within the home? Exhibit 1. Place ramp over the front steps. 2. Move client's bedroom downstairs. 3. Remove throw rugs. 4. Secure furniture so client can use for support. 5. Apply nonskid strips to shower stall.

1,2,3,5

During an assessment interview with a client, what alternative healing modalities should the nurse inquire about? 1. "Tell me about your use of teas, herbs, and vitamins." 2. "What traditional or folk remedies are used in your family?" 3. "Do you meditate, pray, or use relaxation techniques for healing purposes?" 4. "What prescription medications are you taking?" 5. "What alternative therapies have you used?"

1,2,3,5

The nurse is caring for a client admitted to the psychiatric unit with a diagnosis of major depression. What behaviors could the nurse expect upon assessment of this client? 1. Withdrawn behavior 2. Sitting in room, lights out, drapes closed 3. Unkempt appearance 4. Overeating 5. Severe insomnia

1,2,3,5

The nurse is working with a committee at the local school to develop an emergency preparedness plan for tornados. What should be included in the plan? 1. Identification of safe zones. 2. Methods for accounting for all people present in the building. 3. Warning system activation. 4. Identification of the gymnasium as the routine safe place. 5. Regular practice protocols.

1,2,3,5

What should the nurse teach a pregnant client who comes to the clinic reporting hemorrhoids and constipation? 1. Increased rectal pressure from the gravid uterus may result in hemorrhoids. 2. Hormones decrease maternal GI motility, resulting in constipation. 3. The client needs more fiber in the diet. 4. A mild laxative is recommended to alleviate constipation. 5. The client needs to increase fluid intake. Rationale

1,2,3,5

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client? 1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen

1,2,4,5

A client diagnosed with rheumatoid arthritis has been prescribed celecoxib. What should the nurse include in the client's education regarding this medication? 1. Do not take celecoxib with ibuprofen. 2. GI complaints and headache are among the most common side effects. 3. Drink a lot of water to offset the dehydration that may occur. 4. Notify the healthcare provider immediately if black stools are noted. 5. This medication provides relief of pain and swelling so you can perform normal daily activities.

1,2,4,5

A nurse is planning to provide information regarding suicide to a high school assembly. What information should the nurse include? 1. Do not keep secrets for the suicidal person. 2. Express concern for a person expressing thoughts of suicide. 3. Teens often don't mean what they say, so only take suicide seriously if grades are dropping as well. 4. Inform group of suicide intervention sources. 5. Do not leave a suicidal person alone.

1,2,4,5

A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions for at risk clients. What steps should the QA manager include in this evaluation? 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Poll staff to identify what fall precautions are implemented for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.

1,2,4,5

An elderly client arrives in the emergency department (ED) after a fall. What assessment findings would lead the nurse to suspect that the client has a fractured right hip? 1. Severe pain in the right hip and groin. 2. Inability to bear weight on the right leg. 3. Right leg slightly longer in length than the left leg. 4. External rotation of right lower leg. 5. Bruising and swelling around the right hip.

1,2,4,5

The home care nurse visits a client who has moderate cognitive impairment and whose family provides care for the client. Which suggestions would be helpful for this family to reduce the risk of injury? 1. Suggest that the family lock up medications and poisons and keep the keys. 2. Encourage the family to place locks high on the door frame to make it difficult for the client to leave. 3. Suggest that the family talk with the client weekly about safety issues around the house. 4. Suggest that the family remove knobs from stove when not in use. 5. Keep fire extinguishers present and in working order.

1,2,4,5

The nurse is teaching parents of a school aged child about interventions to keep the child safe. Which interventions would be appropriate to include in the health promotion plan? 1. Encourage bicycle helmet use when riding bikes. 2. Teach children to swim at an early age. 3. Use booster seats until the child is at least 6 years old. 4. Keep firearms in the home locked and unloaded. 5. Teach "stop, drop, and roll" in case clothing catches on fire.

1,2,4,5

The nurse is teaching the client about benzodiazepines. Which comments by the client indicate adequate understanding of the drug effects/side effects? 1. I should not drive my car until I see how the medication affects me. 2. I can expect my reaction time to be slowed in the beginning. 3. I may need to double the dose if I continue to be anxious. 4. I must be careful to take the medication for a limited time. 5. There is a risk for dependence on this medication.

1,2,4,5

What should a nurse teach family members prior to them entering the room of a client who has agranulocytosis? 1. Meticulous hand washing is needed. 2. Do not visit if you have any infection. 3. The client must wear a mask. 4. Children under 12 may not visit. 5. Flowers are not allowed in the room.

1,2,4,5

What statements by a client diagnosed with a hiatal hernia would indicate to the nurse that the discharge teaching was effective? 1. "I should eat six small meals a day." 2. "Sitting up for an hour after I eat will decrease symptoms." 3. "Eating a grapefruit for breakfast will help digest the rest of my food." 4. "Ten inch blocks need to be placed under the head of my bed." 5. "I will get assistance for lifting heavy objects." 6. "I will avoid using laxatives."

1,2,4,5

While examining a client's health history, which data indicates to the nurse that the client is at increased risk for developing cancer? 1. Family history 2. Alcohol consumption 3. Spicy diet 4. Human papillomavirus 5. Tobacco use

1,2,4,5

A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar with this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the nurse expect on assessment? 1. Fever and shivering 2. Agitation 3. Decreased body temperature 4. Constipation 5. Increased heart rate

1,2,5

A client with a history of command hallucinations was admitted to the hospital yesterday. What questions are most important for the nurse to ask? 1. "Are you hearing voices today?" 2. "What are the voices saying?" 3. "How are you feeling today?" 4. "Did you have difficulty sleeping last night?" 5. "Are the voices telling you to harm yourself or anyone else?"

1,2,5

The nurse is advising the family of a client receiving palliative care on alternative methods for pain control to be used in conjunction with pain medications. Which method should the nurse include? 1. Providing a back massage 2. Administering pain medication when pain is rated at 5 out of 10 3. Distracting with music 4. Exercise 5. Prayer

1,2,5

The nurse is caring for a client on the psychiatric unit with a diagnosis of obsessive-compulsive disorder. The client has frequent hand washing rituals. Which nursing interventions would be advisable for this client? 1. Allow time for ritual. 2. Provide positive reinforcement for nonritualistic behavior. 3. Provide a flexible schedule for the client. 4. Remove all soap and water sources from the client's environment. 5. Create a regular schedule for taking client to bathroom.

1,2,5

Which immunizations obtained by the age of two would indicate to the pediatric nurse that the child is up-to-date on immunizations? 1. Diptheria-tetanus-pertussis (DTaP). 2. Inactivated polio (IPV). 3. Herpes zoster. 4. Meningococcal 5. Haemophilus influenza type B (Hib).

1,2,5

Which interventions should the nurse include when planning care for a client diagnosed with paranoid personality? 1. Develop a trusting relationship. 2. Be honest when communicating with the client. 3. Encourage the client to participate in group therapy. 4. Encourage the client to clean the day room daily. 5. Give clear explanations of procedures before hand.

1,2,5

Which tasks would be appropriate for the nurse to assign to an LPN/VN? 1. Changing a colostomy bag. 2. Administer antibiotic via intravenous piggyback (IVPB). 3. Teach insulin self administration to a diabetic client. 4. Administer IV pain medication to a two day post op client. 5. Check for urinary retention. 6. Remove wound sutures.

1,2,5,6

An adult client has just returned to the nursing care unit following a gastroscopy. Which intervention should the nurse include on the plan of care? 1. Vital sign checks every 15 min x 4 2. Supine position for 6 hours 3. NPO until return of gag reflex 4. Irrigate NG tube every 2 hours 5. Raise four siderails

1,3

The nurse is caring for a client in an outpatient clinic. The client is being treated with warfarin for prevention of a stroke due to atrial fibrillation. The international normalized ratio (INR) was noted to be 4.6. What should the nurse do? 1. Inform the primary healthcare provider immediately. 2. Instruct the client to continue medication as ordered. 3. Inform the client to watch for signs of bleeding. 4. Inform the client to return to the clinic per routine monitoring schedule. 5. Take no action as this value is within target range.

1,3

The nurse is caring for a client with hyperparathyroidism. The nurse will monitor the client for which complications? 1. Kidney stones 2. Diarrhea 3. Osteoporosis 4. Tetany 5. Fluid volume deficit

1,3

Which assignment would be most appropriate for the charge nurse to assign to the LPN/VN in the Labor, Delivery, Recovery and Postpartum Unit (LDRP)? 1. Primipara needing assistance with breastfeeding. 2. Multipara reporting a headache and epigastric discomfort. 3. Primipara who is two days post op cesarean section. 4. Primipara who is preeclamptic in active labor. 5. Multipara post op cesarean section with a PCA pump.

1,3

The nurse is caring for a client who has just arrived at the emergency department with suspected acute myocardial infarction. Which medications should the nurse administer immediately? 1. Oxygen 2. Heparin 3. Morphine 4. Sublingual nitroglycerin 5. Furosemide

1,3,4

A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual? 1. Attend an activity with the client who is reluctant to go alone. 2. Allow the client to break an insignificant rule. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when the client is hungry.

1,3,4,5

A nurse is instructing a client who had a cesarean birth 2 days ago about adverse signs that should be reported to the primary health care provider. Which signs should the nurse include? 1. Fever greater than 100.4° F (38° C) for 2 or more days. 2. Change in lochia from rubra to serosa. 3. Calves with localized pain, redness, and swelling. 4. Burning with urination. 5. Feeling of apathy toward newborn. 6. Able to provide self care.

1,3,4,5

The parents of a 4 year old child are concerned about whether the child will adapt to the newborn baby they are expecting in two weeks. What suggestions should the nurse make to assist with sibling adaptation? 1. Allow child to be one of the first to see the newborn. 2. Have child stay with parents during labor and delivery. 3. Arrange for one parent to spend time with the child while the other parent cares for the newborn. 4. Provide a gift from the newborn to give to the child. 5. Have child care for a doll.

1,3,4,5

The primary healthcare provider is preparing to drain a large abdominal abscess. The client has dementia and moves about on the bed frequently. Which personal protective equipment (PPE) should the nurse wear while holding the client for the procedure? 1. Face shield 2. Sterile Gloves 3. Gown 4. Mask 5. Regular exam gloves

1,3,4,5

The public health nurse is planning to participate in local forums regarding the placement of a factory that is known to produce pollution through discharge of chemical by-products into the air. What actions demonstrate ethical nursing practice in the public health arena? 1. Speaking up for the underrepresented, such as the poor and uneducated persons. 2. Encouraging community leaders to accept placement of the factory. 3. Requesting that forums be held throughout the community at various times of the day or evening. 4. Asking for information regarding the health status of people in other factory locations. 5. Requesting information from individuals in areas where the factories are currently located.

1,3,4,5

To reduce the risk of developing a complication following balloon angioplasty, the nurse should implement which measure? 1. Monitor cardiac rhythm 2. Assess the puncture site every 8 hours 3. Measure urinary output hourly 4. Prevent flexion of the affected leg 5. Avoid lifting buttocks off the bed

1,3,4,5

What statements by a new nurse would indicate to the charge nurse an understanding of how to maintain skin integrity for a client on bedrest? 1. "Clients on bedrest should be placed on therapeutic mattresses." 2. "I will assess for the skin every 4 hours." 3. "I will assess the skin using the Braden scale." 4. "A pillow will be placed between the knees when client is side lying." 5. "The incontinent client will be kept clean and dry."

1,3,4,5

What should the nurse include in the post-op care of a client following the removal of the posterior pituitary gland? 1. Monitor intake and output. 2. Restrict fluids to no more than 1500 ml/day. 3. Weigh daily. 4. Monitor urine specific gravity. 5. Assess the level of consciousness (LOC). 6. Instruct client to avoid blowing the nose forcefully.

1,3,4,5,6

A nurse is planning to teach a group of men about their sildenafil prescription. What information should the nurse include? 1. Notify primary healthcare provider if prescribed an alpha-adrenergic blocker. 2. This medication protects against sexually transmitted diseases. 3. Sildenafil should be taken only once per day if needed. 4. This medication is most effective if taken with grapefruit juice. 5. The most common side effects are flushing, headache, and dyspepsia.

1,3,5

A nurse is preparing to conduct a presentation on barriers to therapeutic communication with clients from a culture other than the nurse's culture. Which points should the nurse include in the presentation? 1. Lack of knowledge about a client's culture is a major barrier to therapeutic communication. 2. Follow cultural beliefs when caring for all clients of that particular culture. 3. Ethnocentrism facilitates therapeutic communication. 4. Do not touch the client until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and preferences.

1,4,5

Which statement made by a client post-thyroidectomy would require further investigation by the nurse? 1. "I have a tingling feeling of my fingers." 2. "It hurts when I move my head." 3. "I feel pressure in my arm when you take my blood pressure." 4. "My legs are weak."

1. Correct. After this procedure the nurse should worry about the possibility of some of the parathyroids being accidentally removed with resulting hypoparathyroidism. Hypoparathyroidism results in hypocalcemia. Signs and symptoms include tingling, burning, or numbness of lips, fingers, and toes. The muscles may become tight and rigid, and seizures can result. 2. Incorrect. Pain is expected here. The incision is at the base of the neck, so movement of the head would increase the pain. 3. Incorrect. The sensation of pressure in the arm is considered normal when the BP is being measured. You worry if you see carpal spasm (+ Trousseau's) which is indicative of neuromuscular excitability caused by hypocalcemia secondary to the inadvertent removal of some of the parathyroids. 4. Incorrect. Weak/flaccid extremities would be seen with hyperparathyroidism. In this case, we are concerned that the parathyroids may have been removed, resulting in hypoparathyroidism. The weakness in the legs is apparently from a different cause. However, the signs of possible hypoparathyroidism would be the priority to investigate.

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.

The LPN/VN is preparing to transfer a client from the delivery room to the postpartum unit. Which statement by the client would be the priority for the LPN/VN to notify the charge nurse? 1. "I just felt something gush." 2. "I feel like I am still having contractions." 3. "When I stand up, I feel dizzy for several moments" 4. "My hemorrhoids are hurting."

1. Correct. This could indicate postpartum hemorrhage (PPH) and requires immediate assessment by the nurse. PPH can be caused by the following: placenta previa, cervical lacerations, vaginal tear, or a ruptured or inverted uterus. 2. Incorrect. This is normal postpartum contractions of the uterus to help dispel clots and to return the uterus to normal size. The contractions may occur for several days after delivery. 3. Incorrect. Due to the fluid loss during the delivery, the client may be experiencing orthostatic hypotension. Teach safety measures. Although the LPN would need to inform the charge nurse of this, it is not the priority over the report that may indicate postpartum hemorrhage. 4. Incorrect. The client's hemorrhoids can be painful after delivery. However, this is not the priority to report. Remember, bleeding would be a priority over pain.

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.

The nurse is caring for a client taking a selective serotonin reuptake inhibitor (SSRI). The client tells the nurse "I am sweating more than ever!" What is the nurse's best response? 1. This is a common side effect of antidepressant medications. 2. Excessive sweating can have many causes. 3. You should report this side effect to your primary healthcare provider. 4. This symptom should go away within a few days.

1. Correct: A common side effect of SSRIs is increased sweating. This option gives the client an explanation. 2. Incorrect: This response shows a lack of understanding of the side effects of antidepressant medications. 3. Incorrect: This option does not acknowledge the client's problem and possible causes. 4. Incorrect: Increased sweating may continue throughout treatment with an antidepressant medication.

A client consumes a lacto-ovo vegetarian diet at home. During hospitalization, the primary healthcare provider prescribes an increased calorie diet. Which foods are appropriate for the nurse to serve as between meal snacks to boost caloric intake? 1. Cheese sandwich and milk 2. Boiled eggs but no dairy products 3. Fish sticks and cocktail sausages 4. Fresh vegetables but no milk or eggs

1. Correct: A lacto-ovo vegetarian diet is a vegetarian diet that does not include meat, but does contain eggs and dairy. The client can eat milk and dairy products along with grain products on this diet. 2. Incorrect: Dairy products and eggs are allowed on this diet. Milk, cheese and yogurt can be consumed on a lacto-ovo vegetarian diet. 3. Incorrect: The client does not consume meats. Meats, fish, and poultry should not be provided as a snack. 4. Incorrect: The client can consume milk and eggs as well as fresh fruits and vegetables. Milk and eggs can be consumed on a lacto-ovo vegetarian diet.

The nurse is caring for a client following spinal surgery. The client is placed on methylprednisolone. What additional drug therapy would the nurse expect to be prescribed with methylprednisolone? 1. Pantoprazole 2. Phenytoin 3. Imipramine HCI 4. Aminocaproic acid

1. Correct: A potential side effect of methylprednisolone is a peptic ulcer. The primary healthcare provider will prescribe a proton pump inhibitor or H2 blocker to prevent this side effect. 2. Incorrect: Phenytoin is an anticonvulsant. Seizures are not a side effect of methylprednisolone. 3. Incorrect: Imipramine HCI is an antidepressant which is not routinely given with methylprednisolone (Although mood changes can occur with steroid administration, anti-depressants are not routinely given). 4. Incorrect: Aminocaproic acid is given when clients are bleeding. Bleeding is not a side effect of methylprednisolone.

A nurse is preparing a lecture about suicide. Which target audience would be most appropriate? 1. High school teachers 2. Girl Scout leaders 3. Support group of divorced parents 4. Hispanic immigrant farm workers

1. Correct: Among those who commit suicide, young men between the ages of 15-24 are more likely to commit suicide than young girls and women. The best line of defense is to teach about the warning signs of suicide to high school teachers, students, and parents of teens and young adults, particularly male.2. Incorrect: Although teenage girls may attempt suicide, they are less likely than males to use a lethal method. Additionally, participation in groups such as the scouts will provide support for girls.3. Incorrect: Joining a support group will help eliminate stress of being a single parent. Young males are more likely to attempt suicide by lethal means.4. Incorrect: Hispanics have a lower suicide rate than Caucasians.

Immediately after a liver biopsy, a client is placed on the right side for 60-90 minutes. What is the rationale for placing the client in this position? 1. Helps stop bleeding if any occurs. 2. Restores circulating blood volume. 3. This is the position of greatest comfort. 4. Helps reduce fluid trapped in the biliary ducts.

1. Correct: Anyone who has a liver biopsy is at risk for bleeding. The clotting factors are produced in the liver, as is prothrombin. Any time a needle is inserted into the body and removed, bleeding can occur. Whenever there is a risk for bleeding, the preventive measure is to apply pressure. Lying on the right side applies pressure to the liver. A towel may be rolled up and placed under the right side for added pressure. Again, pick the most life threatening answer. This is what could kill the client. 2. Incorrect: Lying on the right side does not lead to restoration of circulating blood volume. 3. Incorrect: Lying on the right side is not a position of comfort. Applying pressure is the goal, as the client is at risk for bleeding. 4. Incorrect: Lying on the right side does not reduce fluid trapped in the biliary ducts.

A client, who only speaks Spanish, is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure? 1. Use an audiotape made in Spanish to inform the client of the pre-surgical procedure. 2. Draw pictures of what the client can expect prior to surgery. 3. Facial expressions and gestures can be used to let the client know what to expect. 4. Enlist the help of a Spanish speaking family friend to tell the client what to expect prior to surgery.

1. Correct: Audiotapes made in the language of high volume clients who speak a language other than English is helpful to inform clients about admission procedures, room and unit orientation, and pre-surgical procedures. The tapes are received from sources where reliability of information is provided. This is the most reliable option for providing accurate information. 2. Incorrect: This is not the best option. Some pre-surgical procedure may be difficult to draw or difficult for the client to understand what was drawn. There is no way to know if the client is understanding what the nurse is trying to communicate through the pictures. Client safety could be compromised if decisions are made based on inaccurate perceptions. 3. Incorrect: This is called "Getting by" and may have to be used when the nurse cannot speak the client's language, and there are no interpreters, audiotapes, or written materials available to inform the client in their language. This is not the best option and should be used only if other more reliable means for interpreting are not available. 4. Incorrect: Disadvantages of using ad hoc interpreters include compromising the client's right to privacy and relying on someone without training as an interpreter. Due to lack of training or experience, ad hoc interpreters may leave out important words, add words, or substitute terms that make communication inaccurate. This may have to be done at times if tapes or other reliable means of interpreting are not available. However, this is not the best option.

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 glomerulonephritis presents with generalized malaise, weight gain, generalized edema, and flank pain. The primary healthcare provider prescribes antibiotics and strict bedrest. What is the best explanation to give the client regarding the strict bedrest prescription? 1. Promotes diuresis 2. Prevents injury 3. Promotes rest 4. Stimulates RBC production

1. Correct: Bedrest and the supine position promote diuresis. When the client is supine, there is a gradual shift of fluids away from the legs toward the thorax, abdomen and head. This increased volume causes the right atrium of the heart to stretch and release ANP, which leads to diuresis: renal blood flow increases due to vasodilation, and aldosterone and ADH secretion are inhibited. 2. Incorrect: Bedrest can keep the client from falling and injuring self; however, that is not why it has been prescribed. 3. Incorrect: Promotion of rest is good, but this is not why the primary healthcare provider prescribed it. Simply promoting does not help improve the symptoms listed. The reason the client needs bedrest should focus on relieving the symptoms listed in the stem. 4. Incorrect: No relationship between bedrest and red blood cell production exists.

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.

Two hours after a gastrectomy, a client has pink tinged drainage from the nasogastric (NG) tube, and the tube appears occluded. What is the nurse's initial action at this time? 1. Call the primary healthcare provider. 2. Reposition the client. 3. Increase the suction level. 4. Irrigate the tube.

1. Correct: Do not tamper with fresh surgery tubes. Call the primary healthcare provider for blood draining from the NG tube after gastrectomy. 2. Incorrect: This delays care and does not resolve an occluded NG tube. 3. Incorrect: Increasing the suction level is very dangerous for the client. This could cause hemorrhage in this client. Don't be a killer nurse! Call the primary healthcare provider. 4. Incorrect: Although the healthcare provider may prescribe for the tube to be irrigated later, the healthcare provider should be notified of the presence of blood initially. Irrigating the fresh NG tube in this situation could lead to increased bleeding.

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.

An 82 year old client tells the nurse at the clinic, "I have lived a good, successful life and married my best friend". Which of Erikson's developmental tasks does the nurse recognize that this client has probably accomplished? 1. Ego Integrity versus Despair 2. Generativity versus Stagnation 3. Intimacy versus Isolation 4. Industry versus Inferiority

1. Correct: Ego Integrity versus Despair is the major task of those 65 and over: The developmental task for this age involves the individual reviewing one's life and deriving meaning from both positive and negative events, while achieving a positive sense of self. If the individual considers accomplishments and views self as leading a successful life, a sense of integrity is developed. On the contrary, if life is viewed as unsuccessful without accomplishing life's goals, a sense of despair and hopelessness develops. 2. Incorrect: Generativity versus Stagnation is the major task for 40-64 year olds. To achieve the life goals established for oneself while also considering the welfare of future generations. The primary developmental task during this middle age period is one in which the individual contributes to society as well as helping to guide future generations. A sense of generativity (sense of productivity and accomplishment) often results from such things as raising a family and helping to better the society. In contrast, those individuals not willing to work to better society and those who are egocentric and self-centered often develop a sense of stagnation (dissatisfaction and the lack of productivity). 3. Incorrect: Intimacy versus Isolation is the objective from 20-39 year olds to form an intense, lasting relationship or a commitment to another person. If the individual cannot form the intimate relationships (possibly due to personal needs) a sense of isolation may develop which can lead to feelings of depression. 4. Incorrect: Industry versus Inferiority is the major task for 6-12 year olds in which they attempt to achieve a sense of self confidence by learning, competing, performing successfully, and receiving recognition from significant others, peers, and acquaintances. The child must develop the ability to deal with the demands of learning new social and academic skills, or a sense of inferiority, failure, or incompetence may result.

A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most important nursing measure for this client? 1. Observation and support of ventilation 2. Insertion of indwelling urinary catheter 3. Nasogastric suctioning 4. Frequent monitoring of level of consciousness

1. Correct: Guillain-Barre syndrome is an acquired inflammatory disease that results in demyelinization of the peripheral nerves. It is usually ascending in nature and can lead to respiratory paresis or paralysis. 2. Incorrect: Insertion of an indwelling urinary catheter may in fact be necessary but does not prioritize higher than support of ventilation. 3. Incorrect: Nasogastric suctioning is not a need identified with Guillain-Barre syndrome. 4. Incorrect: The client's cognitive function remains intact, and there is no data in the stem of the question that indicates otherwise; therefore, ventilation is the priority. Guillain-Barre does not affect the LOC.

A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most important nursing measure to include in the nursing care plan for this client? 1. Observation and support of ventilation 2. Insertion of indwelling urinary catheter 3. Nasogastric suctioning 4. Frequent assessments of level of consciousness

1. Correct: Guillain-Barre syndrome is an acquired inflammatory disease that results in demyelinization of the peripheral nerves. It is usually ascending in nature and can lead to respiratory paresis or paralysis. 2. Incorrect: Insertion of an indwelling urinary catheter may in fact be necessary but does not prioritize higher than support of ventilation. 3. Incorrect: Nasogastric suctioning is not a need identified with Guillain-Barre syndrome. Guillain-Barre does not affect the LOC. 4. Incorrect: The client's cognitive function remains intact, and there is no data in the stem of the question that indicates otherwise; therefore, ventilation is the priority.

Which comment by the client indicates understanding of possible complications of long term hypertension? 1. "I would like to have my serum creatinine checked at this visit." 2. "My blurred vision is part of getting older." 3. "I have leg pain caused by excessive exercise." 4. "Adding salt to my food is permissible."

1. Correct: Hypertension is one of the leading causes of end stage renal disease. The client understands that renal function is reflected by serum creatinine levels. This request demonstrates understanding of the disease and possible complications. 2. Incorrect: The appearance of the retina provides important information about the severity and duration of hypertension. Manifestations of severe retinal damage include blurred vision, retinal hemorrhage, and loss of vision. 3. Incorrect: Intermittent claudication is a complication of peripheral vascular disease (PVD). Hypertension speeds up the process of PVD. 4. Incorrect: Increasing the salt intake causes an increase in the sodium levels which can reduce the kidney's ability to remove excess fluid. This can result in a worsening of the hypertension. Lifestyle modifications to reduce hypertension include dietary sodium reduction, weight reduction, Dietary Approaches to Stop Hypertension (DASH) eating plan, moderation of alcohol consumption, regular physical activity, avoidance of tobacco use, and management of psychosocial risk factors.

Which action, if done by a new LPN/VN, needs to be interrupted by the precepting LPN/VN? 1. Mixes diazepam and hydromorphone in one syringe. 2. Administers diazepam before meals. 3. Raises side rails after administering hydromorphone. 4. Instructs client to call for assistance getting out of bed after administration of diazepam.

1. Correct: In this question, you are looking for the answer that is unsafe and should not be done. Diazepam cannot be mixed with any other medication. The charge nurse should intervene. 2. Incorrect: This is an appropriate action. Food in the stomach delays absorption of diazepam, so it would need to be given before meals. 3. Incorrect: This would be an appropriate action. Hydromorphone is a narcotic and can decrease level of consciousness (LOC) and increase the risk of falls, so the nurse would be taking appropriate measures to ensure the client's safety. 4. Incorrect: This would be an appropriate action. Diazepam relaxes the muscles, decreases LOC, and can increase the risk of falls.

A client suffers from migraine headaches. What assessment finding would the nurse expect to find during a migraine attack? 1. Unilateral, pulsating pain quality. 2. Bilateral, pressing/tightening pain quality. 3. Ipsilateral nasal congestion and rhinorrhea. 4. Headache occurs after recovering from a headache treated with narcotics.

1. Correct: Migraine headaches have a pulsating pain quality, unilateral location, moderate or severe pain intensity, aggravated by or causing avoidance of routine physical activity (walking, climbing stairs). During headache at least one of the following accompanies the headache: nausea and/or vomiting; photophobia and phonophobia. 2. Incorrect: This is seen in tension headaches. Headaches last 30 minutes to 7 days. Pain is mild or moderate in intensity. It is not aggravated by routine physical activity. Nausea/vomiting, photophobia and phonophobia are not common manifestations with tension headaches. These usually start gradually, often in the middle of the day. 3. Incorrect: This is associated with cluster headaches, which are severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes. Symptoms include stabbing pain in one eye with associated rhinorrhea (runny nose) and possible drooping eyelid on the affected side. The headaches tend to occur in "clusters": typically one to three headaches per day (but may be as many as eight) during a cluster period. 4. Incorrect: Overuse of painkillers for headaches, can, ironically, lead to rebound headaches. Culprits include over the counter medications such as aspirin, acetaminophen or ibuprofen, as well as prescription medications. Too much medication can cause the brain to shift into an excited state, triggering more headaches. Also, rebound headaches are a symptom of withdrawal as the level of medicine drops in the bloodstream. Rebound headaches may have associated issues such as difficulty concentrating, irritability and restlessness but does not typically include photophobia or visual disturbances as seen with migraines.

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.

A client in the inpatient mental health unit has been determined not suicidal. The client is requesting to leave against medical advice (AMA). What should the nurse do first? 1. Inform the primary healthcare provider that the client is wishing to leave. 2. Make arrangements for a commitment hearing 3. Tell her that she must stay until her primary healthcare provider discharges her. 4. Call the primary healthcare provider and request a discharge order.

1. Correct: Protocols on the unit must be followed when someone is requesting to leave AMA. The first step involves calling the primary healthcare provider. 2. Incorrect: The client is not suicidal; however, the primary healthcare provider needs input into this decision. 3. Incorrect: If the client is not a threat or potential threat to self or others, the client may leave. But first the nurse must inform the primary healthcare provider. 4. Incorrect: The nurse should call the primary healthcare provider and discuss the situation. The primary healthcare provider should have input into this decision.

A client has been on the medical unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do? 1. Inform the primary healthcare provider that the client wishes to leave. 2. Make arrangements for a commitment hearing as soon as possible. 3. Tell the client the primary healthcare provider must discharge the client prior to leaving. 4. Call the primary healthcare provider and request a discharge order.

1. Correct: Protocols on the unit must be followed when someone is requesting to leave AMA. The first step is to call the primary healthcare provider about the client's desire to leave AMA. 2. Incorrect: The client is not suicidal; however, the primary healthcare provider needs input into their decision to leave AMA. It is not appropriate to prepare for a commitment hearing. 3. Incorrect: If the client is not a threat or potential threat to self or others, the client may leave. The nurse may discuss the decision to leave; however, this statement is not accurate. 4. Incorrect: The nurse should call the primary healthcare provider and discuss the situation. The primary healthcare provider should have input into this decision.

A client has been on the mental health unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do? 1. Inform the primary healthcare provider that the client wishes to leave. 2. Make arrangements for a commitment hearing, as soon as possible. 3. Tell the client the primary healthcare provider must discharge the client prior to leaving. 4. Call the primary healthcare provider and request a discharge order.

1. Correct: Protocols on the unit must be followed when someone is requesting to leave AMA. The first step is to call the primary healthcare provider about the client's desire to leave AMA. 2. Incorrect: The client is not suicidal; however, the primary healthcare provider needs input into their decision to leave AMA. It is not appropriate to prepare for a commitment hearing. 3. Incorrect: If the client is not a threat or potential threat to self or others, the client may leave. The nurse may discuss the decision to leave; however, this statement is not accurate. 4. Incorrect: The nurse should call the primary healthcare provider and discuss the situation. The primary healthcare provider should have input into this decision.

Based on this data what intervention should the nurse take first?​ 0900 Client alert and oriented. Denies abdominal pain, discomfort, or nausea and vomiting. Active bowel sounds in all quadrants. Abdomen soft, non-tender to palpation. Ranitidine 50 mg IVPB hung to IV line of NS at 100 mL per hour. No redness or edema noted at IV site. 0930 Client confused to place and time. Oxygen sat 95%. Lungs clear bilaterally. Denies pain. BP 118/78, HR 84/min, RR - 20/min, Temp. - 97.8 F (36.55 C). 1. Stop the infusion of ranitidine. 2. Send the client for a CT scan of the head. 3. Provide oxygen at 2L/NC. 4. Notify the primary healthcare provider.

1. Correct: Ranitidine can cause confusion in the elderly as well as agitation. Stop the infusion, then notify the primary healthcare provider. 2. Incorrect: Confusion is a side effect of ranitidine, so the medication should be stopped and then the healthcare provider notified. 3. Incorrect: The oxygen saturation is not low at 95%. Providing oxygen will not correct the confusion. 4. Incorrect: The primary healthcare provider should be notified after stopping the ranitidine.

A staff nurse decides to go to lunch with a friend instead of meeting with a study group for a certification exam. The staff nurse informs the clinical specialist, "Studying more will not do any good anyway." What defense mechanism does the clinical specialist understand that the staff nurse is exhibiting? 1. Rationalization 2. Denial 3. Regression 4. Reaction formation

1. Correct: Rationalization is the mind's way of justifying behavior by offering an explanation other than a truthful response. This is often used to avoid embarrassment. 2. Incorrect: Denial is the unconscious refusal to acknowledge painful realities, feelings, or experiences. It offers a temporary escape from an unpleasant event. 3. Incorrect: Regression is a reversion to immature patterns of behavior. 4. Incorrect: Reaction formation is behaving in a way that is exactly opposite of one's true feelings.

The nurse evaluates the effectiveness of discharge teaching for a client with type I diabetes mellitus. Which statement by the client would indicate to the nurse that teaching has been effective? 1. "Exercising regularly will decrease my insulin need." 2. "I will need to decrease my insulin dose when I develop an infection." 3. "I need to lose weight since obesity decreases insulin resistance." 4. "Increased stress levels will cause the glucose level in my blood to go down."

1. Correct: Regular exercise decreases the need for insulin. Regular exercise reduces insulin resistance and permits increased glucose uptake by cells. This serves to lower insulin levels and reduce hepatic production of glucose. 2. Incorrect: When an infection occurs, blood sugar increases. The normal response to infection is to increase available glucose to assist in combating the infection. This will increase the requirement for insulin, not decrease it. 3. Incorrect: Obesity increases not decreases insulin resistance, so the cells do not respond normally (are resistant) to insulin. Maintaining a healthy weight with exercise and diet can result in less need for insulin (less resistance to insulin) and less problems in individuals with type 2 diabetes. 4. Incorrect: Emotional upset and undue stress results in increased circulating catecholamines. This will increase the blood glucose levels and increase the requirement for insulin.

A young client experiencing a manic episode tells the night nurse, "If you do not go to bed with me, I am going to have you fired." Which statement by the nurse is appropriate? 1. "That is inappropriate behavior and you will need to go to your room." 2. "You've got to be kidding! You can't get me fired." 3. "I don't want to hear that again; don't ever say that again." 4. "I can see that you need attention, but this is not the way to get it."

1. Correct: Set limits on manipulative behaviors. Explain what is expected and what the consequences are if limits are violated. 2. Incorrect: Do not argue with the client. 3. Incorrect: This is confrontational and does not set consequences. 4. Incorrect: Remember to set limits and do not encourage this behavior.

The client had a thoracentesis with removal of 2500 mL of fluid from the chest cavity. What is the priority nursing assessment for this client? 1. Vital signs 2. Pain 3. O2 sat 4. Signs of infection

1. Correct: That's right. Should be watching the vital signs for shock, tachycardia, and hypotension because a lot of fluid has just been removed from the body. 2. Incorrect: Not priority; remember, pain never killed anyone. 3. Incorrect: We will watch but isn't highest priority. 4. Incorrect: Monitoring vital signs would show signs of infection.

The nurse is searching for information about the nursing care of a client receiving an experimental drug for the treatment of obesity. Which database is most likely to address this issue? 1. Cumulative Index for Nursing and Allied Health Literature (CINAHL) 2. Cochrane Library 3. Health and Wellness Resource Center 4. MEDLINE

1. Correct: The Cumulative Index for Nursing and Allied Health Literature (CINAHL) is a source for reviewing nursing and allied health information. It is also located in other healthcare data bases. 2. Incorrect: Cochrane Library includes evidence based medicine databases. 3. Incorrect: The Health and Wellness Resource Center provides access to a variety of journal articles, magazines, and pamphlets. 4. Incorrect: MEDLINE is one of the major sources for biomedical information.

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.

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.

Which primary healthcare prescription should the nurse perform first? 1. Insert intermittent catheter in client who has not voided in 8 hours. 2. Administer a bolus feeding via a client's gastrostomy tube. 3. Reinsert nasogastric tube (NG) that was pulled out. 4. Remove wound sutures.

1. Correct: The client who has not voided after 8 hours needs to be catheterized. This is the priority since the bladder is likely full and could lead to backflow of urine to the kidneys. 2. Incorrect: Not the priority here. The feeding can be done after the catheter is inserted into the client who cannot void. 3. Incorrect: Again, not the priority. This can be done after the catheter is inserted. 4. Incorrect: Removing sutures is not a priority. This could be done last.

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.

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.

A client is reporting pain rated an 8 out of 10 on the numeric pain scale. The nurse administers an oral pain medication to the client and starts a CD of the client's favorite relaxing music. Fifteen minutes later, the client rates the pain as 2 out of 10 on the numeric pain scale. What type of nonpharmacologic pain relief intervention has the nurse used? 1. Distraction 2. Biofeedback 3. Progressive relaxation 4. Cutaneous stimulation

1. Correct: The nurse uses distraction in the form of music while the oral analgesic takes effect.2. Incorrect: Biofeedback is a behavioral therapy that trains individuals to take control of the physiological responses to stressors. 3. Incorrect: Progressive relaxation uses a combination of breathing exercises and muscle group contractions and relaxation. 4. Incorrect: Cutaneous stimulation uses stimulation of the skin through heat, cold, or even electrical nerve stimulation to decrease or eliminate pain.

Which task should the nurse perform first? 1. Suctioning the tracheostomy. 2. Changing a colostomy bag that is leaking. 3. Performing an admission assessment on a client. 4. Administering pain medication to a postoperative client.

1. Correct: The tracheostomy tube must be suctioned to keep the client's airway open. Suctioning the tracheostomy should take priority. Remember, airway first. 2. Incorrect: The client may be uncomfortable from the colostomy bag leaking. This task can be delegated. The suctioning of the client does not have priority over airway. 3. Incorrect: Important, but not priority over airway. There is no indication from the question that the new client is in distress. The priority intervention is to maintain the airway. 4. Incorrect: Important, but it does not take priority over airway.

The emergency department nurse is assessing a client who presents with severe epigastric pain. The client reports that three rolls of calcium carbonate were consumed in the past eight hours to treat the indigestion. Which blood gas report does the nurse associate with this situation? 1. pH - 7.49, pCO2 - 40, HCO3 - 30 2. pH - 7.32, pCO2 - 48, HCO3 - 20 3. pH - 7.38, pCO2 - 52, HCO3 - 32 4. pH - 7.29, pCO2 - 54, HCO3 - 26

1. Correct: These ABGs are indicative of metabolic alkalosis. The pH is high, the pCO2 is within normal limits and the bicarb is high (alkalosis). So, the excess Tums (calcium carbonate) could have caused metabolic alkalosis. 2. Incorrect: The client is not hypoventilating and would not be in metabolic acidosis because he ate 3 rolls of Tums which is a base. These ABGs are indicative of acidosis. The pH is low (acidosis), the pCO2 is high (acidosis) and the bicarb is low (acidosis). 3. Incorrect: The client is not a long-term COPD client as these ABGs might suggest. These ABGs are indicative of fully compensated respiratory acidosis. The pH is normal. The pCO2 is high (as with chronic retention) and the bicarb is high to help compensate. 4. Incorrect: These ABGs are the result of an acute ventilation problem. They are indicative of respiratory acidosis. The pH is low, the pCO​2 is high, and the bicarb is normal. No compensation has begun at this point.

A client who presents with severe epigastric pain, reports that three rolls of calcium carbonate were consumed in the past eight hours to treat the indigestion. Which blood gas report does the nurse associate with this situation? 1. pH - 7.49, pCO2 - 40, HCO3 - 30 2. pH - 7.32, pCO2 - 48, HCO3 - 20 3. pH - 7.38, pCO2 - 52, HCO3 - 32 4. pH - 7.29, pCO2 - 54, HCO3 - 26

1. Correct: These ABGs are indicative of metabolic alkalosis. The pH is high, the pCO2 is within normal limits and the bicarb is high (alkalosis). So, the excess Tums (calcium carbonate) could have caused metabolic alkalosis. 2. Incorrect: The client is not hypoventilating and would not be in metabolic acidosis because he ate 3 rolls of Tums, which is a base. These ABGs are indicative of acidosis. The pH is low (acidosis), the pCO2 is high (acidosis) and the bicarb is low (acidosis). 3. Incorrect: The client is not a long-term COPD client as these ABGs might suggest. These ABGs are indicative of fully compensated respiratory acidosis. The pH is normal. The pCO2 is high (as with chronic retention) and the bicarb is high to help compensate. 4. Incorrect: These ABGs are the result of an acute ventilation problem. They are indicative of respiratory acidosis. The pH is low, the pCO​2 is high, and the bicarb is normal. No compensation has begun at this point.

A client presents to the after-hours clinic with reports of pain that occurs with walking but generally subsides with rest. The nurse notes coolness and decreased pulses in lower extremities bilaterally. What condition would the nurse recognize these symptoms being most indicative of? 1. Chronic Arterial Insufficiency 2. Chronic Venous Insufficiency 3. Chronic Unstable Angina 4. Chronic Coronary Artery Disease

1. Correct: These symptoms are indicative of arterial insufficiency as there is pain with walking that is relieved by rest. This pain is known as intermittent claudication. In addition, the pulses are decreased or may be absent with arterial insufficiency, and the extremities are cool to touch. Other s/s include: paleness of extremity when elevated or possible redness when lowered, loss of hair on affected extremity, and thick nails. 2. Incorrect: Venous insufficiency is not characterized by pain with walking. Pulses are generally normal and color is generally normal with the exception of the brown pigmentation that may be noted (especially around the ankles). 3. Incorrect: The description in the stem is evident of peripheral arterial insufficiency and is not descriptive of decreased coronary artery perfusion. No reports of chest pain were noted. 4. Incorrect: The description is evident of peripheral arterial insufficiency and is not descriptive of decreased coronary artery perfusion. The symptoms listed in the stem are indicative of a peripheral artery problem.

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.

A psychiatric nurse, caring for several clients, recognizes that which client presents the greatest risk for violence toward others? 1. Twenty four year old man with paranoid delusions. 2. Sixty two year old woman with bi-polar disorder 3. Seventy year old man with major depression. 4. Twenty eight year old woman with borderline personality disorder

1. Correct: This client has a diagnosis that is consistent with a risk of violence, and his age falls within the age range for males who are most likely to present a risk of violence toward others. 2. Incorrect: This client may be irritable; however, it is not likely that she will present a great risk for violence. Her age does not fall within the range for women that are most likely to present a threat of violence. 3. Incorrect: This client is more likely to hurt himself. 4. Incorrect: This client is more likely to present a risk of violence toward self.

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 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.

The nurse is preparing to administer iron dextran IM. Which injection site would be best for administration? 1. Ventrogluteal 2. Vastus lateralis 3. Rectus Femoris 4. Deltoid

1. Correct: This site would be used for Z track IM injections. Iron preparations are administered by the Z track technique, preferably in a large, deep muscle such as the ventrogluteal muscle. 2. Incorrect: The vastus lateralis site could be used in adults with enough muscle mass, but the ventrogluteal is the preferred site. 3. Incorrect: The rectus femoris site can be used in adults when other sites are no longer accessible. It is not the preferred site. 4. Incorrect: The deltoid is a small muscle that is not well developed in many clients. It is not a recommended site for Z track medication administration.

The nurse is preparing to administer iron dextran IM. Which injection site would be best for administration? 1. Ventrogluteal site 2. Vastus lateralis site 3. Rectus Femoris site 4. Deltoid site

1. Correct: This site would be used for Z track IM injections. Iron preparations are administered by the Z track technique, preferably in a large, deep muscle such as the ventrogluteal muscle. 2. Incorrect: The vastus lateralis site could be used in adults with enough muscle mass, but ventrogluteal is preferred site. 3. Incorrect: The rectus femoris site can be used in adults when other sites are no longer accessible. It is not the preferred site. 4. Incorrect: The deltoid is a small muscle that is not well developed in many clients. It is not a recommended site for Z track medication administration.

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.

A client who has schizophrenia tells the nurse, "I am Jesus and I am here to save the world". The client is warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What action should the nurse take? 1. Set limits and send the client to room. 2. Explain to the client that not all people are Christians. 3. Remove the Bible from the client and explain that the client is not Jesus. 4. Ask the client, "Share with the group how you know that you are Jesus."

1. Correct: Yes! You must set limits of where the client is allowed to preach. This is disrupting others, and the client needs to be redirected to the client's room for a cool down and then another activity shortly thereafter. 2. Incorrect: No, you should not tell the client that not all people are Christians, because the client will then go on a quest of salvation. 3. Incorrect: No, don't argue with the client. 4. Incorrect: This is ridiculing the client and also inflaming the situation.

The nurse is planning care for a pediatric client reporting acute pain with sickle cell crisis? What should the nurse identify as an appropriate goal for this client? 1. Client will report a pain level of less than 2 on a Faces scale. 2. The nurse will administer prescribed pain meds around the clock. 3. Client will only take breakthrough pain medication. 4. Client will use distraction instead of pain medication.

1. Correct: Yes, having a pain level of less than 2 is the best goal for pain and the use of a Faces scale, instead of a numerical scale is age appropriate. Sickle cell crisis is extremely painful, and oftentimes, the pain is not completely relieved during the acute stage. 2. Incorrect: The goal should be client centered. This option is a nursing intervention, not a client goal. 3. Incorrect: We are focusing on client response, not limiting pain meds. The goal of a pain crisis should be aimed at reducing the client's pain. 4. Incorrect: Sickle cell crisis is very painful, and pain medication is needed.

A client asked the nurse what could have caused them to develop right sided heart failure? What would be the best response by the nurse? 1. High blood pressure in the lungs. 2. Long term hypertension. 3. The inability of the mitral valve to close properly. 4. Narrowing of the aorta.

1. Correct: Yes, the right side of the heart pumps to the lungs. When the client has higher pressure in the pulmonary circuit from such things as emphysema, the pulmonary pressure can exceed the systemic pressure. The result is back flow to the right side of the heart and resulting right sided heart failure. 2. Incorrect: No, that's left-sided heart failure. Hypertension increases afterload which can ultimately result in back flow to the left side of the heart and resulting left sided heart failure. 3. Incorrect: Not related to pulmonary hypertension. The mitral valve is located between the left atrium and left ventricle. If mild, there may be little or no obvious symptoms. However, if severe, left sided heart failure may occur. 4. Incorrect: Not related to pulmonary hypertension. Narrowing of the aorta makes it harder to get blood out of the left ventricle (high afterload). The resulting backflow of blood would result in left sided heart failure.

A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who will need assistive devices upon discharge. Which devices should the case manager include for this client

1. Dinner plate food guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip eating utensils The goal is to promote self-care by the client as much as possible. The case manager should evaluate the need for assistive devices to help with eating, bathing, dressing, and ambulating. The dinner plate food guard will prevent food from being pushed off the plate. The transfer belt will provide safety for the client to get into a chair or back in bed. A raised toilet seat makes it easier for the client to sit on the toilet without falling. The long-handled shoe horn allows the client to put on shoes without assistance. Wide grip utensils accommodate a weak grip.

The nurse educator is teaching a group of nursing students about client advocacy. What should the educator tell the students are the consequences of failure to act as a client advocate?

1. Life-threatening complications for the client. 2. Legal action against the nurse and/or healthcare facility. 3. Suspension or loss of license to practice nursing. 5. Loss of client autonomy and right to make decisions.

727. Which actions should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom.)

1. Place stethoscope in suprasternal area to auscultate from bronchial sounds. 2. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces. 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds. 4. Document normal breath sounds and location of adventitious breath sounds.

A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis. What interventions should the nurse initiate? SATA 1. Wear an N95 respirator when caring for client. 2. Restrict fluid intake to 500 mL per day. 3. Position client in semi-Fowler's position. 4. Place client in a negative pressure airflow room. 5. Do not allow visitors for 48 hours.

1. Wear an N95 respirator when caring for client. 3. Position client in semi-Fowler's position. 4. Place client in a negative pressure airflow room. The nurse should suspect that the client is suffering from tuberculosis. Early pulmonary TB is asymptomatic. When the bacterial load increases, nonspecific symptoms of fatigue, weight loss, afternoon fevers, and night sweats may set in. As disease advances, cough, sputum production, and hemoptysis may appear. This client has the classic symptoms of TB and should be placed on airborne precautions. N95 respirator ensures that the nurse does not inhale the TB organism. Placing in a semi-Fowler's position reduces the work of breathing.

The home health nurse is assessing the home environment for possible irritants that could increase/precipitate symptoms of respiratory problems. Which assessment questions would be important to determine level of risk?

1. What type of heat do you use in the home? 2. Does anyone in the home have hobbies that involve sanding of wood or use of chemicals? 3. Is there anyone in the home who smokes? 4. Do you routinely use aerosol sprays for personal care or cleaning? Presence of wood smoke could increase respiratory problems. Poorly vented gas heaters could increase carbon monoxide in the environment. Use of solvents or other agents that produce irritating fumes could increase risk. The particles from the sanding could irritate the respiratory tract as well. Second-hand smoke is irritating to the respiratory tract. Aerosols could trigger respiratory problems.

In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last.

1. apply clean gloves. Second, remove soiled dressings. Third, discard soiled dressings and clean gloves in red bag. Fourth, don sterile gloves. Fifth, clean surgical wound with moistened sterile 4x4's. Sixth, clean around Penrose drain using circular pattern inside to outside. Seventh, place dry, sterile 4x4's over surgical wound and Penrose drain. Eighth, apply abdominal dressing pad.

Which assignments would be most appropriate for the RN to delegate to an LPN/VN?

1. child with pneumonia admitted two days ago 2. the child admitted for developmental studies. 3. The twelve year old with post op wound infection taking oral antibiotics is also stable.

An RN on the general pediatric unit has been reassigned to the spinal/neurology unit. What assignment by the charge nurse would be appropriate for this RN? 1. Child with spina bifida with a previous shunt revision 2. Adolescent who is 4 days post op from a spinal fusion 3. Child with a ventriculoperitoneal shunt one day post-op 4. Child with spinal muscle atrophy who is ventilator assisted 5. Child with cerebral palsy who had a tracheostomy performed this AM

1., & 2. Correct: The child who had a previous shunt revision and the adolescent who is 4 days post spinal fusion will be the most stable and will require the least skill level when compared with the other choices. On a general pediatric unit, the nurse would be familiar with checking for increased ICP, which would be necessary for caring for any client with a previous shunt revision. Immediately postop, the adolescent with spinal fusion would require special turning and lung assessment to prevent and observe for congestion/pneumonia, skills not acquired on a general floor. However, at 4 days postop this client should be ambulating and will not need specialized turning, so the nurse from the general pediatric unit could care for this client. 3. Incorrect: This client is more acute and requires a higher skill level. Nursing care for this child would involve frequent neurologic assessments and monitoring for infection. The child should also be monitored for signs of possible complications including bowel perforation. 4. Incorrect: This client is more acute and requires a higher skill level. The nurse on the general pediatric unit would not be experienced in caring for a child on a ventilator. 5. Incorrect: This client is more acute and requires a higher skill level. A child who is fresh post-op following a tracheostomy is at risk for airway obstruction from thick secretions, mucous plug, blood clot or dislodgement of the tube. Cardio-respiratory arrest can occur from these complications. The child is also at risk for hemorrhage. Nursing care would include frequent suctioning as needed, monitoring for early signs of airway obstruction, and trach care. The nurse from the general pediatric unit may not have the skills required to care for this child who also has cerebral palsy which could complicate the care required.

How should the nurse prepare a client for a paracentesis? (SATA) 1. Place client in the Fowler's position. 2. Position client flat with right arm behind the head. 3. Ask the client to empty bladder. 4. Obtain client's vital signs every 4 hours. 5. Maintain NPO status for 4 hours pre-procedure.

1., & 3. Correct: The correct position is HOB elevated to allow fluid to pool in one spot for the paracentesis. The nurse knows this is a lower abdominal puncture and the bladder should be empty to avoid puncturing the bladder. 2. Incorrect: The optimal position is HOB elevated to allow the fluid to pool in one spot. If the nurse were to lie the client flat, the fluid would go everywhere. 4. Incorrect: Obtain a set of vital signs immediately prior to the procedure and immediately after the procedure. Vital signs every 4 hours will not give you needed data on the client's status. 5. Incorrect: This procedure does not require NPO status. NPO status is initiated when there is a risk of aspiration during or following the procedure.

An adult client has just returned to the nursing care unit following a gastroscopy. Which intervention should the nurse include on the plan of care? 1. Vital sign checks every 15 min x 4 2. Supine position for 6 hours 3. NPO until return of gag reflex 4. Irrigate NG tube every 2 hours 5. Raise four side rails

1., & 3. Correct: Vital signs post procedure are important to monitor for any post-procedure complications such as bleeding or any signs of respiratory compromise. VS are checked frequently for the first hour post procedure. Any client who has a scope inserted down the throat and has received numbing medication in the back of the throat to depress the gag reflex should be kept NPO until the gag reflex returns. 2. Incorrect: Supine position for 6 hours is contraindicated. The HOB should be elevated. In the event the client vomits, he/she is less likely to aspirate with the HOB elevated. Supine position for 6 hours is used after a heart catheterization. 4. Incorrect: A client who is going for a gastroscopy procedure cannot have a nasal gastric tube. An NG tube would interfere with the procedure. 5. Incorrect: Raising all side rails is a form of restraint. Have the bed in low locked position. Raise three side rails, and have call light within reach.

A primipara at 36 weeks gestation is seen in the OB/GYN clinic. Which sign/symptom should the nurse immediately report to the primary healthcare provider? (SATA) 1. Puffy hands and face 2. Reports indigestion 3. Pedal edema 4. Backache 5. Severe headaches rated 9/10

1., & 5. Correct: Facial and upper extremity edema can be a sign of pre-eclampsia, which can endanger both the mother and fetus. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in a woman whose blood pressure had been normal. Even a slight rise in blood pressure may be a sign of preeclampsia. Left untreated, preeclampsia can lead to serious, even fatal, complications. Signs and symptoms of preeclampsia include hypertension and may include proteinuria, severe headaches. changes in vision, upper abdominal pain, nausea or vomiting, decreased urine output, thrombocytopenia, impaired liver function, shortness of breath, sudden weight gain, and edema (particularly in face and hands). 2. Incorrect: Indigestion should be assessed for severity, but it is a common symptom in the 3rd trimester of pregnancy. 3. Incorrect: Pedal edema should be assessed but is common in the 3rd trimester of pregnancy. 4. Incorrect: Backache is common in the 3rd trimester. It is caused by the center of gravity shifting.

What risk factors should the nurse include when conducting a class about type 2 diabetes mellitus? Select all that apply 1. Fat distribution greater in abdomen than in hips. 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. 5. Polycystic ovary syndrome.

1., & 5. Correct: If the body stores fat primarily in the abdomen, risk of type 2 diabetes is greater than if body stores fat elsewhere, such as hips and thighs. Women with polycystic ovary syndrome have increased risk of diabetes. 2. Incorrect: Being overweight is a primary risk factor for type 2 diabetes. The more fatty tissue, the more resistant cells become to insulin. 3. Incorrect: A type 1 diabetic will remain a type 1 diabetic. 4. Incorrect: African Americans, Hispanics, American Indians, and Asian Americans are more likely to develop type 2 diabetes than Caucasians are.

What risk factors should the nurse identify when screening individuals for type 2 diabetes mellitus? (SATA) 1. Fat distribution greater in abdomen than in hips. 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. 5. Polycystic ovary syndrome.

1., & 5. Correct: If the body stores fat primarily in the abdomen, the risk of developing type 2 diabetes is greater than if the body stores fat elsewhere, such as the hips and thighs. Women with polycystic ovary syndrome have increased risk of developing type 2 diabetes. 2. Incorrect: Being overweight is a primary risk factor for type 2 diabetes. The more fatty tissue, the more resistant cells become to insulin. 3. Incorrect: A type 1 diabetic will remain a type 1 diabetic. 4. Incorrect: Blacks, Hispanics, American Indians, and Asian Americans are more likely to develop type 2 diabetes than Caucasians.

A nurse who has never had varicella has been exposed to a client diagnosed with herpes zoster. What actions should the nurse take? (SATA) 1. Notify the infection control nurse. 2. Continue to care for client as varicella and herpes zoster are not related. 3. Go to the lab to have a Tzanck smear performed. 4. Obtain herpes zoster vaccine for protection from this exposure. 5. Receive the varicella-zoster immune globulin within 96 hours of exposure.

1., & 5. Correct: Notify the person responsible for infection control to get post-exposure treatment initiated within a timely manner. For persons who are susceptible, the varicella-zoster immune globulin should be given within 96 hours of exposure. The infection of herpes zoster is contagious until the crusts have dried and fallen off the skin. 2. Incorrect: Varicella is chickenpox and herpes zoster is shingles. Both are closely related. Exposure to herpes zoster by someone who has not had varicella places the person at risk for developing herpes zoster. 3. Incorrect: A Tzanck test consists of examining tissue from the lower surface of a lesion in a vesicular condition to determine cell type. The Tzanck test is not associated with immunity from the varicella-zoster virus. 4. Incorrect: The vaccine will not prevent the nurse from developing shingles from this exposure. The nurse needs immune globulin for immediate protection.

A nurse who has never had varicella has been exposed to a client diagnosed with herpes zoster. What actions should the nurse take? Select all that apply 1. Notify the infection control nurse. 2. Continue to care for client as varicella and herpes zoster are not related. 3. Go to the lab to have a Tzanck smear performed. 4. Obtain herpes zoster vaccine for protection from this exposure. 5. Receive the varicella-zoster immune globulin within 96 hours of exposure.

1., & 5. Correct: Notify the person responsible for infection control to get post-exposure treatment initiated within a timely manner. For persons who are susceptible, the varicella-zoster immune globulin should be given within 96 hours of exposure. The infection of herpes zoster is contagious until the crusts have dried and fallen off the skin. 2. Incorrect: Varicella is chickenpox and herpes zoster is shingles. Both are closely related. Exposure to herpes zoster by someone who has not had varicella places the person at risk for developing herpes zoster. 3. Incorrect: A Tzanck test consists of examining tissue from the lower surface of a lesion in a vesicular condition to determine cell type. The Tzanck test is not associated with immunity from the varicella-zoster virus. 4. Incorrect: The vaccine will not prevent the nurse from developing shingles from this exposure. The nurse needs immune globulin for immediate protection.

What information should be reinforced for parents regarding the promotion of adequate bowel elimination in their toddler? (SATA) 1. Include adequate fiber in the diet through whole grains and fruits. 2. Increase intake of water daily. 3. Provide toileting opportunities that are free from distractions. 4. Encourage the toddler to go to the bathroom at least three times daily. 5. Take away attention from the toddler unable to potty.

1., 2. & 3. Correct: Fiber is important for achieving adequate bowel elimination. Fruits and whole grains may help. Water intake is important, coupled with adequate fiber. Distractions at toileting times may result in poor elimination results. 4. Incorrect: The toddler should be taken to the bathroom after meals and at bedtime to encourage adequate elimination. Routine is very important. Peristalsis increases after meals. 5. Incorrect. Embarrassment or punitive measures will not yield positive results. Rather, the toddler should be praised for using the potty.

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.

The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client? (SATA) 1. Document the client's statement in the client's own words. 2. Provide information on advance directives to the client. 3. Provide personnel for assistance with completing an advance directive. 4. Encourage client to complete advance directive as soon as possible. 5. Determine if the client's daughter agrees with the client's decision.

1., 2. & 3. Correct: The nurse should document the client's statement in the client's own words. The nurse should provide the client with information on advance directives and assurance that there are hospital personnel to assist with completing the advance directive. 4. Incorrect: The nurse should explain to the client that the law requires all clients be asked about the existence of an advance directive at the time of hospital admission. Preparing an advance directive ensures that the client's wishes will be followed in the event that the client is unable to make healthcare decisions. The decision about an advance directive is the client's decision to make and not the nurse's decision. 5. Incorrect: Providing information is the appropriate nursing action, not questioning the daughter.

The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client? Select all that apply 1. Document the client's statement in the client's own words. 2. Provide information on advance directives to the client. 3. Inform the client that personnel are available to assist with completing an advance directive. 4. Avoid inquiring about a client's advance directive as this could cause the client anxiety and concern. 5. Ask the daughter if she agrees with her mother's decision.

1., 2. & 3. Correct: The nurse should document the client's statement in the client's own words. The nurse should provide the client with information on advance directives and assurance that there are hospital personnel to assist with completing the advance directive. 4. Incorrect: The nurse who avoids inquiry about a client's advance directive is not serving the client's best interests. The nurse should explain to the client that the law requires all clients be asked about the existence of an advance directive at the time of hospital admission. Preparing an advance directive ensures that the client's wishes will be followed in the event that the client is unable to make healthcare decisions.5. Incorrect: Providing information is the appropriate nursing action, not questioning the daughter.

The nurse is caring for a client on the psychiatric unit with a diagnosis of obsessive-compulsive disorder. The client has frequent hand washing rituals. Which nursing interventions would be advisable for this client? 1. Allow time for ritual. 2. Provide positive reinforcement for non ritualistic behavior. 3. Provide a flexible schedule for the client. 4. Remove all soap and water sources from the client's environment. 5. Create a regular schedule for taking client to bathroom.

1., 2. & 5. Correct: Initially meet the client's dependency needs as required to keep anxiety from escalating. Anything that increases the client's anxiety tends to increase the ritualistic behavior. Positive reinforcement for non ritualistic behavior takes the focus off of the ritual. A lack of attention to ritualistic behaviors can help to decrease the ritual. By creating a regular schedule when the client goes to the bathroom, (where the hand washing ritual occurs most frequently) allows the client a structured but limited time for the ritual. This can help give the client a sense of control of the maladaptive behavior until the client can start setting own limits on the behavior and develop more adaptive coping mechanisms. 3. Incorrect: A structured schedule is needed for this client. If the client is allowed to perform the maladaptive behavior whenever desired, the client will not begin to problem solve ways to limit the ritual nor lessen the anxiety associated with the ritualistic behavior. The set schedule helps the client to develop trust with the nurse, knowing that time will be allowed for the behavior until better coping skills are developed. 4. Incorrect: Sudden and complete elimination of all avenues for dependency would create intense anxiety in the client. This increased anxiety would only serve to increase the ritualistic behavior. When time is not allowed for the ritual, the client fears that something bad is happening and the anxiety escalates.

A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar with this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the nurse expect on assessment? 1. Fever and shivering 2. Agitation 3. Decreased body temperature 4. Constipation 5. Increased heart rate

1., 2. & 5. Correct: Serotonin syndrome is a group of symptoms that can result from the use of certain serotonin reuptake inhibitors. These symptoms can range from mild to severe and include high body temperature, agitation, increased reflexes, diaphoresis, tremors, dilated pupils and diarrhea. The client is likely to experience shivering with fever. Increased heart rate and blood pressure are also commonly experienced. More severe symptoms, including muscle rigidity and seizures, can occur. If not treated, serotonin syndrome can be fatal. 3. Incorrect: Increased body temperature is expected as is increased diaphoresis. 4. Incorrect: Diarrhea, not constipation, is a symptom of serotonin syndrome.

A client with a history of command hallucinations was admitted to the hospital yesterday. What questions are most important for the nurse to ask? 1. "Are you hearing voices today?" 2. "What are the voices saying?" 3. "How are you feeling today?" 4. "Did you have difficulty sleeping last night?" 5. "Are the voices telling you to harm yourself or anyone else?"

1., 2. & 5. Correct: The nurse must assess for hallucinations. The nurse needs to know what the voices are saying to determine the level of threat. The nurse needs to know if the command hallucination exists and whether it involves harming self or others which must be reported. These answers are important to know, as the client has a history of command hallucinations. 3. Incorrect: The priority is safety of the client and others on the unit. This question does not get the most essential information related to command hallucinations that may cause the client to engage in behavior that is harmful to self or others. 4. Incorrect: This question does not focus on the problem: command hallucinations. If you assume the worse, you want to know if the voices from the command hallucinations are telling the client to harm self or others.

The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which clients would be appropriate for the nurse to assign to the LPN/VN? 1. In Buck's traction requiring frequent pain medication. 2. 24 hours post appendectomy. 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM. 4. Admitted 6 hours ago in adrenal insufficiency. 5. Client newly diagnosed with Type 2 diabetes.

1., 2., & 3. Correct These clients are stable and require predictable care that can be done appropriately by the LPN/VN. 4. Incorrect: This client has adrenal insufficiency. Primary adrenal insufficiency occurs when at least 90 percent of the adrenal cortex has been destroyed generally from autoimmune disorders. Secondary adrenal insufficiency can be caused by such things as abrupt stoppage of corticosteroid medications and surgical removal of pituitary tumors. As a result, often both glucocorticoid (cortisol) and mineralocorticoid (aldosterone) hormones may be lacking. This puts the client at risk for fluid volume deficit (FVD) and shock. This requires the higher level assessment skills of the RN. 5. Incorrect: A newly diagnosed client may be unstable and would require assessment, care plan development and teaching for the newly diagnosed diabetic which cannot be performed by the PN.

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 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.

What information should a nurse include when educating a client regarding buccal administration of a medication? 1. This route allows the medication to get into the bloodstream faster than the oral route. 2. Stinging may occur after placing the medication in the cheek. 3. If swallowed, the medication may be inactivated by gastric secretions. 4. The buccal dose of medication will need to be increased from the oral dose. 5. Remove the tablet from buccal area after 15 seconds.

1., 2., & 3. Correct: These are correct statements about buccal administration of medication. Buccal administration involves the medication being placed between the gums and cheek, where it dissolves and becomes absorbed into the bloodstream. The cheek area has many capillaries that allow the medication to be absorbed quickly without having to pass through the digestive system. The degree of stinging experienced depends on the medication being administered. Some effects of certain medications can be lessened by digestive processes. 4. Incorrect: When given by the buccal route, the medication does not go through the digestive system. This means that the medication is not metabolized through the liver, and thus a lower dose can be used. 5. Incorrect: Placement should be maintained until the tablet is dissolved in order to get the dosage and effects desired.

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.

What should a community health nurse include when planning a presentation on prevention and early detection of colon cancer? 1. Maintain a diet high in fruits, vegetables, and whole grains. 2. Exercise regularly. 3. Regular screening should begin at age 30. 4. Yearly guaiac-based fecal occult blood test. 5. Flexible esophagogastroduodenoscopy every 5 years.

1., 2., & 4. Correct: A diet high in vegetables, fruits, and whole grains has been linked with a decreased risk of colorectal cancer; whereas, a diet high in red meats, processed meats, and cooking meats at very high temperature (frying, broiling or grilling) creates chemicals that may increase the risk for colorectal cancer. There is a greater risk of developing colorectal cancer in individuals who live a sedentary life style. The guaiac-based fecal occult blood test detects blood in the stool through a chemical reaction. This test is done yearly. 3. Incorrect: If there are no identified risk factors (other than age), regular screening should begin at age 50. 5. Incorrect: Flexible sigmoidoscopy looks at the rectum and colon to detect polyps and colon cancer. For people who have none of the risks described earlier, digital rectal examination and testing of the stool for hidden blood are recommended annually beginning at age 40. Flexible sigmoidoscopy is recommended every 5 years at age 50 or older. A double contrast barium enema every 5 to 10 years and colonoscopy every 10 years are acceptable alternatives.

Which symptoms would the nurse be likely to observe in the client who overdosed on diazepam? Select all that apply 1. Bradypnea 2. Bradycardia 3. Hyperthermia 4. Somnolence 5. Hyperreflexia 6. Psychosis

1., 2., & 4. Correct: Benzodiazepines are central nervous system (CNS) depressants. Diazepam is a benzodiazepine. They will slow respirations (bradypnea) and the heart rate (bradycardia). Somnolence (extreme, prolonged drowsiness) would be seen.3. Incorrect: Benzodiazepines would not cause hyperthermia.5. Incorrect: Benzodiazepines would diminish reflexes since it is a CNS depressant.6. Incorrect: Psychosis is not a common symptom with CNS depression.

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 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.

What discharge instructions should the nurse provide to the client post abdominal hysterectomy? Select all that apply 1. Ambulate at least 3-4 times per day. 2. Notify the primary healthcare provider if there is a yellow discharge from the surgical wound. 3. Swimming is allowed if staples were used to close the skin. 4. Press a pillow over incision when coughing to ease discomfort. 5. Apply moist heat to surgical site the first couple of days for pain relief.

1., 2., & 4. Correct: The client should get up and move to prevent complications such as deep vein thrombosis (DVT), pneumonia, constipation, etc. The healthcare provider should be notified if the surgical wound is bleeding, red and warm to touch or has a thick, yellow, or green drainage. Pressing a pillow over incision when coughing or sneezing will ease discomfort and protect the incision. 3. Incorrect: Do not go swimming or soak in a bathtub or hot tub until the primary healthcare provider says it is ok. You worry about infection. 5. Incorrect: In the first couple of days, an ice pack may help relieve some pain at the site of surgery. Remember NCLEX wants you to think safety first when it comes to the use of heat.

What discharge instructions should the nurse reinforce to the client post abdominal hysterectomy? (SATA) 1. Ambulate at least 3-4 times per day. 2. Notify the primary healthcare provider of a yellow discharge from the surgical wound. 3. Swimming is allowed if staples were used to close the skin. 4. Press a pillow over incision when coughing to ease discomfort. 5. Apply moist heat to surgical site the first couple of days for pain relief.

1., 2., & 4. Correct: The client should get up and move to prevent complications such as deep vein thrombosis (DVT), pneumonia, constipation, etc. The healthcare provider should be notified if the surgical wound is bleeding, red and warm to touch, or has a thick, yellow, or green drainage. Pressing a pillow over incision when coughing or sneezing will ease discomfort and protect the incision. 3. Incorrect: Do not go swimming or soak in a bathtub or hot tub until the primary healthcare provider says it is ok. You worry about infection. 5. Incorrect: In the first couple of days, an ice pack may help relieve some pain at the site of surgery. Remember, NCLEX wants you to think safety first when it comes to the use of heat.

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.

Which immunizations obtained by the age of two would indicate to the pediatric nurse that the child is up-to-date on immunizations? 1. Diphtheria-tetanus-pertussis (DTaP). 2. Inactivated polio (IPV). 3. Herpes zoster. 4. Meningococcal 5. Haemophilus influenzae type B (Hib).

1., 2., & 5. Correct: By the age of two, the DTaP, IPV, MMR, Hib, varicella, pneumococcal, and rotavirus vaccines should have been received. The nurse should clarify this with the parent. 3. Incorrect: This vaccine is recommended for people 60 years or older whether or not the person has ever had chicken pox and is at risk for developing shingles. Although the vaccine can be given to adults between the ages of 50-59, routine administration is not recommended. 4. Incorrect: The minimum age for administering the meningococcal vaccine is two years of age. The recommended age for administering the meningococcal vaccine is at 11 or 12 years of age, or 13 through 18 years of age if they did not previously receive this vaccine. It is especially important for teens going to college and who are likely to stay in close quarters such as a dorm.

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.

The nurse is caring for a client admitted to the emergency department with a history of asthma. Which assessment findings would the nurse anticipate? Select all that apply 1. Coughing 2. Chest tightness 3. 3 + pitting edema to ankles 4. Kussmaul respirations 5. Increased respiratory rate

1., 2., & 5. Correct: The client with asthma has a pattern of dyspnea (shortness of breath), chest tightness, coughing, wheezing, and increased respiratory rate. 3. Incorrect: There should be no dependent edema with asthma.4. Incorrect: This respiration classification relates to metabolic acidosis and is seen in DKA.

Which interventions should be included in the plan of care for an adult client with constipation? 1. Allow adequate time for defecation. 2. Provide privacy for bowel elimination. 3. Suggest increasing fluid intake (unless contraindicated). 4. Encourage client to increase fiber in the diet. 5. Encourage the client to delay the urge to defecate until after a meal.

1., 2., 3. & 4. Correct: Clients should have ample time for defecation. Rushing the client may lead to a client ignoring the urge. Since clients may be hesitant to have a bowel movement in the presence of others, privacy should be provided. (The nurse may need to stay with weak or disabled clients.) Increasing fluid intake will lead to softer stools. This makes defecation easier. Fiber deficiencies may contribute to constipation. Fiber in the diet adds bulk to the stools which help them pass more readily through the intestines. 5. Incorrect: Ignoring the urge to defecate may increase the risk of constipation. Trying to defecate after a meal when peristalsis is increased may be helpful; however, if the urge occurs at other times, the client should go to the bathroom at that time to prevent constipation.

The home health nurse is assessing the home environment for possible irritants that could increase/precipitate symptoms of respiratory problems. Which assessment questions would be important to determine level of risk? Select all that apply 1. What type of heat do you use in the home? 2. Does anyone in the home have hobbies that involve sanding of wood or use of chemicals? 3. Is there anyone in the home who smokes? 4. Do you routinely use aerosol sprays for personal care or cleaning? 5. Is your water supply treated by a municipal agency?

1., 2., 3. & 4. Correct: Presence of wood smoke could increase respiratory problems. Poorly vented gas heaters could increase carbon monoxide in the environment. Use of solvents or other agents that produce irritating fumes could increase risk. The particles from the sanding could irritate the respiratory tract as well. Second-hand smoke is irritating to the respiratory tract. Aerosols could trigger respiratory problems.5. Incorrect: Water safety would not necessarily increase respiratory risk.

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.

The nurse is working with a committee at the local school to develop an emergency preparedness plan for tornados. What should be included in the plan? 1. Identification of safe zones. 2. Methods for accounting for all people present in the building. 3. Warning system activation. 4. Identification of the gymnasium as the routine safe place. 5. Regular practice protocols.

1., 2., 3. & 5. Correct: Everyone should be aware of safe zones within the school. Personnel should be given this information and signs posted in safe zones. There must be systems in place to accurately determine the number of people in the building at any given time. There also must be a system in place to alert personnel and students of tornado warnings. Regular practice prepares everyone for an actual event. 4. Incorrect: Gymnasiums are not considered safe places due to wide expanse of roof. Safe zones should be on interior walls, no windows, and a strong concrete floor if possible.

A client is preparing to be discharged after a total hip replacement. Which statements, if made by the client, would indicate to the nurse that teaching has been successful regarding prevention of hip prosthesis dislocation? 1. I should not cross my affected leg over my other leg. 2. I should not bend at the waist more than 90 degrees. 3. While lying in bed, I should not turn my affected leg inward. 4. It is necessary to keep my knees together at all times. 5. When I sleep, I should keep a pillow between my legs.

1., 2., 3. & 5. Correct: One of the most common problems after hip surgery is dislocation. Until the hip prosthesis stabilizes, it is necessary to follow these instructions for proper positioning to avoid dislocation. Flexion and movement of the leg on the affected side past midline should be avoided. 4. Incorrect: The knees should be kept apart at all times. This is called abduction and is needed to keep the new head of the femur (prosthetic device) in the acetabulum and therefore prevent hip dislocation until healing occurs and tissues are strong enough to hold the joint in place.

The nurse educator is teaching a group of nursing students about client advocacy. What should the educator tell the students are the consequences of failure to act as a client advocate? Select all that apply 1. Life-threatening complications for the client. 2. Legal action against the nurse and/or healthcare facility. 3. Suspension or loss of license to practice nursing. 4. Suspension or loss of license to practice medicine. 5. Loss of client autonomy and right to make decisions.

1., 2., 3. & 5. Correct: The role of client advocate is a nurse's responsibility. Failure to act as a client advocate could result in a range of complications for the client, including life-threatening or life-ending complications. Failure to act as client advocate exposes the nurse to liability, potential legal action against the nurse and/or healthcare facility, and potential suspension or loss of license to practice nursing. The client advocate protects client autonomy and right to make decisions. 4. Incorrect: The nurse does not have a license to practice medicine. The nurse cannot work outside of their scope of practice. This action may result in the possible suspension or loss of license to practice nursing.

Which prescriptions are appropriate for the nursery nurse to initiate on a newborn prior to discharge home? Select all that apply 1. Hepatitis B vaccine 2. Erythromycin Ointment 3. Vitamin K 4. Lanolin 5. PKU Screening

1., 2., 3. & 5. Correct: This vaccine is recommended at birth to decrease the incidence of hepatits B virus. Mandatory prophylactic agent is applied in newborn's eyes as precaution against ophthalmia neonatorium. Vitamin K (Aquamephyton) routine injection to prevent hemorrhagic disease of newborn. PKU-Screening for phenylketonuria is not reliable until the newborn has ingested an ample amount of the amino acid, phenylalanine, a constituent of both human and cow's milk. Nurse must document initial ingestion of milk and perform test at least 24 hours after that time. This test is thus done just prior to discharge. 4. Incorrect: Lanolin is not something that is applied on newborns when admitted to the nursery.​ Lanolin is an emollient for the skin. The normal newborn does not need an emollient applied to the skin.

What should the nurse tell the parents of a newborn about a Guthrie test? 1. The purpose of this test is to determine the presence of phenylalanine in the blood. 2. A positive test indicates a metabolic disorder. 3. To conduct this test, a sample of blood is taken from the baby's heel. 4. An increase in protein intake can interfere with the test. 5. This test will be done when your baby is 6 weeks old.

1., 2., 3. Correct: These are true statements. A positive test indicates decreased metabolism of phenylalanine, leading to phenylketonuria. The normal level of phenylalanine in newborns is 0.5to 1 mg/dl. The Guthrie test detects levels greater than 4 mg/dl. Only fresh heel blood, not cord blood, can be used for the test. The main objective for diagnosing and treating this disorder is to prevent cognitive impairment. 4. Incorrect: A lack of protein intake can interfere with the test. The screening test is most reliable when the blood sample is obtained after the baby has ingested a source of protein. 5. Incorrect: Screening protocol involves testing the infant as close to discharge as possible but no later than 7 days after birth. If the infant is less than 24 hours old when the specimen is collected, a repeat test should be done before the infant is 2 weeks of age.

The charge nurse is making assignments for one RN and one LPN/VN on a pediatric unit. Which clients would be most appropriate for the charge nurse to assign to the RN? 1. 2 year old with asthma receiving IV medication. 2. 6 year old with new onset seizures. 3. 12 year old with colitis receiving TPN. 4. 2 month old with urinary tract infection. 5. 10 year old paraplegic needing assistance with bowel training.

1., 2., 3. Correct: These clients should be assigned to the RN as they will require more frequent assessment due to the nature of each diagnosis and have a potential for more rapid change in condition. Also, these clients may require skills by the RN that the LPN/VN could not do; for example, giving IV medications that asthma clients take; teaching the family about seizures, meds, and management; and administering TPN intravenously. 4. Incorrect: There is nothing in this option to indicate that the child is unstable. This assignment is appropriate for LPN/VN 5. Incorrect: This assignment is appropriate as the LPN/VN can provide care related to elimination needs.

What measures should the unit nurse initiate after admitting a client who had a chest tube inserted for pleural effusion of the right lung? 1. Place in semi-Fowler's position. 2. Connect to oxygen saturation monitor. 3. Assess respiratory status every 2 hours. 4. Prevent dependent loops in closed drainage unit tubing. 5. Maintain closed drainage unit at the level of the client's chest.

1., 2., 3., & 4. Correct: A pleural effusion is a collection of fluid in the pleural space that moves to the bottom of the chest cavity when upright. The semi-Fowler's position allows the client to be in an upright position to promote drainage and facilitate ease of respirations by promoting lung expansion. Since lung expansion is compromised with a pleural effusion, the oxygen level should be assessed using an oxygen saturation monitor. The client's respiratory status should be assessed at least every 2 hours: respiratory rate, work of breathing, breath sounds, pulse oximetry. The development of kinks, loops, or pressure on the drainage tubing can produce back pressure, which may force fluid back into the pleural space or interfere with the drainage. 5. Incorrect: The closed drainage unit should be placed below the level of the client's chest to prevent drainage from flowing backward into the pleural space.

A home care nurse is visiting a client who delivered her first baby one week ago. What behavior by the client would indicate to the nurse that maternal-infant bonding is occurring? (SATA) 1. Holds baby face to face 2. Talks about the baby's features 3. Touches baby frequently 4. Talks to baby 5. Allows baby to cry vigorously for 15 minutes

1., 2., 3., & 4. Correct: Positive behaviors that would indicate that maternal-infant bonding is occurring include making eye contact; assuming the in face position when holding the infant; pointing out common features; smiling and gazing at the infant; touching infant, progressing from touching with fingertips to holding; speaking in soft, high-pitched tones; and speaking positively about the infant. 5. Incorrect: Crying vigorously for 15 minutes is an indication that the baby has a need that the mom is ignoring. This is not a common behavior promoting maternal-infant bonding.

A nurse is caring for a client admitted with chronic fatigue and weakness. During the physical assessment, the nurse notes jaundiced sclera, abdominal distension, swelling in the legs and ankles, and bruises in various stages of healing throughout the body. What nursing interventions should the nurse initiate? 1. Measure abdomen 2. Monitor intake and output 3. Obtain daily weight 4. Place on fall precautions 5. Provide three meals per day 6. Dangle legs

1., 2., 3., & 4. Correct: The symptoms presented are indicative of liver disease. Measuring abdominal girth will monitor for accumulating ascitic fluid. Clients with liver disease have fluid volume problems, so daily weight and I&O are indicated. This client is at risk for injury related to chronic fatigue and weakness, so fall prevention is indicated. The client may need help eating if fatigue is severe. 5. Incorrect: Poor tolerance to larger meals may be due to abdominal distension and ascites. Clients should eat smaller, more frequent meals (6/day). The recommended diet is high calorie and low sodium with protein regulated based on liver function. Between meal snacks should be provided. 6. Incorrect: Elevating legs enhances venous return and reduces edema in extremities. Dangling the leg would cause the fluid in the lower extremities to accumulate more.

A school nurse is teaching a group of preteens with acne how to care for the skin. What points should the nurse include? 1. Wash face with soap and warm water. 2. Avoid using oily creams. 3. Do not use cosmetics that block sebaceous gland ducts. 4. Do not squeeze lesions. 5. Clean face vigorously with a terry cloth.

1., 2., 3., & 4. Correct: Washing the face frequently (at least twice a day) with mild soap or detergent and warm water will remove oil, dirt, and bacteria which increase inflammatory reactions and resulting acne. Oily creams and oil based cosmetics can block the ducts of the sebaceous gland ducts and the hair follicles making the acne worse. These should be avoided. Squeezing or picking at lesions will increase potential for infection and scarring. 5. Incorrect: Clean face gently, as trauma during acne breakouts may worsen the acne and cause scarring. When washing face, use hands, as terry cloth or other scrubbing material may cause acne sores to rupture.

A client diagnosed with mania and hypertension is hospitalized due to confusion and polyuria. Based on current data, what interventions should the nurse implement? Ataxia and mild hand tremors noted. BP 120/74, Respirations 18, Heart rate 92. Lithium carbonate 1000 mg po daily Aripiprazole 10 mg po daily Furosemide 10 mg po daily. Sodium - 140 mEq /L (130 mmol/L) Potassium - 4.5 mEq/L (4.5 mmol/L) Glucose - 122 mg/dl (6.77 mmol/L) Lithium level - 2.1 mEq/L Select all that apply 1. Hold the lithium carbonate dose. 2. Notify primary healthcare provider of lithium level. 3. Connect client to heart monitor. 4. Administer sodium polystyrene for hyperkalemia. 5. Pad the siderails of the client's bed.

1., 2., 3., & 5. Correct: Symptoms of lithium toxicity begin to appear at blood levels greater than 1.5 mEq/L. Additionally, concurrent administration of lithium and diuretics such as furosemide increase the chance of toxicity. At serum levels of 1.5-2.0 mEq/L: blurred vision, ataxia, tinnitus, persistent nausea and vomiting, severe diarrhea. At serum levels of 2.0-3.5: excessive output of dilute urine, increasing tremors, muscular irritability, psychomotor retardation, mental confusion, giddiness. At serum levels above 3.5: impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmias, myocardial infarction, cardiovascular collapse. Arrhythmias and seizures can occur with toxicity. So the lithium dose should be held, and the healthcare provider notified. The client is at risk for arrhythmias, so connect to a heart monitor. The client is also at risk for seizures, so pad the side rails.4. Incorrect: The potassium level is normal, so there is no need to treat hyperkalemia.

The nurse is caring for a client admitted to the psychiatric unit with a diagnosis of major depression. What behaviors could the nurse expect upon assessment of this client? 1. Withdrawn behavior 2. Sitting in room, lights out, drapes closed 3. Unkempt appearance 4. Overeating 5. Severe insomnia

1., 2., 3., & 5. Correct: The client with severe depression has extremely low self-esteem and low energy levels and may just sit for hours. Depressed clients prefer to be alone and avoid social interactions. The room environment mimics the mood of the client (dark and gloomy). The client may not have the energy to bathe, change clothes, or even comb hair. The severely depressed person may have severe insomnia. However, sleeping too much is also a symptom of mild depression. 4. Incorrect: The client who is severely depressed, as in the depressive disorder, usually has no appetite and loses weight. A mildly depressed client is more likely to overeat as a coping mechanism.

During an assessment interview with a client, what alternative healing modalities should the nurse inquire about? 1. "Tell me about your use of teas, herbs, and vitamins." 2. "What traditional or folk remedies are used in your family?" 3. "Do you meditate, pray, or use relaxation techniques for healing purposes?" 4. "What prescription medications are you taking?" 5. "What alternative therapies have you used?"

1., 2., 3., & 5. Correct: These are all inquiries the nurse should make when conducting an assessment interview in order to find out about alternative healing modalities. Alternative or complementary medicine is used to describe over 1800 therapies practiced around the world. Approximately 65 to 80% of the world's population use non-conventional (alternative) healing modalities. These alternative healing modalities can be such things as: Natural products (herbs, dietary supplements, etc.) mind and body practices (yoga, mediation, prayer, etc.), folk remedies and other non-traditional practices. 4. Incorrect: Prescription medications would be part of traditional, western medicine. Although the nurse needs to find out what prescription medications are being taken, it is not part of alternative medicine.

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.

A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who will need assistive devices upon discharge. Which devices should the case manager include for this client? 1. Dinner plate food guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip eating utensils 6. Button closures on clothes

1., 2., 3., 4., & 5. Correct: The goal is to promote self-care by the client as much as possible. The case manager should evaluate the need for assistive devices to help with eating, bathing, dressing, and ambulating. The dinner plate food guard will prevent food from being pushed off the plate. The transfer belt will provide safety for the client to get into a chair or back in bed. A raised toilet seat makes it easier for the client to sit on the toilet without falling. The long-handled shoe horn allows the client to put on shoes without assistance. Wide grip utensils accommodate a weak grip. 6. Incorrect: It is hard for someone with hemiplegia to use buttons. Velcro fasteners are best.

What should the nurse document after a client has died? (SATA) 1. Time of death 2. Who pronounced the death 3. Disposition of personal articles 4. Destination of body 5. Primary healthcare provider's prescriptions 6. Time body left facility

1., 2., 3., 4., & 6. Correct: All of these are correct options that should be documented. In addition to these things, the nurse should also document consideration of and preparation for organ donation, family notified and decisions made, and location of identification tags. 5. Incorrect: The primary healthcare provider's prescriptions do not need to be documented after a client dies.

What should the nurse document after a client has died? Select all that apply 1. Time of death 2. Who pronounced the death 3. Disposition of personal articles 4. Destination of body 5. Primary healthcare provider's prescriptions 6. Time body left facility

1., 2., 3., 4., & 6. Correct: All of these should be documented. Also document consideration of and preparation for organ donation; family notified and decisions made; location of identification tags. 5. Incorrect: The primary healthcare provider's prescriptions do not need to be documented after a client dies.

A home health nurse inspects the home of a client scheduled to be discharged home after receiving care for a cerebrovascular accident with generalized weakness. What safety interventions should the nurse recommend based on findings within the home? 1. Place ramp over the front steps. 2. Move client's bedroom downstairs. 3. Remove throw rugs. 4. Secure furniture so client can use for support. 5. Apply non skid strips to shower stall. Exhibit: Nurse's Home Assessment: Two story, four bedroom home located in quiet neighborhood. Yard uncluttered. Five steps leading to front door. Sturdy railings on both sides of steps. Interior home clean and well organized. No clutter noted on floors. Multiple throw rugs throughout the downstairs living area. Three bedrooms and two bathrooms located upstairs. One bedroom and one bathroom located downstairs. Client's bedroom is upstairs. Shower stall in downstairs bathroom.

1., 2., 3., 5. Correct: The client will have difficulty navigating the steps, both outside and inside the home. The client may trip on throw rugs, and shower stalls are slippery when wet. These things, along with the generalized weakness, makes the client more prone to falls. These interventions will promote safety for the client and decrease the risk of falling. 4. Incorrect: Do not have client rely on furniture for support while walking as they may not provide the consistent support needed to prevent falls. The client should use prescribed assistive devices, which are designed to help prevent falls when used properly.

A nurse is planning to provide information regarding suicide to a high school assembly. What information should the nurse include? 1. Do not keep secrets for the suicidal person. 2. Express concern for a person expressing thoughts of suicide. 3. Teens often don't mean what they say, so only take suicide seriously if grades are dropping as well. 4. Inform group of suicide intervention sources. 5. Do not leave a suicidal person alone.

1., 2., 4. & 5. Correct: If a person reveals that suicide is being considered, this should never be kept secret. Help should be sought for the person immediately. It is also important to be direct and non-secretive with suicidal clients. It is appropriate to express concern for their thoughts. The use of empathy, warmth and concern indicates to the client that their feelings are being understood and viewed as real, which helps to build trust with the client. Resources for assistance are important to include in all health teaching programs. The teens need to know what resources are readily available if someone is considering suicide. The client contemplating suicide should not be left alone. This is for the client's safety until further assistance can be obtained 3. Incorrect: Most clients who commit suicide have told at least one person that they were contemplating suicide before thy actually committed the act. Therefore, suicidal comments should be considered important risk factors that require evaluation, and all comments should be taken seriously. Anyone expressing suicidal feelings needs immediate attention.

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.

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client? 1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen

1., 2., 4., & 5. Correct: An alternating pressure mattress will help to prevent pressure ulcers. The risk of respiratory compromise increases as the neurologic status deteriorates. A hospital bed is needed so that the head of the client's bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. The client with hepatic encephalopathy is unresponsive due to accumulation of toxins and may need suctioning if unable to clear secretions from the oropharynx. Hepatic encephalopathy frequently has associated bleeding varices. The increasing ascites leads to hypovolemia. Both of these conditions can result in hypoxemia for the client at the end stages of liver disease; therefore, oxygen therapy is provided. 3. Incorrect: As hepatic encephalopathy progresses and toxins accumulate, the client lapses into a coma. Therefore, the unresponsive client will not be ambulatory and would not need a walker.

A client diagnosed with rheumatoid arthritis has been prescribed celecoxib. What should the nurse include in the client's education regarding this medication? 1. Do not take celecoxib with ibuprofen. 2. GI complaints and headache are among the most common side effects. 3. Drink a lot of water to offset the dehydration that may occur. 4. Notify the healthcare provider immediately if black stools are noted. 5. This medication provides relief of pain and swelling so you can perform normal daily activities.

1., 2., 4., & 5. Correct: Concomitant use of celecoxib with aspirin or other NSAIDs (for example, ibuprofen, naproxen, etc.) may increase the occurrence of stomach and intestinal ulcers. This would increase the risk of GI bleeders. GI complaints and headache are two of the most common side effects. The client should stop taking celecoxib and get medical help right away if the client notices bloody or black/tarry stools. This would be an indication of GI bleeding. This medication is a nonsteroidal anti-inflammatory drug (NSAID), which relieves pain and swelling. It is used to treat arthritis. The pain and swelling relief provided by this medication should help the client perform normal daily activities. 3. Incorrect: The client may develop fluid retention while taking this medication. They should decrease the intake of sodium to decrease fluid retention.

While examining a client's health history, which data indicates to the nurse that the client is at increased risk for developing cancer? 1. Family history 2. Alcohol consumption 3. Spicy diet 4. Human papillomavirus 5. Tobacco use

1., 2., 4., & 5. Correct: Family history of cancer increases the risk for having the same type of cancer. Alcohol and tobacco use increase the risk of cancer. When used together, they have a synergistic effect. Human papillomavirus (HPV) increases the risk of cervical, head, and neck cancers. 3. Incorrect: Although there are some dietary factors associated with cancer development, a spicy diet does not necessarily increase the risk of cancer.

What should a nurse teach family members prior to them entering the room of a client who has agranulocytosis? 1. Meticulous hand washing is needed. 2. Do not visit if you have any infection. 3. The client must wear a mask. 4. Children under 12 may not visit. 5. Flowers are not allowed in the room.

1., 2., 4., & 5. Correct: Protective isolation is needed for this client because of the presence of a low white blood cell count. We are protecting the client from acquiring an infection. So any visitors will need to have meticulous hand washing prior to entering. The visitor should not enter if he or she has any type of infection. To decrease the risk of infection, small children should not visit. Even the mildest symptom of infection could be detrimental to the client. Flowers have bacteria and should not be brought into the room. 3. Incorrect: A mask must be worn by the visitor, not the client. The mask is worn by visitors to prevent a possible spread of an airborne infection to the immunocompromised client.

Which assessment findings would be of concern to the nurse who is caring for a client who has an arterial line to the radial artery? Select all that apply 1. Capillary refill: Left hand-2 seconds; Right hand- 4 seconds. 2. Blue tinged color to finger tips of right hand. 3. Warm skin to right and left hand. 4. Left radial pulse-88/min; Right radial pulse-82/min 5. Blanching to right hand.

1., 2., 4., & 5. Correct: These are all signs of poor circulation to the right hand. The arterial line could be occluding circulation and needs to be removed. 3. Incorrect: This is a good sign. We would worry with cool skin/extremity.

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.

A client who is obese and paraplegic needs to be repositioned in the bed. What actions should the nurse take? (SATA) 1. Obtain assistance from a coworker. 2. Place the bed in the lowest position with the client close. 3. Adjust the bed to a workable position and move close to the client. 4. Use a draw sheet with the assistance of a coworker and pivot the hips while pulling the draw sheet upward. 5. Use the client's arms and pull to head of bed to aid positioning.

1., 3. & 4. Correct: The nurse should solicit a coworker for help, adjust the bed to a workable position, move close to the client, use a draw sheet with the assistance of a coworker, and pivot the hips while pulling the draw sheet upward. These steps will prevent injury to the nurse and client. 2. Incorrect: The bed needs to be adjusted to the nurse's working height, not in the lowest position. 5. Incorrect: The client's arms should not be pulled on or used to position a client.

A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis. What interventions should the nurse initiate? Select all that apply 1. Wear an N95 respirator when caring for client. 2. Restrict fluid intake to 500 mL per day. 3. Position client in semi-Fowler's position. 4. Place client in a negative pressure airflow room. 5. Do not allow visitors for 48 hours.

1., 3. & 4. Correct: The nurse should suspect that the client is suffering from tuberculosis. Early pulmonary TB is asymptomatic. When the bacterial load increases, nonspecific symptoms of fatigue, weight loss, afternoon fevers, and night sweats may set in. As disease advances, cough, sputum production, and hemoptysis may appear. This client has the classic symptoms of TB and should be placed on airborne precautions. N95 respirator ensures that the nurse does not inhale the TB organism. Placing in a semi-Fowler's position reduces the work of breathing.2. Incorrect: Unless contraindicated, 3-4 liters of fluid is needed per day to liquefy secretions.5. Incorrect: Visitors are allowed if standard and airborne precautions are followed.

A nurse is teaching a group of small farm owners how to prevent pesticide exposure for field workers. What points should the nurse include? Select all that apply 1. Importance of hand washing before eating. 2. Wearing protective clothing while working in the field and at home. 3. Removing clothing and shoes worn in the field before entering the home. 4. Washing fruit and vegetables prior to eating. 5. Boiling all vegetables for a minimum of 5 minutes prior to eating.

1., 3. & 4. Correct: The standard precautions of hand hygiene is recommended prior to eating. This will reduce the transmission of pathogens and possible pesticides. The pesticides may be present on their clothing, so the clothing and shoes should be removed. Fruits and vegetables should be washed to remove pathogens and pesticides. All points are important to include when teaching prevention of pesticide exposure. 2. Incorrect: Yes, wear protective clothing while working in the field, but it is not necessary to wear protective clothing at home.5. Incorrect: No, it is not necessary to boil or cook vegetables to remove chemicals from fresh produce. Washing thoroughly with water is adequate.

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.

The nurse is caring for a client hospitalized with dissociative amnesia. Which nursing interventions are appropriate for this client? (SATA) 1. Obtain client likes and dislikes from family members. 2. Expose the client with data regarding the forgotten past. 3. Expose client to stimuli that was a happy memory of the past. 4. Hypnotize the client to help restoration of memory. 5. Ensure client safety.

1., 3. & 5. Correct: Considering likes and dislikes may help the client to remember. Using information to expose the client to stimuli that were happy memories may help the client remember. The client's disorder may lead to inattention to safety. Think safety first! 2. Incorrect: Do not expose the client to data regarding the forgotten past. Clients who are exposed to painful information from which the amnesia is providing protection may decompensate even further into a psychotic state. Dissociative amnesia is marked by an inability to recall important personal information, often traumatic or stressful in nature. 4. Incorrect: Hypnosis therapy requires advanced training in noninvasive modalities.

When caring for a client on bedrest, which interventions should the nurse implement to decrease the risk of deep vein thrombosis? (SATA) 1. Apply compression hose. 2. Place pillow under knees while supine. 3. Assist client to perform active foot and leg exercises. 4. Place client on intermittent pneumatic compression device. 5. Assess extremities for negative Homan's sign.

1., 3., & 4. Correct. The client will need compression or compression hose and/or intermittent pneumatic compression device. The client should perform leg and foot exercises to decrease stagnation of blood. Compression hose, foot and leg exercises, as well as pneumatic compression devices increase venous return and prevents stasis of blood. Other interventions to decrease deep vein thrombosis (DVT) include early ambulation, passive and active range of motion, isometric exercises, and anticoagulant drugs such as heparin. 2. Incorrect: Do not compromise blood flow by placing pillows under the knees, crossing legs, or sitting for long periods of time. When pillows are left under the knees for an extended time, venous return could be compromised. A pillow under the knees is not a recommended intervention for DVT prevention. 5. Incorrect: Do not assess Homan's sign, as it may dislodge a clot. Homan's sign is not a preventative intervention. Assessing a Homan's sign is considered to be controversial, and this test may contribute to the release or dislodgement of a clot.

The nurse is caring for a client who has just arrived at the emergency department with suspected acute myocardial infarction. Which medications should the nurse administer immediately? 1. Oxygen 2. Heparin 3. Morphine 4. Sublingual nitroglycerin 5. Furosemide

1., 3., & 4. Correct: Initial management should take place immediately. According to the American Heart Association/Heart & Stroke Foundation of Canada and the American College of Cardiology, oxygen, SL nitroglycerin, morphine, and aspirin should be administered immediately. The initial goal of therapy for clients with an acute MI is to restore perfusion to the myocardium as soon as possible. Oxygen is appropriate and advisable when hypoxia is present. Pain from acute MI's may be intense and requires prompt administration of analgesia. Morphine sulfate is the medication of choice (2-4 mg every 5-15 minutes). Reducing the myocardial ischemia also helps reduce pain, so oxygen therapy and nitrates are main components of the therapy. The vasodilation effects of morphine and the nitroglycerin improve coronary blood flow and reduce myocardial ischemia. 2. Incorrect: Heparin is not part of the protocol within the guidelines and is not recommended at this time. 5. Incorrect: Furosemide is not part of the protocol within the guidelines and is not indicated at this time.

Following a total hip replacement, the nurse provides discharge teaching to the client. The nurse knows that teaching was effective when the client states which activities are safe to perform? Select all that apply 1. Using an abduction pillow while sleeping 2. Crossing the legs 3. Using a toilet extender 4. Showering rather than taking a bath 5. Tying shoes

1., 3., & 4. Correct: The client should use an abduction pillow to keep hip in proper alignment and prevent hip dislocation. A toilet extender keeps the hip in proper alignment and prevents hip dislocation. Showering rather than sitting in a tub will prevent flexion of the hip.2. Incorrect: Crossing the leg can pop the hip out of place and prevent total healing and success with the replacement. 5. Incorrect: To tie shoes, the client has to bend over which can pop the hip out of place. The client would need to have shoes that do not require tying or have someone do it for them.

Following a total hip replacement, the nurse reinforces discharge teaching to the client. The nurse knows that reinforcement of teaching was effective when the client states which activities are safe to perform? (SATA) 1. Using an abduction pillow while sleeping 2. Crossing the legs 3. Using a toilet extender 4. Showering rather than taking a bath 5. Tying shoes

1., 3., & 4. Correct: The client should use an abduction pillow to keep hip in proper alignment and prevent hip dislocation. A toilet extender keeps the hip in proper alignment and prevents hip dislocation. Showering, rather than sitting in a tub, will prevent flexion of the hip. 2. Incorrect: Crossing the leg can pop the hip out of place and prevent total healing and success with the replacement. 5. Incorrect: To tie shoes, the client has to bend over which can pop the hip out of place. The client would need to have shoes that do not require tying or have someone do it for them.

The clinic nurse answers a call from a client who is voicing intent to commit suicide. The client tells the nurse, "I am sitting here with a bottle of pain killers in my hand." What response by the nurse is appropriate? (SATA) 1. "I want to help you to resolve the problem." 2. "You should drive yourself to the emergency room." 3. "You did the right thing by calling." 4. "I want you to stay on the phone with me." 5. "Someone is calling 911 for an ambulance."

1., 3., 4. & 5. Correct: The nurse wants to establish a positive relationship with the client as quickly as possible. The nurse wants to recognize positive qualities. Keeping the client on the phone may prevent the client from taking the pain killers. The clinic nurse keeps the person on the line as long as possible as this is most important. Losing contact is a threat to the client's safety. This client is planning action with access to the plan. Emergency personnel should be called. 2. Incorrect: The client has a plan and the means available for suicide. The client does not need to drive to the emergency room. The nurse keeps the client on the phone as the 911 call is being activated.

The nurse should reinforce which instructions given to the unlicensed assistive personnel (UAP) about care needed to reduce the risk of infection when a client has an indwelling catheter? (SATA) 1. Check catheter for kinks in the tubing when the client is in the bed or chair. 2. Disconnect the catheter from the bag when measuring output. 3. Wash hands before providing personal care to the client. 4. Ensure that catheter remains secured to the thigh. 5. Make sure that the drainage bag is always below the level of the bladder.

1., 3., 4. & 5. Correct: Tubing that becomes obstructed cannot allow adequate urine flow. The urine flow occurs by gravity. Adequate handwashing before providing care is one defense against infection. Tension on the tubing may cause irritation and subsequent infection. The bag should be below the level of the bladder so that urine flows appropriately. 2. Incorrect: A closed drainage system should be maintained to prevent entry of microorganisms. Disconnecting the catheter from the bag would be incorrect and potentially cause harm to the client.

Which instructions should the nurse give the unlicensed assistive personnel (UAP) about care needed to reduce the risk of infection when a client has an indwelling catheter? Select all that apply 1. Check catheter for kinks in the tubing when the client is in the bed or chair. 2. Instruct the UAP to disconnect the catheter from the bag when measuring output. 3. Wash hands before providing personal care to the client. 4. Ensure that catheter remains secured to the thigh. 5. Make sure that the drainage bag is always below the level of the bladder.

1., 3., 4. & 5. Correct: Tubing that becomes obstructed cannot allow adequate urine flow. The urine flow occurs by gravity. Adequate handwashing before providing care is one defense against infection. Tension on the tubing may cause irritation and subsequent infection. The bag should be below the level of the bladder so that urine flows appropriately.2. Incorrect: A closed drainage system should be maintained to prevent entry of microorganisms. This would be incorrect and potentially cause harm to the client.

A nurse is caring for a client diagnosed with Alzheimer's disease. What actions should the nurse initiate? (SATA) 1. Monitor client's ability to perform activities of daily living. 2. Perform activities of daily living for the client. 3. Place a clock and calendar in client's room. 4. Encourage family to visit client often. 5. Have nursing staff spend time talking and listening to client.

1., 3., 4., & 5. Correct: All of these should be included in this client's care. Monitor the client's ability to perform activities of daily living and allow client to perform alone if capable. Facilitate orientation by placing items such as a clock, newspaper, and calendar. Encourage family to visit to maintain socialization. Plan for staff to spend some time talking and listening to the client. 2. Incorrect: The staff should facilitate client's independence in all activities for as long as they are able. Encouraging self-care and allowing the client to be involved in activity of daily living (ADL) is a basic right and core principle of client-centered care.

A long-term care nurse is planning care for a newly admitted client diagnosed with Alzheimer's disease. What should the nurse include in the plan of care? Select all that apply 1. Assess client's ability to perform activities of daily living. 2. Perform activities of daily living for the client. 3. Place a clock and calendar in client's room. 4. Encourage family to visit client often. 5. Have nursing staff spend time talking and listening to client.

1., 3., 4., & 5. Correct: All of these should be included in this client's plan of care. Assess the client's ability to perform activities of daily living and allow client to perform alone if capable. Maintain stimuli such as a clock, newspaper, calendar, and/or weather status. Encourage family to visit to maintain socialization. Plan for staff to spend some time talking and listening to the client. 2. Incorrect: Teach staff to facilitate client's independence in all activities for as long as they are able. Encouraging self-care and allowing the client to be involved in activity of daily living (ADL) is a basic right and core principle of planning client-centered care.

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.

What should the nurse include when providing education to a client receiving tetracycline? Select all that apply 1. Wear long sleeves when going outside. 2. Take tetracycline on a full stomach. 3. Wait at least two hours after taking tetracycline prior to taking iron supplements. 4. Tetracycline can decrease the effectiveness of birth control pills. 5. Do not take this medicine after the expiration date on the label has passed.

1., 3., 4., & 5. Correct: Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Tetracycline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun. Take tetracycline on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective. Tetracycline can make birth control pills less effective. Use a second method of birth control while you are taking this medicine to keep from getting pregnant. Throw away any unused tetracycline when it expires or when it is no longer needed. Do not take this medicine after the expiration date on the label has passed. Expired tetracycline can cause a dangerous syndrome resulting in damage to the kidneys. 2. Incorrect: Take tetracycline on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective.

To reduce the risk of developing a complication following balloon angioplasty, the nurse should implement which measure? 1. Monitor cardiac rhythm 2. Assess the puncture site every 8 hours 3. Measure urinary output hourly 4. Prevent flexion of the affected leg 5. Avoid lifting buttocks off the bed

1., 3., 4., & 5. Correct: The primary healthcare provider should be notified of any rhythm changes or report chest pain/discomfort. These could be signs of re-occlusion. Decreased urinary output (UOP) could be due to poor renal perfusion, which can result from decreased cardiac output and shock. Frequent VS and UOP measurements are needed. Flexion should be avoided at the catheter access site to allow time for the clot to stabilize and reduce the risk of bleeding and hematoma formation. The client should avoid lifting the buttocks off the bed because this increases pressure at the insertion site which increases the risk of hematoma formation/bleeding. 2. Incorrect: Assessments are needed more frequently than every 8 hours. Although policies may differ, assessment of the insertion site is usually every 15 minutes for 1 hour, every 30 minutes for 1 hour, and then hourly for 4 hours. More frequent monitoring may be required. During the assessment, the nurse should observe the catheter access site for bleeding or hematoma formation and should assess the peripheral pulses in the affected extremity.

Which signs and symptoms, if noted by the nurse, would indicate that the client with hyperthyroidism is experiencing thyroid crisis? Select all that apply 1. Hyperkinesis 2. Bradycardia 3. Hypertension 4. Restlessness 5. Confusion

1., 3., 4., & 5. Correct: These are symptoms of thyroid crisis and should be reported immediately. 2. Incorrect: Tachycardia would occur, not bradycardia. Bradycardia is a symptom of hypothyroidism.

The parents of a 4 year old child are concerned about whether the child will adapt to the newborn baby they are expecting in two weeks. What suggestions should the nurse make to assist with sibling adaptation? 1. Allow child to be one of the first to see the newborn. 2. Have child stay with parents during labor and delivery. 3. Arrange for one parent to spend time with the child while the other parent cares for the newborn. 4. Provide a gift from the newborn to give to the child. 5. Have child care for a doll.

1., 3., 4., & 5: These are good recommendations for the nurse to make to the parents in an effort to promote sibling adaptation. Make the 4 year old part of the process as much as possible. Demonstrate the importance of the child by allowing the child to see the baby first. Provide personal time with the 4 year old. This shows that the 4 year old is important to the family. The baby is providing a gift to the child which promotes a bond between the two and demonstrates to the child that he or she is important. Having a 4 year old care for a doll gets the child involved in caring for another. The child can learn what a newborn needs both physically and emotionally by imitating the parents. 2. Incorrect: This child is young and may not understand what is happening with their mother during contractions and delivery. Does not promote sibling adaptation. This is a 4 year old who would not understand what is going on during labor and delivery. It can be very frightening to the child and does nothing to support sibling adaptation.

A home health nurse is assessing the home environment for safety issues concerning ambulation. Which finding would require the nurse to counsel the client and family? Select all that apply 1. Dim hall lighting 2. Grab bar in bath tub 3. Nonskid strips on outside steps 4. Throw rug at front entrance to home 5. Waxed linoleum kitchen floor

1., 4., & 5. Correct: Rooms and hallways should have adequate lighting so client can see while ambulating and see any objects which may be in the way. Throw rugs (rugs that are not secured) can slide and cause a fall. Slippery floors will contribute to falls. 2. Incorrect: Adequate supports such as railings and grab bars can help prevent falls. 3. Incorrect: Having nonskid strips on outside steps and inside stairs help prevent falls.

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.

Which interventions are appropriate for the nurse to identify for a client admitted to the psychiatric unit for management of anorexia nervosa? (SATA) 1. Weigh daily at the same time each day. 2. Allow only 20 minutes of exercise daily. 3. Allow the client to bargain for privileges as long as the client eats. 4. Stay with the client during the established time for meals. 5. Maintain visual observation for 1 hour following meals.

1.,4. & 5. Correct: Weigh daily, immediately upon rising and following morning void, using same scale and clothes if possible. The established time for meals is usually 30 minutes. This takes the focus off of food and eating and provides the client with attention and reinforcement. Observation for 1 hour following meals is important to monitor if the client is attempting to discard food stashed from tray or to engage in self-induced vomiting, which could be detrimental to the anorexic client. 2. Incorrect: The client will work with their primary healthcare provider to create a controlled exercise program. This is usually done once healthy eating habits and some weight gain is achieved. See the word "only" in this option and think incorrect. 3. Incorrect: Do not argue or bargain with the client who is resistant to treatment. Be matter of fact about which behaviors are unacceptable and how privileges will be restricted for noncompliance. The person who is denying a problem and who also has a weak ego will use manipulation to achieve control.

Dilantin

10-20

Theophylline

10-20

716. An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? a- 0800, 1200, 1600, 2000 b- Administer with meals and a bedtime snack c- Five in equally divided doses during waking hours d- 1000, 1600, 2200, 0400

1000, 1600, 2200, 0400.

A postoperative surgical client has a prescription for monitoring of intake and output (I&O). The I&O sheet has been picked up by the unlicensed assistive personnel (UAP) for the 7AM-3PM shift. Calculate the client's output for the shift in mL. Intake: IV fluid-1025 mL PRBC-250 mL Output: Urine - 1350 mL NG tube - 75 mL Jackson Pratt - 22 mL

1350 + 75 + 22 = 1447 mL

A postoperative surgical client has a prescription for monitoring of intake and output (I&O). The I&O sheet has been picked up by the unlicensed assistive personnel (UAP) for the 7AM-3PM shift. Intake Output IV fluid-1025 mL Urine - 1350 mL PRBC-250 mL NG tube - 75 mL Jackson Pratt - 22 mL Calculate the client's output for the shift in mL.

1447

The nurse is caring for a client on the surgical unit. The primary healthcare provider prescribed morphine sulfate 20 mg IM one time dose. The nurse has available: morphine sulfate in a 20 mL vial, labeled 15 mg per mL. How many mL should the nurse administer? Record answer using one decimal place.

15 mg: 1 mL = 20 mg: x mL 15x = 20 x= 1.33 = 1.3

Burns

1st Degree - Red and Painful 2nd Degree - Blisters 3rd Degree - No Pain because of blocked and burned nerves

A 13 year old, found unresponsive in the park, is brought into the emergency department. The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and an attempt to call them has been unsuccessful. What action should the nurse take? 1. Obtain consent from the social worker on duty in the emergency department. 2. Begin treatment by inserting two large bore IVs of Normal Saline. 3. Give glucogon IM and wait for the arrival of a parent to consent to further treatment. 4. Withhold treatment until a parent arrives to the emergency department.

2

A child is being admitted with possible rheumatic fever. What assessment data would be most important for the nurse to obtain from the parent? 1. 102° F (38.89° C) temperature that started 2 days previously. 2. History of pharyngitis approximately 4 weeks ago. 3. Vomiting for 3 days. 4. A cough that started about 1 week earlier.

2

A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R 36. The client is extremely anxious and crying uncontrollably. Based on this assessment, the nurse should anticipate that this client is likely in which acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

2

A client diagnosed with major depression has been taking a selective serotonin reuptake inhibitor for the past 6 weeks. When visiting the mental health center, the nurse discusses the medication and response with the client. The nurse's assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation? 1. Are you having trouble sleeping at night? 2. Do you have periods of muscle jerking? 3. Are you having any sexual dysfunction? 4. Is your mood improving?

2

A client diagnosed with major depression is admitted to the psychiatric unit for electroconvulsive therapy (ECT). The client asks the nurse, "How many of these treatments do you think I will need?" What is the nurse's best response? 1. That is a question you need to discuss with your primary healthcare provider. 2. Everyone responds differently, but on average clients need 6-12 treatments. 3. You will need to take a treatment every month for at least a year. 4. Let's just take one treatment at a time, shall we?

2

A client has been admitted with a diagnosis of septic shock and has been successfully intubated. The nurse performs and documents a rapid assessment. Which information from the assessment requires the most immediate action by the nurse? Exhibit 1. Lung assessment finding. 2. Blood pressure reading. 3. Elevated temperature 4. Urine description and output.

2

A client has been prescribed chlorpromazine for the treatment of schizophrenia. The nurse makes afternoon rounds and finds the client's temperature to be 104.7º F/40.4º C. The client has extreme muscle rigidity, and the vital signs have been fluctuating for the last four hours. What should the nurse do first? 1. Provide a tepid sponge bath. 2. Notify the primary healthcare provider immediately. 3. Administer an antipyretic immediately. 4. Administer the chlorpromazine as prescribed.

2

A client has been taught guided imagery as a method to relieve pain. How should the nurse first assess for pain relief after completion of guided imagery by the client? 1. Assess vital signs 2. Use of pain intensity scale 3. Ask client to describe the pain 4. Observe ability to perform activities of daily living

2

A client is in the surgical suite to have a left total knee replacement. Prior to the surgeon initiating the first incision, what should the circulating nurse remind the surgical team to perform? 1. Surgical scrub 2. Time-out 3. Sponge and instrument count 4. Inspection of the surgical site

2

A client received a leg cast that was applied following fracturing the left femur. What assessment finding would be a priority for the nurse to report to the primary healthcare provider? 1. Reports of a feeling of warmness under the cast after application. 2. Pain not relieved by elevation, cold packs, and pain medication. 3. Reports of itching under the cast not relieved by cool air. 4. Slight swelling of the toes of the affected extremity.

2

A client who has developed hypovolemic shock is receiving albumin. What assessment finding by the nurse indicates that the albumin has been effective? 1. Swelling in the legs 2. Increase in uninary output 3. Proteinuria 4. Increase in waist measurement

2

A client with a history of increasing dyspnea over the past week comes to the emergency department. After arterial blood gases (ABGs) are drawn, which information would be important for the nurse to document? 1. The client had not been NPO prior to the test. 2. The client was on 2 L of oxygen by nasal canula. 3. Lung sounds are wet. 4. Client is sitting in upright position.

2

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 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 place the feeding tube down the client. 4. Insert the feeding tube as learned in nursing school.

2

A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book, the nurse crushes the tablet and mixes it into 3 ounces of applesauce. The new nurse proceeds to the client's room. What priority action should the supervising nurse take? 1. Tell the new nurse to recheck the drug reference book before administering the medication. 2. Suggest that the new nurse reconsider the client's developmental needs. 3. Check the prescription order and the client dose. 4. Observe the new nurse administer the medication.

2

A newly admitted client with schizophrenia has an unkempt appearance and needs to attend to personal hygiene. Which statement by the nurse is most therapeutic? 1. A shower will make you feel better. 2. It is time to take a shower. 3. Have you thought about taking a shower? 4. I need you to take a shower.

2

A nurse, assigned to take care of a client who is HIV positive, refuses the assignment, stating fear of personal injury. What action should the charge nurse take first? 1. Re-assign the client to a nurse who does not mind caring for HIV positive clients. 2. Inform the nurse that refusing client care is not acceptable nursing practice. 3. Have the nurse document rationale and support for refusing the client assignment. 4. Transfer the nurse to a unit where there are no HIV positive clients.

2

An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse respond to this? 1. Encourage the family to accept nursing home placement as the best option for their loved one. 2. Listen to the family's concerns and report those to the primary healthcare provider. 3. Ask the client what she wants and tell the family to abide by the client's wishes. 4. Realize that the nurse does not need to be involved in this decision.

2

An elderly client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200 mL/hr via pump. What is the priority nursing action? 1. Intake and output every shift. 2. Lung assessments every 2-4 hours. 3. Vital signs every shift. 4. IV site assessment every 2-4 hours.

2

During the insertion of a urinary catheter, the tip of the catheter touches the client's thigh. What action should the nurse take? 1. Wipe the tip of the catheter with alcohol. 2. Call for another urinary catheter and a pair of sterile gloves. 3. Insert the catheter and obtain a prescription for antibiotics. 4. Leave the room to obtain another sterile urinary catheter kit.

2

The RN is caring for a client diagnosed with an abdominal aortic aneurysm. Which prescription can the RN delegate to the LPN? 1. Obtain vital signs every 15 minutes. 2. Insert a urinary catheter for hourly urinary outputs. 3. Place a PICC line for fluid management. 4. Provide morphine 1 mg per PCA pump at a 10 minute lockout.

2

The charge nurse is evaluating knowledge of tracheostomy suctioning of a new nurse prior to that procedure being performed. Which statement by the new nurse would indicate to the charge nurse that additional education is needed? 1. "Prior to suctioning, I will hyper-oxygenate the client." 2. "I will instill normal saline bullets to liquefy secretions." 3. "I will allow at least 20 seconds between suctioning passes." 4. "Suctioning will be limited to a maximum of three catheter passes."

2

The client at the mental health center has voiced suicidal thoughts and has access to firearms at home. Which action by the nurse is priority? 1. Empathize with the client and listen to feelings. 2. Inform the family and ask them to remove the guns. 3. Chart the thinking pattern and make a follow up appointment. 4. Ask the client to return to the clinic tomorrow for further evaluation.

2

The family member of a schizophrenic client asks the nurse why the client is receiving chlorpromazine and benztropine. What is the best response by the nurse? 1. The chlorpromazine makes the benztropine more effective so a smaller dose of both drugs can be used. 2. Benztropine is given to treat the side effects produced by the chlorpromazine. 3. Chlorpromazine is used for severe hiccups that can occur with the use of benztropine. 4. Chlorpromazine is used for psychosis and benztropine is used for preventing agranulocytosis.

2

The nurse in the emergency department suspects that a client's lesion is caused by anthrax. What assessment question is most important? 1. Have you traveled out of the United States recently? 2. Have you recently worked with any farm animals or any animal-skin products? 3. Have you experienced any gastrointestinal upset recently? 4. Have you eaten any home-canned foods recently?

2

The nurse in the outpatient clinic performs an assessment on a client who takes propranolol for management of palpitations associated with mitral valve prolapse. Which statement by the client should be reported immediately to the primary healthcare provider? 1. "My resting pulse was 60 this morning." 2. "I feel a little short of breath when walking." 3. "I have lost 5 pounds in the last 2 weeks." 4. "My blood pressure (BP) was lower this visit than last time."

2

The nurse is administering the prescribed Mantoux tuberculin skin test to a client. The nurse does not observe the tense blister-like formation at the injection site. Which action should the nurse take? 1. Chart the injection site response as the only action. 2. Administer another Mantoux tuberculin skin test at a different site. 3. Circle the area, wait 48 to 72 hours, and assess for a reaction. 4. Call the primary healthcare provider.

2

The nurse is caring for a client diagnosed with herpes varicella zoster. What pharmacologic agent should the nurse anticipate the primary healthcare provider will prescribe? 1. Metronidazole 2. Acyclovir 3. Ceftriaxone 4. Ampicillin

2

The nurse is caring for a client in the emergency department after a violent altercation with her husband. She describes increasingly violent episodes over the past 10 years. She says, "This is the last time he will hit me." Which response by the nurse demonstrates understanding of the violence cycle? 1. When you leave, you don't have to worry anymore. 2. You are at greatest risk when you leave. 3. That is the best decision you can make. 4. I am glad that you won't be hurt ever again.

2

The nurse is caring for a client who is receiving a prostaglandin agonist for the treatment of glaucoma. Which comment by the client indicates a lack of understanding of the treatment regimen? 1. I must only use the drops in the eye with the increased pressure. 2. My eyes may be different colors, so I will use the drops in both eyes. 3. I must be careful not to overmedicate even if it is just an eye drop. 4. The eyelashes in the eye with the higher pressure may get longer.

2

The nurse is giving discharge instructions to an Asian client following a colonoscopy. During the instructions, the client stares directly at the floor, despite being able to speak English. Based on the client's body language, how would the nurse classify this behavior? 1. Embarrassment. 2. Attentiveness. 3. Disinterest. 4. Confusion.

2

The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider? 1. "When I was 8 years old I had chickenpox." 2. "I had rheumatic fever when I was 10 years old." 3. "There is a strong history of gastric cancer in my family." 4. "I have pain in my hip with any movement."

2

The nurse is teaching a newly diagnosed diabetic about the action of regular insulin. The nurse verifies that teaching has been successful when the client verbalizes being at greatest risk for developing hypoglycemia at what time following the 8:00 a.m. dose of regular insulin? 1. 8:30 AM 2. 11:00 AM 3. 1:30 PM 4. 4:00 PM

2

The nurse is teaching the Type II diabetic about monitoring average blood glucose levels over time. The nurse evaluates teaching has been effective when the client verbalizes the need to return to the clinic for which test? 1. Glucose tolerance test 2. Glycosylated hemoglobin 3. Glucose-6-phosphate dehydrogenase 4. Fasting blood glucose

2

The nurse is working at the triage station. Which client should the nurse triage first? 1. A client with hepatitis A who states, "My arms and legs are itching." 2. A client with a cast on the right leg who states, "My right leg is killing me and nothing I do makes it stop hurting. " 3. A client with nausea and vomiting for two days states, "I am very weak and can't eat." 4. A client with hematuria and reports left flank pain.

2

The occupational health nurse is leading a group discussion about addiction. What should the nurse include as the primary barrier to the client with alcohol addiction seeking treatment? 1. Co-dependency 2. Denial 3. Depression 4. Stigma

2

The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat for an adult client. What is the least amount of time that the nurse can safely administer this medication? 1. 1 minute 2. 2 minutes 3. 5 minutes 4. 10 minutes

2

Which client should the nurse place in the room with a 6 year old with glomerulonephritis? 1. Twenty-two month old diagnosed with respiratory syncytial virus (RSV). 2. Four year old with nephrotic syndrome. 3. Three year old admitted with febrile seizures. 4. Two year old who has a fractured tibia.

2

IV push should go over at least

2 minutes

A nurse educator is explaining the Health Insurance Portability and Accountability Act (HIPAA) of 1996 to a group of nursing students. What points about HIPAA should the nurse educator include? 1. Primary healthcare providers employed at the facility where a client receives treatment can legally access any client's health information at any time. 2. Health related information revealed by a client to healthcare personnel must be kept confidential. 3. The client has the right to access personal healthcare records and to obtain copies of those records. 4. A client's information can be revealed only with the client's permission, or when the primary healthcare provider or facility is required by law to do so. 5. Unlicensed assistive personnel employed where a client receives treatment can legally access any client's health information at any time.

2,3,4

A nurse is caring for a client who delivered a baby vaginally two hours ago. What signs and symptoms of postpartum hemorrhage should the nurse report to the primary healthcare provider? 1. Two blood clots the size of a dime. 2. Perineal pad saturation in 10 minutes. 3. Constant trickling of bright red blood from vagina. 4. Oliguria 5. Firm fundus

2,3,4

The nurse is teaching a client regarding buspirone. The nurse recognizes that teaching has been effective when the client makes which statements? 1. "I should start feeling better in two or three days." 2. "I should not drink alcohol while taking this medication." 3. "I will rise slowly from lying to sitting or standing." 4. "I will notify my primary healthcare provider of any unusal facial movements." 5. "I need to keep the medication in a closed container in the refrigerator."

2,3,4

The nurse wants to provide anticipatory guidance for a group of young parents who have children between the ages of 18 months to 3 years. What points about the next year should the nurse be sure to provide these parents? 1. Be strict and rigid with toilet training, rather than being accepting and letting the child lead the training. 2. Tell the parents about the importance of letting the child do tasks alone. 3. Provide finger foods for the child to eat. 4. Your child will want you to provide emotional support when needed. 5. Assist your child with all tasks to promote independence.

2,3,4

A client has been admitted to the medical unit and placed on airborne precautions for suspected pulmonary tuberculosis (TB). The nurse will assess for which signs and symptoms? 1. Weight gain 2. Fatigue 3. Hemoptysis 4. Diaphoresis during sleep 5. Anorexia

2,3,4,5

A nurse is calling the primary healthcare provider about a client who is experiencing dyspnea and chest pain two days post total knee replacement. Which statements by the nurse are appropriate according to the communication tool SBAR (Situation, Background, Assessment and Recommendation)? 1. "Hello Dr, I am calling about one of your clients." 2. "Jane Doe is having increasing dyspnea and is reporting chest pain." 3. "Jane Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Resp 32. She is restless." 4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism." 5. "I recommend that you see the client immediately and that we start oxygen stat. Do you agree?"

2,3,4,5

The school nurse has identified a large outbreak of viral conjunctivitis among one middle school class and plans to educate these students on this illness. Which data should the nurse be sure to include? 1. Use personal handkerchief to wipe the eye of discharge. 2. Light cold compresses over the eyes several times a day will ease discomfort. 3. Do not share towels or linens. 4. Discard all makeup and use new makeup after infection resolves. 5. Wash hands frequently with soap and water.

2,3,4,5

The nurse on a neuro rehabilitation unit is caring for a client with a T4 lesion. The client suddenly reports a severe, pounding headache. Profuse diaphoresis is noted on the forehead. The blood pressure is 180/112 and the heart rate is 56. What interventions should the nurse initiate? 1. Place client supine with legs elevated. 2. Assess bladder and bowel for distention. 3. Examine skin for pressure areas. 4. Eliminate drafts. 5. Remove triggering stimulus. 6. Administer hydralazine if BP does not return to normal.

2,3,4,5,6

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.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Check client for signs of skin breakdown. 2. Check client's vital signs after ambulating. 3. Administer 8 ounces of polyethylene glycol electrolyte solution every 10 minutes. 4. Obtain a stool specimen. 5. Determine what activities the client can do independently.

2. & 4. Correct. These tasks are within the scope of practice for the UAP. 1. Incorrect. The UAP cannot assess the client for signs of skin breakdown. 3. Incorrect. The UAP cannot administer medication. 5. Incorrect. The UAP cannot assess which activities that the client can perform.

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 68 year old client was admitted two days ago to a long-term care facility. The client has chronic kidney disease, coronary artery disease and chronic obstructive pulmonary disease. Oxygen 2 L/per nasal cannula is being administered. Assistance is needed with activities of daily living. The primary healthcare provider visits today and writes new prescriptions. Who is the best person for the charge nurse to delegate carrying out these prescriptions? Sputum for culture and sensitivity Incentive spirometry every 2 hours while awake Monitor SaO2 every 4 hours Levofloxacin 250 mg by mouth every 8 hours 1. Unlicensed assistive personnel (UAP) 2. LPN/LVN 3. RN 4. Charge Nurse

2. Correct. All the nursing responsibilities associated with the healthcare provider's prescriptions are within the scope of practice of the LPN/LVN. 1. Incorrect. Giving medications is out of the scope of practice of the Unlicensed assistive personnel (UAP). 3. Incorrect. All the nursing responsibilities associated with the healthcare provider's prescriptions are within the scope of practice of the LPN/LVN. The RN would need to be assigned to more unstable clients than this one. 4. Incorrect. The charge nurse is responsible for assuring that all client care is provided during the shift, so carrying out these prescriptions is not the best use of time and resources available to the charge nurse

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.

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 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 place the feeding tube down the client. 4. Insert the feeding tube as learned in nursing school.

2. Correct. The best action for the nurse to take is to look up how the procedure is done in the agency by looking it up in the policy and procedure manual. The nurse could then discuss the procedure with an experienced nurse and ask the nurse to observe the new nurse while inserting the feeding tube. 1. Incorrect. This is passive and would not benefit the new nurse to strengthen the skills. The best action would be to look up how to do the procedure, discuss with another nurse, and ask that nurse to observe the insertion of the feeding tube. 3. Incorrect. This is not the best option. The new nurse needs to insert the feeding tube in order to become more proficient with this skill. This option will not help the new nurse gain confidence in nursing skills. 4. Incorrect. Although the new nurse should have the basic knowledge of feeding tube insertion, the nurse should follow agency policy and procedure. It is then best to discuss the procedure with another nurse and ask the nurse to observe the feeding tube insertion since this nurse has never performed the skill.

A nurse, assigned to take care of a client who is HIV positive, refuses the assignment, stating fear of personal injury. What action should the charge nurse take first? 1. Re-assign the client to a nurse who does not mind caring for HIV positive clients. 2. Inform the nurse that refusing client care is not acceptable nursing practice. 3. Have the nurse document rationale and support for refusing the client assignment. 4. Transfer the nurse to a unit where there are no HIV positive clients.

2. Correct. This action by the charge nurse demonstrates an understanding of the code of ethics for nurses. Any nurse who feels compelled to refuse to provide care for a particular type of client faces an ethical dilemma. The reasons given for refusal range from a conflict of personal values to fear of personal risk of injury. Such instances have increased since the advent of acquired immunodeficiency syndrome (AIDS) as a major health problem. The ethical obligation to care for all clients is clearly identified in the first statement of the Code of Ethics for Nurses. To avoid facing these moral and ethical situations, a nurse can follow certain strategies. For example, when applying for a job, one should ask questions regarding the client population. If one is uncomfortable with a particular situation, then not accepting the position would be an option. Denial of care, or providing substandard nursing care to some members of our society, is not acceptable nursing practice. As a professional, the nurse should provide the same level of care to every client, regardless of diagnosis, skin color, ethnicity or economic status. 1. Incorrect: This is not the best action for the charge nurse to take.The charge nurse should remind the nurse of the responsibility for the agency to provide nondiscriminatory care to all clients. The re-assignment of the client to another nurse does not resolve the ethical dilemma by the nurse refusing to provide care. 3. Incorrect: The nurse can inform the employer of the reluctance to care for a certain population, but must provide strong rationale and documentation to support the necessity for refusal of the assignment. Recognition by the organization of an individual nurse's right to refuse to care for a specific client population sets a major personnel precedent and will not be made lightly. A health care agency has a responsibility to provide care for all clients accepted into the organization. Due to this responsibility the nurse cannot be guaranteed that he/she will never be asked to provide care for the client in question. 4. Incorrect: This is generally a decision made on a level beyond the charge nurse. This is a last resort after documentation and consideration by management to accept the nurse's request. If honored, the nurse should expect to be transferred. However, the nurse may encounter the situation again.

Which client should the nurse place in the room with a 6 year old with glomerulonephritis? 1. Twenty-two month old diagnosed with respiratory syncytial virus (RSV). 2. Four year old with nephrotic syndrome. 3. Three year old admitted with febrile seizures. 4. Two year old who has a fractured tibia.

2. Correct. This child is not infectious and could be placed in the room with the child who has glomerulonephritis. Since the children are close in age, they will adapt well together. 1. Incorrect. Respiratory syncytial virus (RSV) is a common and highly contagious virus that infects the respiratory tract of many children before their second birthday. This client requires contact and droplet precautions and should not be in the room with the client who has glomerulonephritis. 3. Incorrect. Febrile seizures are one of the most common neurologic childhood problems often caused by a fever with a viral infection. Although the underlying infection is not identified, this child with a probable infection should not be placed in the room with the client with glomerulonephritis. 4. Incorrect. Although this child is not infectious, it is not the best option because the child is too young to be in the room with the 6 year old. Place children within the same age group together whenever possible.

The nurse is teaching a newly diagnosed diabetic about the action of regular insulin. The nurse verifies that teaching has been successful when the client verbalizes being at greatest risk for developing hypoglycemia at what time following the 8:00 a.m. dose of regular insulin? 1. 8:30 AM 2. 11:00 AM 3. 1:30 PM 4. 4:00 PM

2. Correct: 11:00 AM: Regular insulin peaks 2-3 hours after administration. Clients are at greatest risk for hypoglycemia when insulin is at its peak. 1. Incorrect: 8:30 AM: Rapid acting insulin will begin peaking in 30 minutes. 3. Incorrect: 1:30 PM: Intermediate acting insulin begins peaking at 4 hours. So at 1:30 PM this would be a time of worry. 4. Incorrect: 4:00 PM: At 4 PM you would still be worried about intermediate acting insulin. But you would also be worried about long acting insulin as well. Which starts to peak at 6 hours.

What information should the nurse reinforce about decreasing the risk of spreading influenza? 1. Influenza is transmitted via the influenza vaccine. 2. Use a shirtsleeve when coughing or sneezing if tissue is not available. 3. Tissues are not effective in decreasing the spread of influenza. 4. Antibiotics are effective in treating influenza.

2. Correct: A shirtsleeve should be used as a barrier when coughing or sneezing if tissue is not available. This prevents germs being spread via the hands. 1. Incorrect: The vaccine contains a dead virus that is not capable of causing influenza. Clients may experience influenza symptoms from the vaccine, but they won't contract the full-fledged virus. 3. Incorrect: Tissues are effective in decreasing the spread of influenza if disposed of in the trash after use. 4. Incorrect: Antibiotics are not effective in treating influenza. Influenza is treated with antipyretics, fluids, and rest.

The nurse is participating in educating a group of parents about the importance of immunizing their daughters against the human papillomavirus (HPV) in an effort to prevent the development of which cancer? 1. Breast 2. Cervical 3. Ovarian 4. Uterine

2. Correct: A vaccine that offers protection from the virus responsible for most cases of cervical cancer is the latest addition to the official childhood immunization schedule. The HPV vaccine is recommended for boys and girls at age 11 or 12 so they are protected before ever being exposed to the virus. 1. Incorrect: This vaccine does not offer protection for breast cancer. HPV does not increase the risk for breast cancer. 3. Incorrect: This vaccine does not offer protection for ovarian cancer. HPV does not increase the risk for ovarian cancer. 4. Incorrect: This vaccine does not offer protection for uterine cancer. HPV does not increase the risk for uterine cancer.

A client with schizophrenia tells the nurse, "I want you to take me to the uniphorum". Which statement would be most appropriate for the nurse to make? 1. "You don't even know what you are saying. Stop making up words". 2. "I don't understand what you mean by that. Would you please explain it to me"? 3. "Think about what you are trying to say, then try again". 4. "I will take you after I finish handing out medications".

2. Correct: Attempt to decode incomprehensible communication patterns. Seek validation and clarification. These techniques reveal to the client how he or she is being perceived by others, and the responsibility for not understanding is accepted by the nurse. 1. Incorrect: Do not argue or belittle clients. This is nontherapeutic. This places all responsibility for communication on the client and suggests that the nurse believes the client is defective. This would likely frustrate and distress the client and reduce self-esteem. 3. Incorrect: Cognitive impairment is persistent rather than momentary, so asking the client to do this will be difficult. 4. Incorrect: Pretending to understand is nontherapeutic because it gives the false impression that the client is communicating effectively.

The family member of a schizophrenic client asks the nurse why the client is receiving chlorpromazine and benztropine. What is the best response by the nurse? 1. The chlorpromazine makes the benztropine more effective so a smaller dose of both drugs can be used. 2. Benztropine is given to treat the side effects produced by the chlorpromazine. 3. Chlorpromazine is used for severe hiccups that can occur with the use of benztropine. 4. Chlorpromazine is used for psychosis and benztropine is used for preventing agranulocytosis.

2. Correct: Benztropine is used to treat parkinsonism of various causes and drug-induced extrapyramidal reactions seen with chlorpromazine, which is an antipsychotic agent. Extrapyramidal symptoms are neurologic disturbances in the area of the brain that controls motor coordination. This disruption can cause symptoms that mimic Parkinson's disease, including stiffness, rigidity, tremor, drooling and the classic "mask like" facial expression. These symptoms can be treated and are reversible using such medications as benztropine. 1. Incorrect: Chlorpromazine does not potentiate the effects of benztropine, so dosage regulation is not appropriate. 3 Incorrect: Chlorpromazine can be used for severe hiccups, but the hiccups are not the result of using benztropine. Chlorpromazine is also used for psychosis in the schizophrenic client. 4. Incorrect: Benztropine is not used to prevent agranulocytosis.

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 menu selection by the client diagnosed with nephrotic syndrome indicates that reinforcement of dietary teaching was understood? 1. Pancakes with whipped butter, syrup, bacon, apple juice 2. Scrambled eggs, sliced turkey, biscuit, whole milk 3. Grits, fresh fruit, toast, coffee 4. Bagel with jelly, hash browns, tea

2. Correct: Client needs low sodium and increased proteins. 1. Incorrect: This selection is too high in sodium and fats. 3. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine. 4. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine.

Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching of proper diet was understood? 1. Pancakes with whipped butter, syrup, bacon, apple juice 2. Scrambled eggs, sliced turkey, biscuit, whole milk 3. Grits, fresh fruit, toast, coffee 4. Bagel with jelly, hash browns, tea

2. Correct: Client needs low sodium and increased proteins. 1. Incorrect: This selection is too high in sodium and fats. 3. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine. 4. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine.

What precautions should be taken with computer monitors that display client health information to ensure client's confidentiality? 1. Turn the screen facing the client rooms so that healthcare personnel can access the information easily. 2. Have the screen placed facing away from any visitor or client care area. 3. Turn the computer monitors off when the computer is not in use. 4. The computer should be kept in a secured, locked area.

2. Correct: Computer monitors that display client health information should be positioned away from the view of any visitors or unauthorized persons. Even a well-guarded computer monitor, with an authorized employee sitting in front of it, could be a potential breach of confidentiality, depending on the angle of the monitor screen and who was attempting to view the information on it. The responsibility for keeping health information safe is on every member of the healthcare team. 1. Incorrect: No, this would be easily viewed by unauthorized individuals. 3. Incorrect: Not necessary to turn off if proper precautions are taken. 4. Incorrect: Not necessary to keep in secured area if proper precautions are taken.

The nurse in the emergency department suspects that a client's lesion is caused by anthrax. What assessment question is most important? 1. Have you traveled out of the United States recently? 2. Have you recently worked with any farm animals or any animal-skin products? 3. Have you experienced any gastrointestinal upset recently? 4. Have you eaten any home-canned foods recently?

2. Correct: Cutaneous anthrax may be contracted by working with contaminated animal-skin products. Anthrax is found in nature and commonly infects wild and domestic hoofed animals. 1. Incorrect: Cutaneous anthrax is also found in the United States, so asking about travel abroad would not be necessary. 3. Incorrect: Cutaneous anthrax can be contracted by spores entering cuts or abrasions in the skin. This is cutaneous anthrax that causes edema, itching and macule or papule formation, resulting in ulceration. Ingestion of anthrax can cause GI symptoms such as nausea and vomiting, abdominal pain, and bloody diarrhea. Inhalation of anthrax may result in flu-like symptoms that progress to severe respiratory distress. 4. Incorrect: This question would be appropriate if botulism were suspected in a client.

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.

A primary healthcare provider informs the nurse to prepare for an amniotomy on a client who's labor has not progressed. What should the nurse assess for prior to the primary healthcare provider performing this procedure? 1. Fetal attitude 2. Fetal engagement 3. Fetal lie 4. Fetal position

2. Correct: Fetal engagement is important prior to rupturing the membranes so that the umbilical cord cannot prolapse. Fetal engagement is when the fetus is at station 0 (level of mom's ischial spines). 1. Incorrect: Fetal attitude is where the extremities and chin of the fetus are in relation to the fetal body. 3. Incorrect: Fetal lie refers to the maternal spine in relation to the fetal spine. 4. Incorrect: Fetal position tells us the presenting part of the fetus to mom's pelvis.

A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client? 1. "Do you take metronidazole on an empty stomach?" 2. "Are you using any products that contain alcohol?" 3. "How long have you had these symptoms?" 4. "What other medications are you currently taking?"

2. Correct: Flushing, nausea and vomiting, palpitations, tachycardia, psychosis are signs of disulfiram-type reaction seen when using products containing alcohol (cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking metronidazole. 1. Incorrect: Although it is preferable to take metronidazole on an empty stomach, this is not the most important question to ask at this time. 3. Incorrect: How long the client has had these symptoms is not as important as whether the client is using any alcohol containing products. 4. Incorrect: Although the nurse needs to know what other medications the client is taking, it is not as important as knowing if the client is using any alcohol containing products.

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.

The nurse is teaching the Type II diabetic about monitoring average blood glucose levels over time. The nurse evaluates teaching has been effective when the client verbalizes the need to return to the clinic for which test? 1. Glucose tolerance test 2. Glycosylated hemoglobin 3. Glucose-6-phosphate dehydrogenase 4. Fasting blood glucose

2. Correct: Glycosylated hemoglobin (also known as hemoglobin A1C) tests the average blood glucose over 90 days, or 2-3 month time period. Specifically, this test measures the percentage of hemoglobin that is coated with blood sugar (glycated). 1. Incorrect: Glucose tolerance test will show the immediate tolerance or response, to a glucose load. This test is often used to screen for gestational diabetes, and can be used to screen for type II diabetes. However it does not indicate what the blood glucose levels have been over time. 3. Incorrect: Glucose-6-phosphate is an enzyme that assists in maintaining the level of glutathione in erythrocytes to help protect against oxidative damage and breakdown of red blood cells (hemolytic anemia). Deficiency in glucose-6-phosphate dehydrogenase is linked to a genetic defect. This test does not measure blood glucose levels. 4. Incorrect: Fasting blood glucose tests immediate glucose levels, after an overnight fast. This does not indicate what the blood glucose levels have been over time.

Which electrolyte imbalance would be the nurse's priority concern in the burn client? 1. Hypernatremia 2. Hyperkalemia 3. Hypoalbuminemia 4. Hypermagnesemia

2. Correct: Good job. When the cells lyse they release potassium, and then the serum potassium goes up. And if the kidneys stop, we are in real trouble. 1. Incorrect: Well this one does occur when the client becomes very dehydrated, but it's not as dangerous as the potassium one. 3. Incorrect: Low albumin can cause problems keeping fluid in the vascular space, but albumin is not an electrolyte. 4. Incorrect: No, the magnesium doesn't go up unless the kidneys shut down.

Which electrolyte imbalance would be the nurse's priority concern in the burn client? 1. Hypernatremia 2. Hyperkalemia 3. Hypoalbuminemia 4. Hypermagnesemia

2. Correct: Good job. When the cells lyse, they release potassium, and then the serum potassium goes up. And if the kidneys stop functioning, we are in real trouble. 1. Incorrect: Well, hypernatremia does occur when the client becomes very dehydrated, but it's not as dangerous as the potassium one. 3. Incorrect: Low albumin can cause problems keeping fluid in the vascular space, but albumin is not an electrolyte. 4. Incorrect: No, the magnesium doesn't go up unless the kidneys shut down.

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.

The nurse is caring for a client diagnosed with herpes varicella zoster. What pharmacologic agent should the nurse anticipate the primary healthcare provider will prescribe? 1. Metronidazole 2. Acyclovir 3. Ceftriaxone 4. Ampicillin

2. Correct: Herpes varicella zoster is a virus that causes chickenpox in children and shingles in adults. An antiviral such as acyclovir, is indicated. 1. Incorrect: Herpes varicella zoster is a virus; an antiviral is indicated, not a nitroimidazole antimicrobial, such as metronidazole. Metronidazole may have additional classifications such as: amebicide, antibiotic, antibacterial, etc. 3. Incorrect: Herpes varicella zoster is a virus; an antiviral is indicated, not an antibiotic such as ceftriaxone. 4. Incorrect: Herpes varicella zoster is a virus; an antiviral is indicated, not an antibiotic such as ampicillin.

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 client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R 36. The client is extremely anxious and crying uncontrollably. Based on this assessment, the nurse should anticipate that this client is likely in which acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

2. Correct: Hyperventilation due to anxiety, pain, shock, severe infection, fever, liver failure can lead to respiratory alkalosis. With each of these, the client loses too much CO2. The reduction of CO2 creates an excessive loss of acid, resulting in an alkalotic state. Since the problem is respiratory, it is respiratory alkalosis. 1. Incorrect: This problem is respiratory, but there is excessive CO2 loss. CO2 combines with water to form an acid. If too much of the CO2 is lost, the result of the acid forming substance loss would be alkalosis-Not acidosis. 3. Incorrect: The problem in this situation is respiratory in origin and has acid loss. Therefore, it is not metabolic nor acidotic in nature. 4. Incorrect: The problem in this situation is the excessive loss of CO​2 from the respiratory system secondary to hyperventilation. Although the CO2 loss creates an alkalotic state, it is respiratory, not metabolic in origin.

When reinforcing teaching, what symptom would the nurse include as being the most common initial visual change associated with glaucoma? 1. Central vision is lost. 2. Progressive tunnel vision occurs. 3. Sudden flashes of light in the eyes. 4. Eye floaters begin to be noticed.

2. Correct: If glaucoma is not diagnosed and treated early, an individual starts to lose peripheral vision, or the area of vision outside the central field of sight. People who have glaucoma experience tunnel vision and cannot see objects to the side, near the head, or by their feet. Central vision can be lost later if the disease progresses. 1. Incorrect: Central vision loss is the classic visual disturbance for macular degeneration but peripheral vision is usually maintained. 3. Incorrect: Individuals experiencing retinal detachment may have sudden flashes of light in the affected eye, but this is not an initial visual change related to glaucoma. 4. Incorrect: Eye floaters are more common in eye disorders such as retinal detachment or may occur associated with the aging process.

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.

A client, hospitalized with possible acute pancreatitis secondary to chronic cholecystitis, has severe abdominal pain and nausea. The client is kept NPO, an NG tube is inserted, and IV fluids are being administered. What is the rationale for the client being NPO with an NG tube to low suction? 1. Relieve nausea 2. Reduce pancreatic secretions 3. Control fluid and electrolyte imbalance 4. Remove the precipitating irritants

2. Correct: In clients with pancreatitis, the pancreatic enzymes cannot exit the pancreas. These enzymes, when activated, begin to digest the pancreas itself. The enzymes become activated in the pancreas when fluid or food accumulates in the stomach. The goal in treating this client is to stop the activation of the pancreatic enzymes. Treatment is focused on keeping the stomach empty and dry. This allows the pancreas time to rest and heal. Note: Autodigestion (pancreas digesting itself) is painful for the client and can lead to other problems such as bleeding. 1. Incorrect: The primary purpose of the NG tube to suction is to keep the stomach empty and dry to decrease pancreatic enzyme production, not to relieve nausea. 3. Incorrect: Because gastric contents are removed, the NG tube to suction may lead to fluid and electrolyte disturbances rather than helping to control them. 4. Incorrect: Although the food in the stomach causes the pancreatic enzymes to become activated in the pancreas due to the obstruction, the food is not considered an irritant. Precipitating irritants are not a part of the pathophysiology occurring with pancreatitis.

A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What information should the nurse reinforce to help reduce this side effect? 1. Stop taking the medication. 2. Drink plenty of water with the medication. 3. Take the medication before bedtime. 4. An antacid should be taken with the medication.

2. Correct: Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet. 1. Incorrect: There is no need to stop the medication due to mild heartburn. Measures such as those listed above should be utilized to minimize heartburn. However, if extreme pain or difficulty swallowing develops, this should be reported to the primary healthcare provider. 3. Incorrect: The client should take the medication in the morning, thus preventing prolonged contact with the esophagus. 4. Incorrect: The absorption of the medication is decreased when it is taken with calcium, iron, and magnesium, or antacids containing calcium, aluminum, or magnesium. Thirty minutes should elapse before taking the antacid following administration of the alendronate.

A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What should the nurse suggest to reduce this side effect? 1. Stop taking the medication and call the primary healthcare provider. 2. Drink plenty of water with the medication. 3. Take the medication before bedtime. 4. Take antacids when taking the medication.

2. Correct: Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet.1. Incorrect: Slight heartburn does not warrant primary healthcare provider report. Extreme pain or difficulty swallowing should be reported, as should heartburn that increases despite suggestions listed above.3. Incorrect: The client should take in the morning, thus preventing prolonged contact with the esophagus.4. Incorrect: The absorption of the medication is decreased when it is taken with calcium, iron, and magnesium, or antacids containing calcium, aluminum, or magnesium. Thirty minutes should elapse before taking the antacid following administration of the alendronate.

During the insertion of a urinary catheter, the tip of the catheter touches the client's thigh. What action should the nurse take? 1. Wipe the tip of the catheter with alcohol. 2. Call for another urinary catheter and a pair of sterile gloves. 3. Insert the catheter and obtain a prescription for antibiotics. 4. Leave the room to obtain another sterile urinary catheter kit.

2. Correct: Indwelling catheter insertion is a sterile procedure. If contamination occurs, do not turn back on sterile field. Get on the call light to request another urinary catheter and sterile gloves to continue the procedure. Continuing the procedure with contaminated equipment would jeopardize the client's safety. 1. Incorrect: This is a sterile procedure. The catheter needs to be replaced because it is no longer sterile. The client would be at high risk of developing a urinary tract infection. The catheter cannot be made sterile by the use of alcohol. 3. Incorrect: This is a sterile procedure. The catheter needs to be replaced because it is no longer sterile. Inserting the now non-sterile catheter puts the client at risk for infection. There is no reason at this time to start antibiotics. 4. Incorrect: The catheter is contaminated, but the sterile field is still okay. It is more cost efficient to have someone bring the nurse another catheter and pair of sterile gloves rather than getting an entire sterile kit.

The oncoming nurse has just received report and is preparing to make initial rounds. Which postpartum client should the nurse see first? 1. A primipara 6 hours postpartum saturating one peripad every two hours 2. A multigravida 1 hour postpartum and reporting intense perineal pain 3. A primigravida 12 hours postpartum with the uterine fundus at the umbilicus 4. A multigravida 72 hours postpartum with a brownish pink lochia discharge.

2. Correct: Intense perineal pain is a symptom of a perineal hematoma which is a medical emergency. 1. Incorrect: Expected findings for the postpartum period are described here. This is a normal peripad saturation and does not indicate a problem. 3. Incorrect: Expected findings for the postpartum period are described here. This is the proper position of the fundus 12 hours postpartum. 4. Incorrect: Expected findings for the postpartum period are described here also. A client postpartal 72 hours should have a brownish pink lochia discharge.

Which client will the charge nurse intervene on behalf when making rounds? 1. The client turned to left side 1 ½ hour ago. 2. Client who has been sitting in a chair for 2 ½ hours. 3. Client who is day one postop from hip replacement with abduction pillow in place. 4. The client who is in buck's traction with foot boots.

2. Correct: Limit sitting in a chair to less than 2 hours. Prolonged sitting or lying in one position predisposes the client to skin breakdown and other hazards of immobility. 1. Incorrect: Clients should be turned at least every 2 hours, so this client is within the acceptable time frame for being turned. 3. Incorrect: The client with hip replacement needs the abduction pillow. This prevents dislocation of the hip prosthesis by helping to maintain the femoral head component in correct position. 4. Incorrect: The client in buck's traction needs foot boots to avoid foot drop. Therefore, this is an appropriate intervention.

Which nursing intervention should receive priority after a client has returned from having had eye surgery? 1. Administer pain medication around the clock. 2. Maintain head of bed at 35°. 3. Alternate applying warm and cold compresses. 4. Instruct on importance of turning, coughing, and deep breathing.

2. Correct: Maintaining head of bed in an elevated position will help to decrease intraocular pressure. Do not lie the client supine as this will increase intraocular pressure. If the intraocular pressure increases too much, damage to the eye structures, including the retina and optic nerve, with resulting loss of vision may result. 1. Incorrect: Although pain management is important, it is not the priority here. The priority intervention of maintaining the bed at 35° is to reduce the risk of increased intraocular pressure. Unless the pain becomes out of proportion or suddenly worsens, it is an expected finding and would not be cause for alarm or require "priority" attention. 3. Incorrect: Warm and hot compresses could possibly increase intraocular pressure and cause damage to the eye structures. 4. Incorrect: Coughing will increase intraocular pressure and could result in damage to the surgical site and/or the structure within the eye. Loss of vision could result if pressure becomes too great. Coughing is a type of valsalva movement which results in an increase in the intraocular pressure.

Which nursing intervention should receive priority after a client has returned from having had eye surgery? 1. Administer pain medication around the clock. 2. Maintain head of bed at 35°. 3. Apply warm compresses. 4. Instruct on importance of turning, coughing, and deep breathing.

2. Correct: Maintaining head of bed in an elevated position will help to decrease intraocular pressure. Do not lie the client supine as this will increase intraocular pressure. If the intraocular pressure increases too much, damage to the eye structures, including the retina and optic nerve, with resulting loss of vision, may result. 1. Incorrect: Although pain management is important, it is not the priority here. The priority intervention of maintaining the bed at 35° is to reduce the risk of increased intraocular pressure. Unless the pain becomes out of proportion or suddenly worsens, it is an expected finding and would not be cause for alarm or require "priority" attention. 3. Incorrect: Warm and hot compresses could possibly increase intraocular pressure and cause damage to the eye structures. 4. Incorrect: Coughing will increase intraocular pressure and could result in damage to the surgical site and/or the structure within the eye. Loss of vision could result if pressure becomes too great. Coughing is a type of valsalva movement which results in an increase in the intraocular pressure.

A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book, the nurse crushes the tablet and mixes it into 3 ounces of applesauce. The new nurse proceeds to the client's room. What priority action should the supervising nurse take? 1. Tell the new nurse to recheck the drug reference book before administering the medication. 2. Suggest that the new nurse reconsider the client's developmental needs. 3. Check the prescription order and the client dose. 4. Observe the new nurse administer the medication.

2. Correct: Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce a new food during an illness. 1. Incorrect: There is nothing in the stem about a problem with the medication dose or route. 3. Incorrect: There is nothing in the stem about a problem with the medication dose or route. 4. Incorrect: This is an appropriate action. However, it is not the priority over ensuring that the new nurse knows how to appropriately prepare the medication for this client.

A client diagnosed with major depression is admitted to the psychiatric unit for electroconvulsive therapy (ECT). The client asks the nurse, "How many of these treatments do you think I will need?" What is the nurse's best response? 1. That is a question you need to discuss with your primary healthcare provider. 2. Everyone responds differently, but on average clients need 6-12 treatments. 3. You will need to take a treatment every month for at least a year. 4. Let's just take one treatment at a time, shall we?

2. Correct: Most clients require an average of 6 to 12 treatments, but some may require up to 20 treatments. These treatments are generally given two to three times per week for three to four weeks. The number of treatments required depends on the severity of the symptoms and how quickly the client improves. 1. Incorrect: The nurse should be able to answer this question based upon the generally accepted regimen for electroconvulsive therapy (ECT). 3. Incorrect: Treatments are usually administered every other day (three times per week). Since the average number of treatments is 6-12, it only takes a couple of weeks to a month, on average for the regimen. Treatments are performed on an inpatient basis for those who require close observation and care, but can be done on an outpatient basis for some clients. 4. Incorrect: This is poor therapeutic communication. The nurse did not answer the question and is belittling. The client has a right to be able to make informed decisions regarding care being provided.

A client diagnosed with major depression has been taking a selective serotonin reuptake inhibitor for the past 6 weeks. When visiting the mental health center, the nurse discusses the medication and response with the client. The nurse's assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation? 1. Are you having trouble sleeping at night? 2. Do you have periods of muscle jerking? 3. Are you having any sexual dysfunction? 4. Is your mood improving?

2. Correct: Myoclonus, high body temperature, shaking, chills, and mental confusion are some of the symptoms of serotonin syndrome. This client may be having symptoms of this adverse reaction which, if severe, can be fatal. 1. Incorrect: Sleep disturbances are common with depression. Selective serotonin reuptake inhibitors (SSRIs) may cause insomnia; however, there is a more pertinent question needed for assessment of this client. You should be concerned with the more serious or life-threatening issue. 3. Incorrect: Sexual dysfunction may occur with the SSRIs; however, the client is exhibiting significant symptoms of an adverse reaction which would take priority. 4. Incorrect: The response to the SSRI medications is important; however, there is a more significant issue in this case. The possible serotonin syndrome is a serious situation that would be the priority for the nurse to address.

Which action by a nurse indicates to the charge nurse that the sterile field has been contaminated? 1. The sterile field is above the level of the waist. 2. Sterile gauze dressing within the one inch border of sterile field. 3. Remains facing the sterile field throughout procedure. 4. Inspects sterile wrapped instruments for tears.

2. Correct: No sterile object should be within the one inch border of the sterile field as the object is no longer considered sterile. 1. Incorrect: This is a correct action. Bacteria tend to settle below the level of the waist, so there is less contamination when the field is above the waist and away from the nurse. 3. Incorrect: This is a correct action. The nurse should never turn their back to the sterile field. The fronts of sterile gowns are considered sterile from the chest to the level of the sterile field. 4. Incorrect: This is a correct action. The sterile wrapped instruments and trays should be purposely inspected for small tears that would compromise sterility before opening and placing the instruments on the field.

Which action by a new nurse indicates to the supervising nurse that the sterile field has been contaminated? 1. Maintains the sterile field above the level of the waist. 2. Places sterile gauze dressing within the one inch border of sterile field. 3. Remains facing the sterile field throughout procedure. 4. Inspects sterile wrapped instruments for damage.

2. Correct: No sterile object should be within the one inch border of the sterile field, as the object is no longer considered sterile. 1. Incorrect: This is a correct action. Bacteria tend to settle below the level of the waist, so there is less contamination when the field is above the waist and away from the nurse. 3. Incorrect: This is a correct action. The nurse should never turn their back to the sterile field. The fronts of sterile gowns are considered sterile from the chest to the level of the sterile field. 4. Incorrect: This is a correct action. The sterile wrapped instruments and trays should be purposely inspected for small tears that would compromise sterility before opening and placing the instruments on the field.

The nurse is giving discharge instructions to an Asian client following a colonoscopy. During the instructions, the client stares directly at the floor, despite being able to speak English. Based on the client's body language, how would the nurse classify this behavior? 1. Embarrassment. 2. Attentiveness. 3. Disinterest. 4. Confusion.

2. Correct: Nurses must be aware of clients' specific cultural or religious beliefs in order to provide appropriate care and discharge planning. Asian societies have a deep respect for others and making eye contact with the nurse would be considered rude and offensive. The nurse is considered superior to the client, so direct eye contact with a superior shows a lack of respect. This client is displaying attentiveness while also showing respect for the nurse. 1. Incorrect: There is nothing in the question to suggest the client is embarrassed. In Asian cultures, making eye contact is considered disrespectful to the superior; therefore, this client's demeanor is a respectful display of cultural influences. 3. Incorrect: The client's body language does not suggest disinterest. Although staring downward, this client does not display other signs of disinterest. A culturally aware nurse understands that the client's Asian background impacts this behavior and conveys the meaning of respect for the nurses' position. 4. Incorrect: The question indicates that the client does speak English. There is no indication that the client is confused or does not comprehend the discharge instructions. There is a more specific cultural basis for the client's behavior.

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.

A client is scheduled for plateletpheresis. When taking the client's history, which information is most significant? 1. Allergies to shellfish 2. Date last donated 3. Time of last oral intake 4. Blood type

2. Correct: Platelet donors can have plateletpheresis as often as every 14 days. 1. Incorrect: Allergies to shellfish have nothing to do with withdrawing platelets from the client. 3. Incorrect: Time of last oral intake has no bearing on whether or not a client can donate platelets. 4. Incorrect: Blood type has no bearing on whether or not a client can donate platelets.

A client, who is having difficulty falling asleep, asks the nurse for a sleeping aid. What is the first action the nurse should provide to the client? 1. Assist client to take a cool bath. 2. Provide a back massage. 3. Administer prescribed triazolam. 4. Give client a crossword puzzle to work.

2. Correct: Research indicates that back massage can enhance client comfort, relaxation, and sleep. This is the least invasive option and should be done first. 1. Incorrect: A cool bath would wake a client, whereas, a warm bath would increase relaxation. 3. Incorrect: Triazolam is a short acting benzodiazepine. Do not go to the sleeping pill first. 4. Incorrect: Distraction is a good strategy for drawing a client's attention away from pain but may increase thinking, thus keeping the client awake.

A child is being admitted with possible rheumatic fever. What assessment data would be most important for the nurse to obtain from the parent? 1. 102° F (38.89° C) temperature that started 2 days previously. 2. History of pharyngitis approximately 4 weeks ago. 3. Vomiting for 3 days. 4. A cough that started about 1 week earlier.

2. Correct: Rheumatic fever is often the result of untreated or improperly treated group A β-hemolytic streptococcal infections (GABHS), such as pharyngitis. Therefore, the history of pharyngitis or upper respiratory infection is a key assessment finding for establishing a diagnosis of rheumatic fever. Subsequent development of rheumatic fever usually occurs 2 to 6 weeks following the GABHS, so the assessment should include a remote history of pharyngitis. 1. Incorrect: The fever with rheumatic fever is usually low grade and is considered a minor manifestation of rheumatic fever. 3. Incorrect: Vomiting is not a commonly associated symptom with rheumatic fever and is not considered a major manifestation of rheumatic fever. Although the child may have a history of vomiting, this finding would not be specific to rheumatic fever. 4. Incorrect: A cough is not an associated symptom of rheumatic fever. The time frame for the development of rheumatic fever is not appropriate if the cough started 1 week earlier, even if it had been associated with an upper respiratory streptococcal infection.

A newly admitted client with schizophrenia has an unkempt appearance and needs to attend to personal hygiene. Which statement by the nurse is most therapeutic? 1. A shower will make you feel better. 2. It is time to take a shower. 3. Have you thought about taking a shower? 4. I need you to take a shower.

2. Correct: Schizophrenia is a thought disorder. Many clients with schizophrenia are concrete thinkers and have difficulty making decisions. The nurse needs to be direct, clear and concise in communicating with the client. This is a direct, clear and concise statement that guides the client to perform the needed activity. 1. Incorrect: Many clients with schizophrenia are concrete thinkers. The nurse needs to be direct, clear and concise in communicating with the client. The client may not comprehend how the shower improves the overall sense of well-being and would remain reluctant to take the shower. 3. Incorrect: Clients diagnosed with schizophrenia often have trouble making decisions. The client needs to be guided with simple, direct instructions. 4. Incorrect: This focuses on the nurse's need, not the client's need. Do not select answers that focus on the nurse. This does not improve the client's decision making ability nor does it provide guidance to the client for meeting the hygiene needs.

Which baseline data would tell the nurse that a school aged child is at risk for obesity? 1. Spends one hour playing sports or swimming daily. 2. Spends at least two hours watching TV after dinner each day. 3. Assists mom in preparing low carb snacks for the family. 4. Participates in the marching band at school.

2. Correct: Sedentary activities, such as watching television, playing video games, and using a computer to surf the internet or engage with friends can also contribute to obesity and cardiovascular health problems in later life. 1. Incorrect: The more active the child is, the less likely the child is to be overweight. Activity for at least one or more hours per day should be encouraged. 3. Incorrect: Children who are exposed to healthy snacks are less likely to be overweight and are more likely to choose healthy snacks. 4. Incorrect: The marching band is an excellent source of exercise for the child. This information does not support the risk for obesity.

A nurse is educating the parents of a child with celiac disease. The nurse knows the teaching is successful if the parents choose which food for their child's dinner? 1. Turkey and lettuce sandwich on rye bread 2. Sirloin steak and diced baked potatoes 3. Chicken, vegetables and a whole wheat roll 4. Hotdog and baked beans

2. Correct: Steak and potatoes are gluten free. 1. Incorrect: Client's with celiac disease should maintain a gluten free diet. Rye bread contains gluten. 3. Incorrect: Client's with celiac disease should maintain a gluten free diet. Wheat contains gluten. 4. Incorrect: Client's with celiac disease should maintain a gluten free diet. Processed meats such as hotdogs and most sausages contain gluten.

Which nursing intervention can the LPN/LVN safely perform? 1. Assess a client for a hearing loss. 2. Reinforce hand-washing with the client who has bacterial conjunctivitis. 3. Evaluate a client's ability to instill eye medication. 4. Create the plan of care for a client post cataract surgery.

2. Correct: The LPN/VN can reinforce education. The LPN/VN must know the scope of practice of the LPN/VN 1. Incorrect: The LPN/VN cannot instruct, assess, evaluate, or create the plan of care. These are RN tasks only. 3. Incorrect: The LPN/VN cannot instruct, assess, evaluate, or create the plan of care. These are RN tasks only. 4. Incorrect: The LPN/VN cannot instruct, assess, evaluate, or create the plan of care. These are RN tasks only.

The nurse is caring for a client who is to receive an IV infusion of heparin. The client's dose is based on a sliding scale prescription. What is the priority lab value to check before initiating the heparin infusion? 1. PT and/or INR 2. aPTT 3. Platelet count 4. WBC count

2. Correct: The activated partial thromboplastin time (aPTT) is a lab value used to assess pathways in the clotting cascade and is used to monitor Heparin therapy in clients. To maintain a therapeutic level of Heparin, the aPTT should be maintained at 1.5-2.5 times the normal range. 1. Incorrect: The PT and INR are lab values used to monitor warfarin therapy in clients3. Incorrect: The platelet count measures an individual's total platelet count. Thrombocytopenia is a platelet count of < 100,000. Thrombocytopenia increases the risk of bleeding; however, since the aPTT directly measures heparin therapy, it is the priority value to monitor.4. Incorrect: The White Blood Cells (WBC) are not involved in the body's mechanism for clotting.

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.

The six bed Labor and Delivery area is full when the Emergency Department nurse calls for a bed for a woman reporting low back pain, pelvic pressure and increased vaginal discharge at 36 weeks gestation. Which would be the most appropriate action for the charge nurse? 1. Transfer a G4P4 who delivered full-term twins one hour ago to the antepartum/postpartum floor. 2. Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the antepartum/postpartum floor. 3. Transfer an 8 hour postpartum G1P1 on Magnesium Sulfate for eclampsia from the LDR unit to the ante/postpartum unit. 4. Request that the new client be admitted to the antepartum/postpartum floor.

2. Correct: The client and newborn are not in any present distress. Also the delivery occurred 3 hours ago. This client would not be a risk and could be cared for on the antepartum/postpartum floor. 1. Incorrect: This client is at high risk for hemorrhage due to still being in the fourth stage of labor and over distention of her uterus with a term multiple gestation. This client needs to stay in current location for close monitoring.3. Incorrect: Close monitoring and frequent vital signs are required since central nervous system alterations and respiratory depression are common side effects of Magnesium Sulfate. 4. Incorrect: This client has subtle signs and symptoms of preterm labor and needs close monitoring. Ante and postpartum unit is for stable clients.

The nurse is caring for a client admitted to the skilled nursing unit approximately 3 months ago. Since admission, the client has lost 8 pounds. There have been no documented changes in the client's physical health. Which strategy may help to improve caloric intake for this client? 1. Encourage the client to eat meals in the room. 2. Take the client to the dining room for all meals. 3. Provide a high protein supplement 30 minutes before meals. 4. Ask the unlicensed assistive personnel to feed the client at each meal.

2. Correct: The client may be lonely and miss the interaction with others, but reluctant to go to the dining room. Eating with others may help to improve appetite and intake of food. The nurse can actively seek out the client and take this client to the dining room. Simply encouraging the client to go to the dining room may not be sufficient to get the client to go. 1. Incorrect: Eating alone may actually lead to reduce food intake. Eating is also a social activity. 3. Incorrect: A high protein supplement may increase caloric intake; however, to give that to the client 30 minutes before a meal will interfere with food intake at mealtime. 4. Incorrect: Assisting the client is important if the client cannot do it, however, there is no data to suggest that the client cannot eat independently. It is important to help the clients maintain their maximum level of independence.

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.

The nurse is caring for a client who is receiving a prostaglandin agonist for the treatment of glaucoma. Which comment by the client indicates a lack of understanding of the treatment regimen? 1. I must only use the drops in the eye with the increased pressure. 2. My eyes may be different colors, so I will use the drops in both eyes. 3. I must be careful not to overmedicate even if it is just an eye drop. 4. The eyelashes in the eye with the higher pressure may get longer.

2. Correct: The color of the iris may darken in the eye being treated; however, it is important that the client understand that drops should not be placed in the unaffected eye. Prostaglandins cause increased permeability in the sclera to aqueous fluid. So, as the prostaglandin agonist increases this activity, the outflow of aqueous fluid increases and the ocular pressure decreases. Administering the drops in the unaffected eye may result in a subnormal intraocular pressure. 1. Incorrect: This comment shows adequate understanding. The client should only treat the eye with the increased pressure. 3. Incorrect: This comment demonstrates that the client does understand the treatment regimen. Overmedicating the affected eye could reduce the intraocular pressure too much. 4. Incorrect: This comment shows understanding. The lashes in the eye being treated will lengthen as opposed to the untreated eye. The changes of the eyelashes (increased length, thickness, pigmentation and number of lashes) are typical with these eye drops and are viewed as a benefit by many clients.

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.

The client at the mental health center has voiced suicidal thoughts and has access to firearms at home. Which action by the nurse is priority? 1. Empathize with the client and listen to feelings. 2. Inform the family and ask them to remove the guns. 3. Chart the thinking pattern and make a follow up appointment. 4. Ask the client to return to the clinic tomorrow for further evaluation.

2. Correct: The family should be notified. Suicidal thinking is one condition that necessitates breach of confidentiality. The client has identified a plan and has access to firearms; therefore, the family should remove them from the house. Client safety is a priority. This client will likely be directly admitted to the hospital. 1. Incorrect: This is appropriate; however, client safety is priority at this time. Suicide risk is higher when a plan is expressed and lethal means are available. 3. Incorrect: Charting the thinking pattern is an appropriate action; however, the priority at this time is the client's safety. Suicide risk is higher when a plan is expressed and lethal means are available. Making a follow up appointment would be delaying care for the immediate action that is needed to protect the client. 4. Incorrect: Suicide risk is higher when a plan is made and lethal means are available. Asking the client to return to the clinic tomorrow would be delaying care for the immediate action that is needed to protect the client. It is likely that this client will be admitted directly to the hospital.

The client in the manic phase of bipolar disorder begins climbing onto a table in the dayroom and shouts, "I can fly! I can fly! Watch me fly!" What should be the initial intervention by the nurse? 1. Leave the client alone and remove clients from the dayroom. 2. Call for personnel to escort the client out of the day room. 3. Restrain the client, and notify the primary healthcare provider. 4. Tell the client that there is no way that a person can fly.

2. Correct: The first priority is the safety of the client. If the client jumps off the table, this action may cause an injury to the client. The nurse may need extra help in case the client becomes violent. 1. Incorrect: The client may cause self injury by jumping from a table and should not be left alone. The other clients can be moved away from the table or removed from the dayroom. 3. Incorrect: The primary healthcare provider does not need to be notified at this time. Restraints should be used as a last resort. 4. Incorrect: The safety of the client at this time is the priority intervention. Presenting a client with reality is a therapeutic communication technique.

The client in the manic phase of bipolar disorder begins climbing onto a table in the dayroom and shouts, "I can fly! I can fly! Watch me fly!" What should be the initial intervention by the nurse? 1. Leave the client alone and remove clients from the dayroom. 2. Call for personnel to escort the client out of the day room. 3. Restrain the client, and notify the primary healthcare provider. 4. Tell the client that there is no way that a person can fly.

2. Correct: The first priority is the safety of the client. If the client jumps off the table, this action may cause an injury to the client. The nurse may need extra help in case the client becomes violent. 1. Incorrect: The client may cause self injury by jumping from a table. The other clients are not in danger. 3. Incorrect: The primary healthcare provider does not need to be notified at this time. Restraints should be used as a last resort. 4. Incorrect: Presenting a client with reality is a therapeutic communication technique. The safety of the client at this time is the priority intervention.

The nurse has observed that the client on the skilled nursing unit has been consuming fewer calories over the past three days. There has been no other change in the client's condition. Which intervention is most important for the nurse to initiate? 1. Suggest that the family seek an appointment with the primary healthcare provider. 2. Ask the dietician to visit the client and discuss food preferences. 3. Note any weight loss over the next month. 4. Continue to monitor intake over the next couple of weeks.

2. Correct: The nurse is using the expertise of other team members by requesting that the dietician visit the client. This is the most important measure to address the client's nutritional needs. The problem may be that the client simply does not like the foods that have been served, and the dietician is the best one to address these issues. 1. Incorrect: An appointment with the primary healthcare provider may not be necessary. It is best to first utilize available team members such as the dietician. The nurse would then notify the primary healthcare provider of any pertinent findings. 3. Incorrect: To simply monitor weight loss for a month would not be an appropriate intervention. There could be significant weight loss within a month. This is much too long to wait before taking measures to ascertain the reason for the client consuming fewer calories. 4. Incorrect: The nurse should monitor intake and weight over the next couple of weeks; however, there is a more immediate action that is appropriate. The nurse takes action by asking the dietician to see the client.

A nurse drops a glass bottle, which shatters on the floor in the hallway. What action should the nurse take? 1. Notify housekeeping to clean up the spill. 2. Pick up glass with a broom and dustpan and dispose into a puncture resistant sharps container. 3. Pick up the glass with gloved hands and dispose into a puncture resistant sharps container. 4. Use a wet mop to collect the glass and dispose of it in the garbage can.

2. Correct: The nurse must not be cut by the broken glass. Proper removal of glass includes using a dustpan and broom to collect the glass and disposing of it into a puncture resistant sharps container. 1. Incorrect: While waiting for housekeeping, someone could fall or get cut. The nurse should initiate cleanup. 3. Incorrect: Hands are never used to pick up glass, even if they are gloved, because of the increased risk of getting cut. 4. Incorrect: A wet mop will not pick up the glass, and glass pieces will stick to a wet mop.

A nurse drops a bottle of IV fluid, which shatters on the floor in the hallway. What action should the nurse take? 1. Notify housekeeping to clean up the spill. 2. Pick up glass with a broom and dustpan and dispose into a puncture resistant sharps container. 3. Pick up the glass with gloved hands and dispose into a puncture resistant sharps container. 4. Use a wet mop to collect the glass and dispose of it in the garbage can

2. Correct: The nurse must not be cut by the broken glass. Proper removal of glass includes using a dustpan and broom to collect the glass and disposing of it into a puncture resistant sharps container.1. Incorrect: While waiting for housekeeping someone could fall or get cut. The nurse should initiate cleanup.3. Incorrect: Hands are never used to pick up glass even if they are gloved because of the increased risk of getting cut.4. Incorrect: A wet mop will not pick up the glass, and glass pieces will stick to a wet mop.

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 primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat for an adult client. What is the least amount of time that the nurse can safely administer this medication? 1. 1 minute 2. 2 minutes 3. 5 minutes 4. 10 minutes

2. Correct: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. 1. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. Giving this dose over only one minute could lead to these or other potential harmful effects. 3. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. Five minutes would be longer than required to be able to safely administer the medication. 4. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. Ten minutes is much longer than required to be able to safely administer the medication.

Which action by two unlicensed nursing personnel (UAPs), while moving the client back up in bed, would require intervention by the nurse? 1. Lowers the side rails closest to them. 2. Places hands under client's axilla. 3. Lowers the head of bed. 4. Raises the height of the bed.

2. Correct: This action is not appropriate and requires intervention by the nurse. This could damage the brachial plexus nerves under the axilla. Use a draw sheet to prevent this from occurring. 1. Incorrect: This is a correct action. The UAPs will need to lower the side rails closest to them to safely move the client up in bed. Not lowering the rails could result in injury to the UAPs' backs. 3. Incorrect: This action is correct. Moving the client upward with the head of the bed raised works against gravity, requires more force, and can cause back strain. 4. Incorrect: This action is appropriate and would not require intervention by the nurse. Raising the height of the bed brings the client close to the UAPs center of gravity and decreases the chance of back injury.

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.

An emergency department (ED) nurse working triage has assessed four clients. Which client should receive the highest priority? 1. Alert client who fell on the side walk. Skin warm and dry to the touch, with a three inch laceration on the right knee continuously oozing dark red liquid. 2. Elderly client who moans when the nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds. 3. A client who "passed out" but regained consciousness when feet were elevated. Awake and confused, with warm and dry skin. 4. An alert, responsive client who reports severe abdominal and shoulder pain that began two hours after eating at a local fast food restaurant. Skin is warm and dry.

2. Correct: This client is responding to verbal stimuli by moaning and has an open airway; but any client with an altered level of consciousness is at risk for airway obstruction. The skin assessment indicates a circulation problem. 1. Incorrect: This client demonstrates no signs of life threatening problems. The client is stable. 3. Incorrect: This client has an open airway and the skin findings do not suggest a circulation problem. This client is confused but alert, so lower priority. 4. Incorrect: The client is alert and talking so the airway is open. The client's skin findings do not suggest a circulation problem. This client has no immediate life-threatening problems.

When assessing a client, the nurse finds that in response to painful stimuli the upper extremities exhibit flexion of the arm, wrist, and fingers with adduction of the limb, while the lower extremity exhibits extension, internal rotation, and plantar flexion. How would the nurse accurately document this finding? 1. Decerebrate posturing 2. Decorticate posturing 3. Reflex posturing 4. Superficial posturing

2. Correct: This describes decorticate posturing because they are moving towards the core of the body. 1. Incorrect: Decerebrate posturing occurs when the client is stimulated, and teeth clench and the arms are stiffly extended, adducted, and hyperpronated. The legs are stiffly extended with plantar flexion of the feet. Abnormal extension occurs with lesions in the area of the brain stem. 3. Incorrect: There is no such condition as reflex posturing. This is a distractor and can be ruled out by focusing on the meaning of the terms and similarities in verbiage. 4. Incorrect: There is no such condition as superficial posturing. This is a distractor and can be ruled out by focusing on the meaning of the terms and similarities in verbiage.

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.

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 nurse is caring for a Mexican-American client post stroke. While in the client's room, a curandero visits at the request of client. What is the best action of the nurse? 1. Leave, and return once the curandero has left. 2. Reinforce client care with the client and curandero. 3. Ask the curandero to leave so that the client can be observed. 4. Explain to the client that the curandero is not a reliable healthcare option.

2. Correct: This is the best course of action for the nurse. The health and healing of a client come from many components, including spirituality, religion, folk remedies, alternative therapies, and modern medicine. Unless something is harmful to the client, it is best to incorporate all components into the care of the person. 1. Incorrect: Leaving will not allow the nurse to discuss and reinforce care of the client with all members of the healthcare team and family. This is a good time to learn about the curandero, health beliefs, etc. 3. Incorrect: The client and family have requested the curandero. Asking him to leave would be insulting. The nurse would not develop a good rapport with the client this way. 4. Incorrect: This does not take into account the client's beliefs in health, wellness, and illness. The nurse should work to incorporate folk medicine from the curandero as long as it will not harm the client.

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.

Which assessment finding would indicate to a nurse that a client receiving chemotherapy may have difficulty maintaining proper nutrition? 1. Fatigue 2. Mucositis 3. Neutropenia 4. Diarrhea

2. Correct: Ulcerations in the oral cavity can make it difficult to chew food or be intolerant to certain foods due to discomfort and pain. Intake may be inadequate as a result of this. 1. Incorrect: Fatigue may make the client tire easily, but ulcerations in the oral cavity will be the primary reason for not wanting to eat. 3. Incorrect: Neutropenia leads to infection. This does not alter intake. 4. Incorrect: Diarrhea may need to be treated by making diet changes. However, the maintenance of nutrition should be focused on intake. The impact of the mucositis should be considered first for maintaining proper nutrition.

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.

A client received 2nd and 3rd degree burns on both arms and the anterior trunk when pouring gas on a burning trash pile. With the percentage of burns indicated, what should the nurse anticipate? 1. Movement of fluid out of the cells into the vascular space. 2. Increased capillary permeability and 3rd spacing of fluids. 3. Rapid fluid shift out of the vascular bed 48 hours after the burn. 4. Severe fluid volume excess in the first 24 hours after the burn

2. Correct: Using the Rule of Nines, the client would have burned approximately 36% of the body. For burns greater than 20-25% of the total body surface area, the nurse should recognize that significant vascular damage occurs which causes increased permeability. The fluid leaks out of the vascular space and out into the tissues (3rd spacing). The client can go into a severe fluid volume deficit and shock. 1. Incorrect: The movement of fluid is out of the vascular space into the tissues, not out of the cells into the vascular space. 3. Incorrect: The majority of fluid shifts out of the vascular bed occur in the first 24 hours. The diuresis phase begins about 48 hours after the burn injury when fluid is returning to the vascular bed. 4. Incorrect: The client is at risk for fluid volume deficit (not fluid volume excess) in the first 24 hours as the fluid leaks out into the tissue.

The nurse is caring for a client in the emergency department after a violent altercation with her husband. She describes increasingly violent episodes over the past 10 years. She says, "This is the last time he will hit me." Which response by the nurse demonstrates understanding of the violence cycle? 1. When you leave, you don't have to worry anymore. 2. You are at greatest risk when you leave. 3. That is the best decision you can make. 4. I am glad that you won't be hurt ever again.

2. Correct: Violence is likely to escalate and may become lethal when the spouse leaves the abusive partner. The risk of death or injury is highest at the time the abused person decides to leave the abusive relationship or shortly after leaving. 1. Incorrect: Just because the victim leaves does not guarantee that the abuser will not follow or find her. The threat of injury or death increases at the time the abused person leaves. This response is giving false reassurance to the abused person. 3. Incorrect: The client should be praised; however, there are risks with both leaving and staying. The client should be informed. The nurse should acknowledge the fear of staying in the relationship and guide the client to resources that can be used to help make informed decisions. 4. Incorrect: Leaving the home and the perpetrator do not guarantee cessation of violence. Again, this only provides false reassurance that the abuser will not find the client and inflict harm.

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.

The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider? 1. BP 150/108 decreases to 138/86 2. Weight gain of 5 pounds (2.27 kg) in one week 3. Urinary output of 1450 mL in 12 hours 4. Apical pulse of 90/min

2. Correct: Weight gain of 5 pounds in one week is a s/s of an adverse effect of ACE inhibitor use. Weight gain is a sign of fluid retention. 1. Incorrect: This is an expected response of an ACE inhibitor. ACE inhibitors block the normal effects of renin-angiotensin-aldosterone system, thereby decreasing the blood pressure. 3. Incorrect: The urinary output is adequate and indicates good renal function and perfusion to the kidneys. 4. Incorrect: The apical pulse is normal.

Which statement, made by a client scheduled for a total laryngectomy, indicates to the nurse a need for further preoperative teaching? 1. After the surgery, I will breathe only through a hole in my neck. 2. My wife will have to get a hearing aid because I will not be able to talk above a whisper. 3. I must have smoke detectors installed at home since I may not be able to smell after surgery. 4. After surgery, I will have a tube going through my nose to my stomach for feeding.

2. Correct: With a total laryngectomy, the vocal cords are removed. The entrance to the trachea is closed, so no air moves upward into the throat or mouth areas. The client will not be able to speak or whisper. The client's wife does not need a hearing aid, so further teaching is necessary. 1. Incorrect: The client will breathe through a hole in his neck (tracheostomy) for the rest of their life. This is a true statement by the client. We are looking for the false statement. 3. Incorrect: Since the entrance to the trachea is closed, the client can no longer move air through the nasopharynx. Therefore, the capacity to smell may be diminished or lost. The ability to smell remains intact because the sensory nerves in the nose are not impacted by the surgery. However, in order to smell normally, air must pass over the sensory cells which is not occurring in this case. This is a true statement by the client. We are looking for the false statement. 4. Incorrect: During surgery, a feeding tube is placed in the stomach or jejunum to assist in nutritional requirements until the surgical area in the throat is healed. With a total laryngectomy, the client will eventually be able to eat because the trachea and esophagus are completely separate from each other. This is a true statement by the client. We are looking for the false statement.

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 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.

Which tasks would be appropriate for the LPN/LVN to assign to an unlicensed assistive personnel (UAP)? (SATA) 1. Ask the client diagnosed with dementia memory-testing questions. 2. Collect the urinary output hourly on the client with renal disease. 3. Demonstrate pursed lipped breathing to the client who has emphysema. 4. Give a tepid sponge bath to the client who has a fever. 5. Assess oxygen saturation on a client experiencing angina.

2., & 4. Correct: The UAP can obtain hourly urine output on clients and can give a tepid sponge bath to a client. The LPN/VN must know what tasks can be assigned to the UAP. 1. Incorrect: The nurse cannot delegate assessment, evaluation, or teaching. This would be an assessment function for the RN to perform. 3. Incorrect: The UAP cannot teach. Demonstration is a method of teaching. This is an RN task. 5. Incorrect: The UAP cannot assess the client experiencing angina. This is an RN task.

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.

Which statements should a nurse make when educating a client about advance directives? 1. Used as guidelines for client treatment should the client's family deem them necessary. 2. Legally binding document. 3. Should be documented in the client's medical record as to whether or not the client has an advance directive. 4. Specifies a client's wishes for healthcare treatment should the client become incapacitated. 5. Allows the client's spouse to make end-of-life decisions.

2., 3. & 4. Correct: Advance directives are legally binding documents. Documentation is required in the medical record as to whether an advance directive exists. If one exists, a copy should be placed in the medical record. The document is prepared by the client detailing wishes for treatment should the client become unable to make informed healthcare decisions. 1. Incorrect: The family's wishes for treatment of the client do not take the place of or negate the client's advance directive. 5. Incorrect: The spouse's wishes for treatment of the client do not take the place of or negate the client's advance directive.

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 nurse educator is explaining the Health Insurance Portability and Accountability Act (HIPAA) of 1996 to a group of nursing students. What points about HIPAA should the nurse educator include? 1. Primary healthcare providers employed at the facility where a client receives treatment can legally access any client's health information at any time. 2. Health related information revealed by a client to healthcare personnel must be kept confidential. 3. The client has the right to access personal healthcare records and to obtain copies of those records. 4. A client's information can be revealed only with the client's permission, or when the primary healthcare provider or facility is required by law to do so. 5. Unlicensed assistive personnel employed where a client receives treatment can legally access any client's health information at any time.

2., 3. & 4. Correct: HIPAA is federal legislation enacted to protect client health information and privacy. Any information the client reveals to healthcare personnel must be kept confidential. Clients have the right to access their personal healthcare records and to obtain copies of the records. A client's health information can be revealed only with the client's permission, or when a healthcare provider or facility is required to do so by law. 1. Incorrect: Healthcare personnel do not have the right to access a client's medical records or health information without treatment necessity. 5. Incorrect: Unlicensed assistive personnel do not have the right to access a client's medical record or health information.

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 wants to provide anticipatory guidance for a group of young parents who have children between the ages of 18 months to 3 years. What points about the next year should the nurse be sure to provide these parents? 1. Be strict and rigid with toilet training, rather than being accepting and letting the child lead the training. 2. Tell the parents about the importance of letting the child do tasks alone. 3. Provide finger foods for the child to eat. 4. Your child will want you to provide emotional support when needed. 5. Assist your child with all tasks to promote independence.

2., 3. & 4. Correct: Letting the child do things on their own will promote a sense of self control and independence during this stage of autonomy versus shame and doubt. Finger foods allow for independence with eating and builds a sense of autonomy. At this age, the child becomes increasingly aware of separateness from the parent. The need is for the parent to be available for emotional support when needed. However, if emotional needs are inconsistently met or if the parent rewards clinging, dependent behaviors and withholds nurturing when the child demonstrates independence, feelings of rage and fear of abandonment may develop in adulthood. The support provided by the parent can lessen feelings of anxiety for the child when the emotional presence is needed. 1. Incorrect: Strict toilet training can result in retention of feces and constipation. In addition, strict toilet training practices before the child is ready can result in frustration and shame. 5. Incorrect: Assisting with all tasks will promote dependence. This does not give the child opportunities to perform age-appropriate tasks independently and gain a sense of autonomy. Notice the word "all"? This conveys a thought or concept that has no exceptions. Words such as just, always, never, all, every, none, and only are absolute and place limits on the statement that generally is considered correct. Statements including these words generally make the statement false as the statement is general and broad and does not allow for exceptions.

Prior to administering medications, the nurse must identify the client using which identifiers? (SATA) 1. Room number 2. Date of birth 3. Identification band 4. Client correctly states name 5. Visitor stating client's name

2., 3. & 4. Correct: The client's date of birth and the client's identification band can be used as the two identifiers per Joint Commission standards. The client may also state their name. Two identifiers must be used. 1. Incorrect: The client's room number or visitor statement is not considered a client identifier. 5. Incorrect: The client's room number or visitor statement is not considered a client identifier.

A nurse is caring for a client in an outpatient clinic. The client lost her husband of 51 years three months ago. Which findings support that the client is experiencing normal grief reactions rather than clinical depression? 1. The client is experiencing anhedonia. 2. The client states, "I have good and bad days." 3. The client smiles at the nurse while talking about her grandchild. 4. The client has a persistent state of dysphoria. 5. The client states, "I am having fewer crying spells."

2., 3. & 5. Correct: A client going through a normal grieving process will experience a mixture of good and bad days. The client experiences moments of pleasure and cries less. 1. Incorrect: Anhedonia is the inability to experience pleasure seen in clinical depression. This would not be a positive sign of normal grieving in a client. 4. Incorrect: Dysphoria is a mood of general dissatisfaction, restlessness, depression, and anxiety. This is often seen in clinical depression.

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.

Which signs and symptoms would the nurse expect to see in a client who has taken prednisone for two months? 1. Weight loss 2. Decreased wound healing 3. Hypertension 4. Decreased facial hair 5. Moon face

2., 3. & 5. Correct: Decreased wound healing is a side effect with prolonged steroid use due to the immunosuppressive effects. All steroid medications, such as prednisone, can lead to sodium retention which then leads to dose related fluid retention. Hypertension is seen due to this fluid and sodium retention. Cushingoid appearance (moon face) is a side effect that is created from the abnormal redistribution of fat from prolonged steroid use. 1. Incorrect: Within one month after corticosteroid administration, weight gain is seen rather than weight loss. 4. Incorrect: Facial and body hair increase with prolonged steroid use. This excessive growth of body hair, known as hirsutism, is one of the numerous potential side effects of prednisone.

The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. Which signs/symptoms are an indication to the nurse that treatment has not been effective? (SATA) 1. Diuresis 2. Dyspnea on exertion 3. Persistent cough 4. Warm, dry skin 5. Heart rate irregular at 118/min 6. Alert and oriented

2., 3. & 5. Correct: When the cardiac output decreases, renal perfusion decreases, which leads to decreased urine output and fluid retention. This leads to difficulty breathing. Tachycardiac and rhythm irregularity are signs of fluid volume excess (FVE) and decreased output. Persistent cough, wheezing, and pink blood tinged sputum are all signs that the client is still sick. 1. Incorrect: Diuresis is what we want, which indicates that the treatment for FVE is effective. 4. Incorrect: Indication of improved cardiac output. 6. Incorrect: Indication of improved cardiac output.

The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. Which signs/symptoms are an indication to the nurse that treatment goals have not been met? Select all that apply 1. Diuresis 2. Dyspnea on exertion 3. Persistent cough 4. Warm, dry skin 5. Heart rate irregular at 118/min 6. Alert and oriented

2., 3. & 5. Correct: When the cardiac output decreases, renal perfusion decreases, which leads to decreased urine output and fluid retention. This leads to difficulty breathing. Tachycardiac and rhythm irregularity are signs of fluid volume excess (FVE) and decreased output. Persistent cough, wheezing, and pink blood tinged sputum are all signs that the client is still sick. 1. Incorrect: No, that is what we want, but there is not enough blood to the kidneys, and the renin angiotensin (aldosterone) mechanism has activated. 4. Incorrect: Indication of improved cardiac output. 6. Incorrect: Indication of improved cardiac output.

What should the nurse include when reinforcing teaching to a female client prescribed doxycycline for the treatment of acne? (SATA) 1. Take this medication with food to maximize absorption. 2. Use a non-hormone method of birth control while taking this medication. 3. Wear protective clothing when outside. 4. Drink plenty of fluids while taking this medication. 5. Iron and calcium supplements can be taken with this medication.

2., 3., & 4. Correct: Doxycycline is a tetracycline antibiotic. Doxycycline can make birth control pills less effective. A non-hormone method of birth control (such as a condom, diaphragm, and/or spermicide) should be used to prevent pregnancy while using doxycycline. Avoid exposure to sunlight or tanning beds. Doxycycline can make you sunburn more easily. Wear protective clothing and use sunscreen (SPF 30 or higher) when outdoors. Take doxycycline with a full glass of water. Drink plenty of liquids while taking this medicine. 1. Incorrect: Take on an empty stomach to maximize absorption, although it may not be tolerated unless administered with food. 5. Incorrect: Do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking doxycycline. Absorption will be altered. For instance, iron can bind to doxycycline in the gastrointestinal tract, which may prevent their absorption into the bloodstream and possibly reduce their effectiveness. To avoid or minimize the interaction, iron containing medications and doxycycline should preferably be taken at least three hours apart in most cases.

What should the nurse include when providing teaching to a female client prescribed doxycycline for the treatment of acne? Select all that apply 1. Take this medication with food to maximize absorption. 2. Use a non-hormone method of birth control while taking this medication. 3. Wear protective clothing when outside. 4. Drink plenty of fluids while taking this medication. 5. Iron and calcium supplements can be taken with this medication.

2., 3., & 4. Correct: Doxycycline is a tetracycline antibiotic. Doxycycline can make birth control pills less effective. A non-hormone method of birth control (such as a condom, diaphragm, spermicide) should be used to prevent pregnancy while using doxycycline. Avoid exposure to sunlight or tanning beds. Doxycycline can make you sunburn more easily. Wear protective clothing and use sunscreen (SPF 30 or higher) when outdoors. Take doxycycline with a full glass of water. Drink plenty of liquids while taking this medicine. 1. Incorrect: Take on an empty stomach to maximize absorption, although may not be tolerated unless administered with food. 5. Incorrect: Do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking doxycycline. Absorption will be altered. For instance, iron can bind to doxycycline in the gastrointestinal tract, which may prevent their absorption into the bloodstream and possibly reduce their effectiveness. To avoid or minimize the interaction, iron containing medications and doxycycline should preferably be taken at least three hours apart in most cases.

The charge nurse on the pediatric unit is reviewing the protocol for blood administration with a staff nurse. Which actions by the staff nurse indicate understanding of blood administration? Select all that apply 1. The blood infusion time was within 6 hours. 2. A filter was used when administering the blood. 3. A second nurse checked the blood compatibility. 4. A set of vital signs was taken 5 minutes after the blood infusion started. 5. One form of client identification were obtained prior to infusion.

2., 3., & 4. Correct: Filters are used when infusing blood. Two nurses must check the blood product label and blood group. Vital signs are checked frequently during a blood transfusion. For example: A baseline set of vital signs are taken, then again 5 minutes after the initiation of the transfusion, then 15 minutes after transfusion started and every 15 minutes for one hour, then every 30 minutes for one hour, then hourly until infusion is complete. 1. Incorrect: Blood should hang for no longer than 4 hours because it increases the chances of a reaction. 5. Incorrect: At least two methods of proper identification should be obtained, such as asking client his/her name and checking ID band.

A nurse is caring for a client who delivered a baby vaginally two hours ago. What signs and symptoms of postpartum hemorrhage should the nurse report to the primary healthcare provider? 1. Two blood clots the size of a dime. 2. Perineal pad saturation in 10 minutes. 3. Constant trickling of bright red blood from vagina. 4. Oliguria 5. Firm fundus

2., 3., & 4. Correct: Lochia should not exceed an amount that is needed to partially saturate four to eight peripads daily, which is considered a moderate amount. Perineal pad saturation in 15 minutes or less is considered excessive and is reason for immediate concern. Saturation of a peripad in one hour is considered heavy. Also, trickling of bright red blood from the vagina can indicate hemorrhage and is often a result of cervical or vaginal lacerations. Bright red blood indicates active bleeding. Oliguria is a sign of fluid volume deficit. As blood volume goes down, renal perfusion decreases and urinary output (UOP) decreases. The kidneys are also attempting to hold on to what little fluid volume is left. 1. Incorrect: A few small clots would be considered normal and occur due to pooling of the blood in the vagina. Passage of numerous or large blood clots (larger than a quarter) would indicate a problem. 5. Incorrect: We worry about a boggy uterus. Uterine atony is a major cause of postpartum hemorrhage. The fundus feels firm as the uterus and uterine muscles contract to reduce the blood loss.

A client is diagnosed with new onset grand mal seizures. Which nursing interventions should the nurse implement for this client? Select all that apply 1. Have an unlicensed assisitve personnel stay with the client. 2. Pad the side rails with blankets. 3. Place the bed in low position. 4. Keep a padded tongue blade at the bedside. 5. Instruct client to call for help when ambulating.

2., 3., & 5. Correct: During a seizure these interventions will help to protect the client from injury. The client may strike the side rails. The bed should be placed in the low position in case the client falls out of the bed. The client would need assistance to the floor if a seizure starts while ambulating. 1. Incorrect: It is not necessary to have someone stay with this client at all times. Place a call light within reach, put the client close to the nurses' station, and pad the side rails. Have the client call for assistance to bathroom. Maintain bed rest until seizures are controlled or ambulate the client with assistance to protect from injury. 4. Incorrect: Do not place a padded tongue blade in a client's mouth during a seizure. The padded tongue blade could cause injury.

A client is diagnosed with seizures. Which nursing interventions should the nurse implement? (SATA) 1. Have an unlicensed assistive personnel stay with the client. 2. Pad the side rails with blankets. 3. Place the bed in low position. 4. Keep a padded tongue blade at the bedside. 5. Instruct client to call for help to ambulate.

2., 3., & 5. Correct: Place a call light within reach, put the client close to the nurses' station, and pad the side rails. Have client call for assistance to BR, maintain bedrest until seizures are controlled, or ambulate with assistance to protect from injury. These interventions will help to protect the client from injury. 1. Incorrect: It is not necessary to have someone stay with this client at all times. After implementing the safety issues and transferring the client closer to the nurses' station, the client can stay alone. 4. Incorrect: Do not stick anything in a client's mouth during a seizure. A padded tongue blade could cause injury.

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 school nurse has identified a large outbreak of viral conjunctivitis among one middle school class and plans to educate these students on this illness. Which data should the nurse be sure to include? 1. Use personal handkerchief to wipe the eye of discharge. 2. Light cold compresses over the eyes several times a day will ease discomfort. 3. Do not share towels or linens. 4. Discard all makeup and use new makeup after infection resolves. 5. Wash hands frequently with soap and water.

2., 3., 4. & 5. Correct: All of these measures will promote comfort and decrease risk of transmitting infection. Clients should also avoid touching the eyes and shaking hands/touching other. Cool compresses provide symptomatic relief. 1. Incorrect: Use a new tissue every time you wipe the discharge from the eye. You can dampen the tissue with clean water to clean the outside of the eye. If a personal handkerchief is used, reinfection can occur.

The nurse's goal is to reduce the risk of flu and its complications by offering a class at the local high school. Which groups of people should be included in the nurse's teaching plan as needing the flu shot? Select all that apply 1. Babies less than 6 months old 2. Any child older than 6 months 3. Pregnant women 4. Parents of young children 5. People with a chronic illness

2., 3., 4. & 5. Correct: All people greater than 6 months of age should get a flu shot, unless allergic to eggs, or if there has been an adverse reaction in the past. Pregnant women should receive the flu shot. Parents of young children may be exposed to the flu and should get the vaccine. People with a chronic illness are more susceptible to flu and its complications.1. Incorrect: Flu vaccine has not been approved for babies less than 6 months old.

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.

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.

What nursing interventions should the nurse implement for a client with Addison's disease? (SATA) 1. Administer potassium supplements as prescribed. 2. Assist the client to select foods high in sodium. 3. Administer Fludrocortisone as prescribed. 4. Monitor intake and output. 5. Record daily weight.

2., 3., 4. & 5. Correct: The client with Addison's disease needs sodium due to low levels of aldosterone. Fludrocortisone is a mineralocorticoid that the client will need to take for life. I&O and daily weights are needed to monitor fluid status. 1. Incorrect: Clients with Addison's disease lose sodium and retain potassium, so this client does not need potassium.

The nurse is planning health promotion strategies for an older client on a limited, fixed income who is trying to increase activity. The client has been cleared for moderate physical activity by the primary healthcare provider. Which strategies would be appropriate for this client? Select all that apply 1. Suggest that the client join a local gym for access to equipment and support. 2. Suggest contacting a neighbor so that they can walk each day in the neighborhood. 3. Encourage client to get up and walk around the house during each TV commercial break. 4. Suggest the client go to the community senior center for daily strengthening exercises. 5. Encourage client to use one-pound soup cans for muscle toning.

2., 3., 4. & 5. Correct: The neighborhood buddy is accessible and can be a source of emotional support too, which increases the likelihood of continuing the plan. This activity is easily accessible and burns calories during the day or evening. Senior centers usually do not cost any money for the client, and other seniors may help motivate the client to increase activity level. The use of ordinary items does not further strain a fixed income. 1. Incorrect: Joining a gym will require monthly fees, thus impacting financial resources in a negative way. Additionally, transportation to and from the gym could impact finances in a negative way.

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.

The nurse is identifying home safety issues to prevent injury for a visually impaired elderly client who also has diabetes. Which findings are important for the nurse to include in this process? (SATA) 1. Episodes of mild anxiety 2. Rugs secured to the floor 3. Adequate lighting 4. Functional eye glasses 5. Client is wearing well-fitting closed toe shoes

2., 3., 4. & 5. Correct: Throw rugs may cause falls, as the client may trip. Diabetes may also impact sensation and the client may be unaware that there is a rug in place. Adequate lighting is important so that the client does not bump into furniture or miss a step when navigating stairs. The visually impaired client needs functioning glasses to maximize sight and safety within the home. Diabetic clients do not need open toed shoes, as injury may occur to the foot and the client may not actually be aware of it. Also, wearing sandals is a risk to the person who is visually impaired and elderly, as the shoe may come off unexpectedly. 1. Incorrect. While depression is common and may result in self harm for elderly clients, anxiety is not likely to result in injury. Data should be gathered regarding depression when caring for elderly clients.

The nurse is reinforcing teaching to a client who has been prescribed fluticasone/salmeterol. What points are important for the client to understand? (SATA) 1. Swallow the capsule when having an acute asthma episode. 2. Rinse mouth after medication administration to decrease infection. 3. Take this medication every day, even on days when breathing fine. 4. Administer by inhalation device twice daily. 5. Carry a rescue inhaler, such as albuterol, when leaving home.

2., 3., 4., & 5. Correct: This medication contains a steroid which can increase the risk of oropharyngeal fungal infections. Rinsing will reduce this risk of infection and will also decrease mouth and throat irritation. The medication should be taken every day as directed, even on days when the client feels they are breathing better. This is a preventative medication, not a rescue medication. This medication is administered by an inhaler. It is not given orally. A rescue inhaler, such as albuterol, is needed when the client leaves home. Fluticasone/salmeterol is not a rescue inhaler, but is for long term control and maintenance treatment for the prevention of bronchospasm and airway inflammation associated with asthma, chronic bronchitis, and COPD. 1. Incorrect: This medication must be taken with an inhaler.

The nurse on a neuro rehabilitation unit is caring for a client with a T4 lesion. The client suddenly reports a severe, pounding headache. Profuse diaphoresis is noted on the forehead. The blood pressure is 180/112 and the heart rate is 56. What interventions should the nurse initiate? 1. Place client supine with legs elevated. 2. Assess bladder and bowel for distention. 3. Examine skin for pressure areas. 4. Eliminate drafts. 5. Remove triggering stimulus. 6. Administer hydralazine if BP does not return to normal.

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

A LPN/VN is caring for a client who reports a pain level of 8 on a numeric scale of 1-10. The LPN/VN reports the client's pain level to the RN and administers pain medication as prescribed. Which actions should a nurse take to advocate for this client? (SATA) 1. Notify the primary healthcare provider. 2. Ensure that bed side rails are raised and locked. 3. Administer naloxone within 30 minutes. 4. Advise the client to call for assistance before getting out of bed. 5. Monitor the client's pain level after administering medication.

2., 4. & 5. Correct: To advocate for this client, the LPN/VN should ensure that client's bed side rails are up and in a locked position and should advise the client to call for assistance before getting out of bed, because pain medication increases the client's risk for falls. The LPN/VN should also monitor the client's pain level after an appropriate amount of time to ensure that the client's pain is under control. 1. Incorrect: The nurse does not need to notify the primary healthcare provider because the LPN/VN reported the client's pain to the RN and had a prescription for pain medication to administer to the client. 3. Incorrect: Naloxone is an opioid antagonist. The question does not identify any adverse symptoms following the administration of the pain medication.

Which tasks would be appropriate for the LPN/LVN to assign to an unlicensed assistive personnel (UAP)? (SATA) 1. Monitor client for signs of skin breakdown. 2. Take client's vital signs after ambulating. 3. Apply bacitracin ointment to right forearm. 4. Obtain a stool specimen. 5. Determine what activities the client can do independently.

2., 4. Correct. These tasks are within the scope of practice for the UAP. The LPN/VN must know the tasks that are appropriate for the UAP in order to assign tasks. 1. Incorrect. The UAP cannot assess, evaluate, or plan care for the client. The LPN/VN knows that checking for signs of skin breakdown requires data collection through monitoring. 3. Incorrect. The UAP cannot administer medication. Bacitracin ointment is a medication. 5. Incorrect. The UAP cannot assess, evaluate, or plan care for the client. This task involves data collection and evaluation.

What interventions should the nurse initiate to keep the airway free of secretions in a client with pneumonia? 1. Evaluate results of ABG's and report abnormal findings. 2. Increase oral intake to at least 2000 mL/day. 3. Administer a cough suppressant medication. 4. Educate client on incentive spirometry. 5. Perform percussion to affected area.

2., 4., & 5. Correct: Liquefy secretions by increasing oral intake to at least eight, 8 ounce glasses of liquid/day unless fluid restrictions are required. Incentive spirometry helps keep alveoli open and prevents further pneumonia and atelectasis. Prescribed percussion can assist with loosening secretions for expectoration. 1. Incorrect: This does not get rid of secretions. This monitors respiratory effectiveness. 3. Incorrect: The nurse knows that client needs to expectorate the sputum to remove bacteria or prevent bacterial growth. If the cough is suppressed, the sputum will remain in the lungs, providing a medium for bacterial growth.

The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider? Select all that apply 1. BP 150/108 decreases to 138/86 2. Weight gain of 5 pounds (2.27 kg) in one week 3. Serum sodium level of 139 mmol/L 4. Angioedema 5. Serum potassium of 5.8 mEq

2., 4., & 5. Correct: Weight gain of 5 pounds in one week is a s/s of an adverse effect of ACE inhibitor use. Weight gain is a sign of fluid retention. Angioedema is an adverse effect of ACE inhibitors and can be life threatening. This should be reported immediately to the healthcare provider. The potassium level is too high. Hyperkalemia is an adverse effect of an ACE inhibitor and needs to be reported.1. Incorrect: This is an expected response of an ACE inhibitor. ACE inhibitors block the normal effects of renin-angiotensin-aldosterone system, thereby decreasing the blood pressure.3. Incorrect: The serum sodium level here is within normal limits. There is no need to report normal lab values.

A client's last two central venous pressure (CVP) readings were 13 cm of water. The nurse would expect the client to manifest which associated signs and symptoms? 1. Dry oral mucous membranes 2. Tachypnea 3. Orthostatic hypotension 4. Rales in the posterior chest 5. Jugular vein distention 6. Weight gain

2., 4., 5. & 6. Correct: The normal range for CVP is 2-8 cmH​2O or 2-6 mmHg. Therefore, the readings of 13 cmH​2O are high and may be the result of fluid volume excess. The signs and symptoms of FVE include: tachypnea, rales, and jugular vein distention from the increased volume and preload. Acute weight gain is one of the best indicators of FVE due to circulatory overload. 1. Incorrect: The CVP is high and correlates with fluid volume excess. Dry oral mucous membranes indicate fluid volume deficit. 3. Incorrect: The CVP is high and correlates with fluid volume excess. Orthostatic hypertension indicates fluid volume deficit.

What symptoms would the nurse anticipate in a client with a calcium level of 3.2 mg/dL (0.80 mmol/L)? (SATA) 1. Slowed deep tendon reflexes 2. Muscle rigidity and cramping 3. Hypoactive bowel sounds 4. Positive Chvostek's sign 5. Seizures 6. Laryngospasms

2., 4., 5., & 6. Correct: Normal serum calcium is 8.7 - 10.3 mg/dL (2.18 - 2.58 mmol/L). The client with a calcium level of 3.2 mg/dL (0.80 mmol/L) is hypocalcemic. With hypocalcemia, the muscle tone is rigid and tight. Therefore, the client may report muscle cramping. A hallmark sign of hypocalcemia is a positive Chvostek's sign, which is a twitching of facial muscles following tapping in the area of the cheekbone that is indicative of hyperirritability. The client may be at risk of having seizures due to the neuromuscular irritability. Prolonged contraction of the respiratory and laryngeal muscles causes laryngospasm and stridor and may result in cyanosis. 1. Incorrect: With hypocalcemia, the deep tendon reflexes are increased, not decreased. 3. Incorrect: The client with hypocalcemia tends to have increased gastric motility, resulting in hyperactive (not hypoactive) bowel sounds. In addition, abdominal cramping and diarrhea are common with hypocalcemia.

What symptoms would the nurse anticipate in a client being admitted to the hospital with a calcium level of 3.2 mg/dL (0.80 mmol/L)? Select all that apply 1. Slowed deep tendon reflexes. 2. Muscle rigidity and cramping. 3. Hypoactive bowel sounds. 4. Positive Chvostek's sign. 5. Seizures 6. Laryngospasms

2., 4., 5., & 6. Correct: Normal serum calcium is 8.7 - 10.3 mg/dL (2.18 - 2.58 mmol/L). The client with a calcium level of 3.2 mg/dL (0.80 mmol/L) is hypocalcemic. With hypocalcemia, the muscle tone is rigid and tight. Therefore, the client may report muscle cramping. A hallmark sign of hypocalcemia is a positive Chvostek's sign, which is a twitching of facial muscles following tapping in the area of the cheekbone, indicative of hyperirritability. The client may be at risk of having seizures due to the neuromuscular irritability. Prolonged contraction of the respiratory and laryngeal muscles causes laryngospasm and stridor and may result in cyanosis. 1. Incorrect: With hypocalcemia, the deep tendon reflexes are increased, not decreased. 3. Incorrect: The client with hypocalcemia tends to have increased gastric motility, resulting in hyperactive (not hypoactive) bowel sounds. In addition, abdominal cramping and diarrhea are common with hypocalcemia.

A client is hospitalized for chronic renal failure. The nurse will need to notify the primary healthcare provider concerning which findings? (SATA) 1. Sodium 135 mEq/L (135 mmol/L) 2. Potassium 5.8 mEq/L (5.8 mmol/L) 3. BP 100/70 4. No weight loss 5. Calcium 8.0 mg/dL (2 mmol/L)

2., 5. Correct: Normal K 3.5-5.0 mEq/L (3.5-5.0 mmol/L); Normal serum Ca 9.0-10.5 mg/dL (2.25-2.62 mmol/L)​. The abnormal lab results need to be reported. Hyperkalemia is a serious electrolyte disorder associated with chronic renal failure due to decreased excretion of potassium from the kidneys. Progressive decrease in kidney function affects mineral and bone metabolism. The low calcium needs to be reported. 1. Incorrect: Normal sodium 135-145 mEq/L (135-145 mmol/L). This is a normal finding and does not need to be reported. 3. Incorrect: Hypertension is a potential complication of chronic renal failure. A BP of 100/70 is not an abnormal finding and does not need to be reported. 4. Incorrect: The desired outcome for clients with chronic renal failure is no rapid increases or decreases in weight. This finding does not need to be reported.

A client is hospitalized for chronic renal failure. The nurse will need to notify the primary healthcare provider concerning which findings? Select all that apply 1. Sodium 135 mEq/L 2. Potassium 5.8 mEq/L 3. BP 100/70 4. No weight loss 5. Ionized Calcium 4.0 mg/dL

2., 5. Correct: Normal K 3.5-5.0 mEq/L; Normal ionized serum Ca 4.5-5.5 mg/dL. The abnormal lab results need to be reported.1. Incorrect: Normal sodium 135-145 mEq/L.3. Incorrect: Hypertension is a potential complication of chronic renal failure.4. Incorrect: Desired outcome: client exhibits no rapid increases or decreases in weight.

Which assignments would be most appropriate for the LPN/VN to accept from the RN? (SATA) 1. Six year old with new onset diabetes. 2. Ten year old with pneumonia admitted two days ago. 3. Three month old admitted with severe dehydration. 4. Four year old admitted for developmental studies. 5. Twelve year old with post op wound infection taking oral antibiotics.

2.,4. & 5. Correct: The best assignments for the LPN/VN would be the child with pneumonia admitted two days ago and the child admitted for developmental studies. The twelve year old with post op wound infection taking oral antibiotics is also stable. 1. Incorrect: The diabetic requires much teaching and supervision. This is an unstable client that should not be assigned to an LPN/VN. 3. Incorrect: The child with dehydration will require close intravenous fluid (IVF) monitoring, assessment and evaluation of condition. This client is unstable and should not be assigned to an LPN/VN.

Which assignments would be most appropriate for the RN to delegate to an LPN/VN? Select all that apply 1. Six year old with new onset diabetes. 2. Ten year old with pneumonia admitted two days ago. 3. Three month old admitted with severe dehydration. 4. Four year old admitted for developmental studies. 5. Twelve year old with post op wound infection taking oral antibiotics.

2.,4. & 5. Correct: The best assignments for the LPN/VN would be the child with pneumonia admitted two days ago and the child admitted for developmental studies. The twelve year old with post op wound infection taking oral antibiotics is also stable. 1. Incorrect: The diabetic requires much teaching and supervision. This is an unstable client that should not be assigned to an LPN/VN. 3. Incorrect: The child with dehydration will require close intravenous fluid (IVF) monitoring, assessment and evaluation of condition. This client is unstable and should not be assigned to an LPN/VN.

The nurse is caring for a client on the psychiatric unit. The client is prescribed fluphenazine 10 mg. The drug is available as an elixir: 2.5 mg / 5 mL. How many mL will the nurse give to the client? Round answer to the nearest whole number.

2.5 mg : 5 mL = 10 mg : x mL 2.5 mg/x mL = 50 mg/mL 2.5 mg/x mL = 50 mg/mL x = 20 mL

Ambient air (room air) contains

21% oxygen

After g-tube placement the stomach contents are drained by gravity for _______ before it can be used for feedings

24 hours

COPD patients remember

2LNC or less (hypoxic NOT hypercapnic drive), Pa02 of 60ish and Sa02 90% is normal for them b/c they are chronic CO2 retainers

A 70 year old client was admitted to the vascular surgery unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's BP is 198/94. What would be the best action for the charge nurse to delegate at this time? 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm in 15 minutes. 3. Have the LPN/LVN administer the 0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for pain.

3

A child is being admitted to the hospital with a diagnosis of acute glomerulonephritis. In performing the history and physical, what would be a priority assessment that the nurse should include when questioning the child and caregivers? 1. Types of contact sports played 2. Amount of acetaminophen intake 3. Recent sore throat 4. Recent exposure to salmonella

3

A child was diagnosed with attention-deficit/hyperactivity disorder (ADHD) in the clinic one week ago. Today the child's mother calls the clinic to tell the nurse, "My child has not been able to sleep since being put on methyphenidate." What is the best response for the nurse to make? 1. "I will discuss this with the primary healthcare provider. A different medication may be prescribed." 2. "The insomnia will get better over time. Just wait it out." 3. "To prevent insomnia, give your child the last daily dose at least 6 hours before bedtime." 4. "Your child may have overdosed on the medication. Go to the emergency department now."

3

A client arrives in the emergency department with fever, nuchal rigidity, and seizures. What action should the nurse take first? 1. Administer Penicillin IVPB. 2. Obtain blood cultures from two sites. 3. Place on droplet precautions. 4. Set up for lumbar puncture.

3

A client at 36 weeks gestation is receiving magnesium sulfate for treatment of pre-eclampsia. Which finding by the nurse requires immediate action? 1. Respiratory rate of 12 2. Deep tendon reflexes (DTR) of 3+ 3. Urinary output (UOP) of 100cc/4hours 4. Fetal heart rate (FHR) of 120

3

A client calls the clinic to ask the nurse if it would be okay to take the herbal medication kava-kava to help reduce anxiety. What is the nurse's best response? 1. "Why do you want to take kava-kava?" 2. "I really doubt your primary healthcare provider will approve you taking kava-kava." 3. "Kava-kava can cause liver damage, so we need to consult your healthcare provider." 4. "Do not take Kava-kava for more than a year without a primary healthcare provider's supervision."

3

A client develops pernicious anemia after a Billroth II procedure and is to receive vitamin B12 intramuscularly. What should the nurse include in discharge instructions? 1. B12 can be stored in a lighted area. 2. The B12 injections will be stopped when symptoms disappear. 3. The B12 injections will be continued for the client's life. 4. Vitamin B12 will be taken by mouth once the maintenance dose is determined.

3

A client has been admitted for exacerbation of ulcerative colitis with severe dehydration. What is the best indicator that this client has an actual fluid deficit? 1. Stool count of 10 episodes of diarrhea in 24 hours. 2. Weight increase of 2 kg and a 24 hour output of 1000 mL. 3. Admission weight of 74.3 kg and 2 days later a weight of 72 kg. 4. Daily intake of 2400 mL and an output of 1600 mL, plus diarrheal stools.

3

A client is admitted to the emergency department reporting abdominal discomfort and constipation lasting 3 days. Which abdominal assessment data would the nurse report to the primary healthcare provider? 1. Striae. 2. Borborygmi. 3. High-pitched bowel sounds. 4. Tympany noted on percussion.

3

A client is hospitalized for recurrent angina with hypertension and has been started on new medications. When reviewing the admission forms, the nurse should immediately question which prescription? Exhibit 1. 2 gram sodium diet. 2. Metoprolol 25 mg. P.O. once daily. 3. Potassium 10 meq. P.O. once daily. 4. Diltiazem 120 mg. P.O. once daily.

3

A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What statement made by the client indicates that teaching has been effective regarding safe needle disposal? 1. "I should wrap the needle in a paper towel and place in the trash." 2. "I should use a hospital issued biohazard container for all needles." 3. "I may use any hard plastic container with a screw-on cap." 4. "I should take my needles to the nearest hospital for disposal. "

3

A client was prescribed thioridazine hcl five days ago and presents to the emergency department with a shuffling gait, tremors of the fingers, drooling, and muscle rigidity. Which adverse reaction to this medication does the nurse suspect? 1. Akinesia 2. Neuroleptic malignant syndrome 3. Pseudoparkinsonism 4. Oculogyric crisis

3

A home care nurse is preparing to perform venipuncture to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What should be the nurse's first action? 1. Hug the client to provide support. 2. Take the client to the emergency department for sedation. 3. Decrease stimuli in the room. 4. Teach the client deep breathing exercises.

3

A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM). The newborn weighs 6 lbs (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What should the nurse do? 1. Administer the drug intravenously (IV) since a large volume is required. 2. Choose three injection sites and give the medication as prescribed. 3. Consult with the pharmacy for a different medication concentration. 4. Read the available drug information to determine how to administer the medication.

3

A nurse from an adult unit was reassigned to the pediatric unit. Which client would be least appropriate to assign to this nurse? 1. Ten year old with 2nd and 3rd degree burns. 2. Five year old that was in a MVA and has a femur fracture. 3. Six year old admitted for evaluation of possible sexual abuse by a parent 4. Two month old with bronchopulmonary dysplasia being admitted for reflux.

3

A nurse has received the following arterial blood gas results on a client with a post bowel resection: pH 7.48; PCO2 30; HCO3 24. Which acid/base imbalance is the client experiencing? 1. Metabolic alkalosis 2. Metabolic acidosis 3. Respiratory alkalosis 4. Respiratory acidosis

3

A teenage client is placed on life-support as a result of a motor vehicle accident (MVA). Following an electroencephalogram (EEG), the client has been declared brain dead. Which action by the nurse would take priority? 1. Call the respiratory department to have the ventilator removed. 2. Notify the facility's pastoral personnel. 3. Contact the regional organ procurement team. 4. Ask the family to select a funeral home.

3

A woman, diagnosed with an ectopic pregnancy, asks the nurse the purpose of receiving methotrexate. What is the best reply for the nurse to make? 1. "Methotrexate will stop your bleeding." 2. "It will destroy fetal cells that got into your blood so that antibodies will not be formed." 3. "This medication will stop the growth of the embryo to save your fallopian tube." 4. "Cervical dilation is expected after receiving this medication."

3

An angry client visits the primary healthcare provider's office and requests a copy of their medical records. The client is angry after being placed on hold several times for over 10 minutes when requesting an appointment. What should the nurse tell this client? 1. All client appointment calls are transferred to the scheduling clerk. 2. The client will have to speak to the primary healthcare provider. 3. A copy of the record may be obtained within 24 hours of the request. 4. Medical records must stay within the facility unless requested by another primary healthcare provider.

3

An elderly male, diagnosed with chronic renal failure and depression, lives alone. Which question should the home health nurse ask first when assessing this client? 1. Have you had suicidal thoughts in the past? 2. How are you feeling today? 3. Have you had thoughts of harming yourself? 4. Do you have guns in your home?

3

Blood and urine samples are sent to the laboratory for a client who has had a spinal cord injury. After reviewing these results, the nurse would expect which finding? Exhibit 1. Gross hematuria 2. Septicemia 3. Urinary tract infection 4. Anemia

3

During evening rounds, the nurse discovers that a violent client with a history of threats against a former girlfriend cannot be located. The client's window is open and personal belongings missing. Based on recent threats of violence against the girlfriend, what is the nurse's initial action? 1. Look for the client quietly to maintain confidentiality. 2. Notify the local police to organize a search party. 3. Initiate the missing client protocol. 4. Complete an "Against Medical Advice" (AMA) form on the client's elopement.

3

On the third postoperative day, a client develops a fever of 103.3ºF (39.6ºC) shivering and nausea. The primary healthcare provider writes these prescriptions. Which should the nurse do first? 1. Apply cooling blanket for fever. 2. Give ceftriaxone 1 gram IVPB stat. 3. Draw blood cultures. 4. Give promazine 50 mg po PRN for nausea.

3

The charge nurse has received report from the emergency department about a client diagnosed with Cushing's disease being admitted to the unit. Which client in a semi-private room would be appropriate for the charge nurse to have this client share? 1. Client who has leukemia. 2. Client diagnosed with gastroenteritis. 3. Client who has a fractured hip. 4. Client diagnosed with bronchitis.

3

The charge nurse is observing the work of an unlicensed assistive personnel (UAP). Which observation will require the nurse to intervene? 1. Placing soiled linen in a hazardous waste linen bag outside of the client's room. 2. Closing the door when exiting the room of a client diagnosed with tuberculosis (TB). 3. Going between client rooms wearing the same pair of gloves to collect I&O reports. 4. Cleaning a blood pressure cuff with a disinfectant.

3

The nurse is assisting an unlicensed assistive personnel (UAP) move an obese and dependent client toward the top of the bed. Which action is most important to prevent shearing forces on the skin? 1. Each person puts hands under the client and slides client toward the top of the bed. 2. Apply powder to the sheet before pulling client toward the top of the bed. 3. Place turn sheet under the client and use it to slide the client toward the top of bed. 4. Seek assistance of another person before pulling up in bed.

3

The nurse is caring for a client who was admitted to the hospital following a severe motor vehicle crash (MVC) in which the client was trapped in the car for several hours. The client is being closely monitored for the development of renal failure. Which assessment finding would warrant immediate reporting? 1. Creatinine 1.1 mg/dl (97.24 mmol/L) 2. Urinary output of 150 mL per hour. 3. Gradual increase of BUN levels. 4. Calcium levels of 9.0 mg/dL (2.25 mmol/L)

3

The nurse is caring for a client with renal failure. The client has a 24 hour intake of 2500 mL and a 24 hour urinary output of 200 mL. What is the priority nursing assessment? 1. Assess for dependent edema. 2. Monitor for cardiac arrhythmias. 3. Auscultate breath sounds. 4. Monitor sodium and potassium levels

3

The nurse is caring for a newly diagnosed diabetic in diabetic hyperosmolar hyperglycemic nonketotic (HHNK) state. What does the nurse anticipate the immediate treatment plan for this client will include? 1. NPH insulin. 2. Potassium 40 mEq (40 mmol/L) slow intravenous push. 3. Intravenous administration of isotonic saline. 4. Intravenous sodium bicarbonate.

3

The nurse is instructing a client on achieving relaxation using deep breathing exercises. Which statement by the client indicates to the nurse that further teaching is necessary? 1. "I can perform deep breathing exercises anywhere and at any time that I feel tension and anxiety." 2. "I should sit or lie in a comfortable position, making sure my back is straight." 3. "I will inhale slowly and deeply through my mouth focusing on my chest expansion." 4. "When I have inhaled in as much as possible, I will hold my breath for a few seconds before exhaling."

3

The nurse is performing morning care on a client on the medical unit. What should the nurse do after changing a client's bed linen? 1. Hold the linen close to the body while transporting it to the dirty utility room. 2. Wear a gown and gloves to transport the linen to the biohazard container. 3. Place the linen into a leak proof container sitting outside the room. 4. Place the linen in a pillow case and set it on the floor until client care is completed.

3

The nurse is performing the admission assessment on a client who is having a breast augmentation. Which client information would be most important for the nurse to report to the surgeon before surgery? 1. Client is concerned about who will care for her two children while she recovers. 2. There is a history of postoperative dehiscence after a previous C-section. 3. Client's last menstrual period was 8 weeks ago. 4. Client is concerned over pain control postoperatively.

3

The nurse is planning daily activities for a client who has a diagnosis of schizophrenia. The client tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for this client? 1. Watching TV with two other clients in the day room. 2. Watching TV alone in a conference room. 3. Spending time in brief one on one interactions with the nurse. 4. Sitting in the day-room away from other clients.

3

The nurse is preparing a client for a renal biopsy. Which is most important for the nurse to assess prior to this procedure? 1. BUN and creatinine 2. NPO status and signature on consent 3. Bleeding time and coagulation studies 4. Serum potassium and urine sodium

3

The nurse is preparing to provide oral care to an unconscious client. What is the most important step for the nurse to provide? 1. Performing hand hygiene. 2. Explaining the procedure to the family. 3. Positioning the client in side-lying position. 4. Raising the head of bed 30 degrees.

3

The nurse is teaching a class to primiparas on breastfeeding. How many extra kilocalories per day would the nurse instruct the class participants to consume post-delivery to compensate for the increased energy requirements of lactation? 1. 1000 2. 300 3. 500 4. 800

3

What is priority for the nurse to determine about a client who is scheduled for a tubal ligation in the outpatient surgical center? 1. Client's prior experiences with outpatient surgery. 2. Medical plan and the extent of insurance coverage for outpatient surgery. 3. Client's plan for transportation and care at home. 4. Client's plan to spend the night at the surgical center.

3

What should a nurse teach a client who has been diagnosed with hepatitis A? 1. Hepatitis A is spread through blood and body fluid. 2. Chronic liver disease is a common complication of hepatitis A. 3. Symptoms of hepatitis A include malaise, dark colored urine, and jaundice. 4. Treatment includes alpha-interferon and ribavirin.

3

When assessing a client's testes, which finding would indicate to the nurse the need for further investigation? 1. Rope like area located at the top of the back of a testicle. 2. Right testicle is slightly larger than the left testicle. 3. Lump the size of a piece of rice. 4. Nonpalpable lymph nodes in groin.

3

Which assessment finding by a nurse would best indicate a positive Mantoux tuberculin skin test in a client? 1. Formation of a vesicle that is 4 mm in diameter 2. A sharply demarcated region of erythema of 10 mm 3. A central area of induration of 15 mm surrounded by erythema 4. A circle of blanched skin surrounding the injection site

3

Which client requires immediate intervention by the nurse? 1. Client diagnosed with Crohn's disease reporting frequent bloody diarrhea and abdominal cramping. 2. Client with renal calculi who reports no pain relief from ketorolac administered 30 minutes ago. 3. Client with a fractured femur reporting sharp chest pain of 4/10. 4. Client admitted with cholelithiasis reporting right-sided abdominal pain of 8/10.

3

Which factor would most likely predispose a client to developing shock following a fracture of the femur? 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

Which intervention can the nurse safely delegate to an unlicensed assistive personnel (UAP)? 1. Irrigate a colostomy in a client who is 2 days postoperative. 2. Remove a fecal impaction in a client. 3. Apply a condom catheter to an incontinent client. 4. Insert a urinary catheter to obtain a urine sample.

3

Which pediatric client should the nurse see first? 1. Six year old with a femur fracture. 2. Two year old with a fever of 102 ° F (38.8 ° C) 3. Three year old with wheezes in right lower lobe. 4. Two year old whose gastrostomy tube came out.

3

A charge nurse is planning care for several clients on the unit. Which activities can the nurse safely delegate to an unlicensed assistive personnel (UAP)? 1. Administer a nebulizer treatment to a client diagnosed with pneumonia. 2. Obtain vital signs on a postoperative client who required naloxone 5 minutes ago. 3. Report a urinary output (UOP) less than 50 ml/hr on a post-op client. 4. Assist a client with obtaining a clean catch urine sample. 5. Remove an indwelling urinary catheter from a client.

3,4

The nurse is working in a long term care facility. What actions by the nurse are appropriate when taking a telephone prescription from a primary healthcare provider? 1. Document the prescription prior to the end of the shift. 2. Explain to the pimary healthcare provider that nurses cannot take telephone prescriptions. 3. Repeat the prescription back to the primary healthcare provider prior to hanging up. 4. Transcribe the prescription in the client's record. 5. Ask the primary healthcare provider to wait and write the prescription during rounds.

3,4

Which findings would indicate to the nurse that a client with Addison's disease has received too much glucocorticoid replacement? 1. Dry skin and hair 2. Hypotension 3. Rapid weight gain 4. Decreased blood glucose level 5. Increased cholesterol

3,4

The nurse is teaching a newly diagnosed diabetic about proper foot care. Which statements by the nurse are correct? 1. Cut the toenails in a rounded fashion. 2. Wash the feet with warm water and betadine. 3. Wear appropriate fitting shoes at all times. 4. View the bottom of the feet daily. 5. Protect feet from hot and cold.

3,4,5

Which clients would be appropriate for the RN to assign to an LPN/LVN? 1. Seventy four year old client with unstable angina who needs teaching for a scheduled cardiac catheterization. 2. Sixty year old client experiencing chest pain scheduled for a graded exercise test. 3. Forty eight year old client who is five days post right-sided cerebral vascular accident (CVA). 4. Eighty four year old client with heart disease and mild dementia. 5. Newly admitted ninety year old client with decreased urinary output, altered level of consciousness, and temperature of 100.8°F (38.2°C) 6. Sixty six year old client with chronic emphysema experiencing mild shortness of breath.

3,4,6

The nurse is caring for a client with pneumococcal pneumonia. Which nursing observations would indicate a therapeutic response to the treatment regime for the infection? 1. Dyspnea on exersion with nonproductive cough 2. Tachypnea with use of accessory muscles 3. Expectorating moderate amounts of thin, white sputum 4. White blood cell count of 18,000 cells per mcL 5. Crackles clearing with cough

3,5

A busy LPN instructs an unlicensed assistive personnel (UAP) to obtain daily weights on a client. The LPN provides initial direction for the task, monitors that the task is successfully completed, reviews the results of the daily weight, and reports the results to the RN. Which action has the LPN taken? (SATA) 1. Failed to supervise the actions of the UAP. 2. Improperly assigned a client care task. 3. Appropriately assigned a client care task. 4. Supervised the performance of a client care task. 5. Functioned outside of the LPN scope of practice.

3. & 4. Correct: The LPN appropriately assigned the performance of a client care task. The LPN appropriately supervised the performance of a client care task. 1. Incorrect: The LPN appropriately supervised the actions of the UAP. 2. Incorrect: The LPN appropriately assigned the task to the UAP. 5. Incorrect: It is within the scope of practice for the LPN to assign daily weights to a UAP if the UAP has been properly trained to carry out the assigned task and is supervised.

The nurse recognizes that treatment has been successful in resolving fluid volume excess based on which assessment findings? Select all that apply 1. Continued lethargy 2. Heart rate 112/min 3. Decreasing shortness of breath 4. BP 114/78 5. Increased thirst

3. & 4. Correct: Urinary output should increase with decreasing shortness of breath as hydration is corrected, and BP should be normal. 1. Incorrect: Level of consciousness (LOC) should improve with perfusion to the brain. 2. Incorrect: Heart rate should decrease if hydration is corrected. 5. Incorrect: Thirst level should be decreased if hydration is corrected.

The nurse recognizes that treatment has been successful in resolving fluid volume excess based on which findings? (SATA) 1. Continued lethargy 2. Heart rate 112/min 3. Decreasing shortness of breath 4. BP 114/78 5. Increased thirst

3. & 4. Correct: Urinary output should increase with decreasing shortness of breath as the FVE is corrected, and BP should be normal. 1. Incorrect: Level of consciousness (LOC) should improve with perfusion to the brain. 2. Incorrect: Heart rate should decrease if FVE is corrected. 5. Incorrect: Thirst is a sign of FVD, rather than FVE, so increased thirst would not be pertinent for FVE.

A client with a history of congestive heart failure has an implantable cardioverter defibrillator (ICD) surgically implanted. What teaching points should the nurse provide the client prior to discharge? SATA 1. Avoid hot baths and showers. 2. Increase intake of leafy green vegetable products. 3. Avoid magnets directly over the site. 4. Notify primary healthcare provider whenever a shock is delivered by the ICD. 5. Driving is not recommended for 1 year after placement of an ICD.

3. Avoid magnets directly over the site. 4. Notify primary healthcare provider whenever a shock is delivered by the ICD.

The nurse is caring for a client who was admitted to the hospital following a severe motor vehicle crash (MVC) in which the client was trapped in the car for several hours. The client is being closely monitored for the development of renal failure. Which assessment finding would warrant immediate reporting? 1. Creatinine 1.1 mg/dl (97.24 mmol/L) 2. Urinary output of 150 mL per hour. 3. Gradual increase of BUN levels. 4. Calcium levels of 9.0 mg/dL (2.25 mmol/L)

3. Correct. Gradual accumulation of nitrogenous wastes results in elevated BUN and serum creatinine. This is an indication of impaired renal function. 1. Incorrect. This is a normal creatinine level. Gradual accumulation of nitrogenous wastes from impaired renal function results in elevated BUN and serum creatinine. 2. Incorrect. This is a normal output level. This level alone would not necessarily be an indicator of acute renal failure and that value alone would not warrant reporting it to the primary healthcare provider. 4. Incorrect. Calcium level of 9.0 mg/dL (2.25 mmol/L) is considered normal. When observing for renal functioning you would assess the BUN and creatinine levels. In addition, the calcium level may drop (hypocalcemia) in renal failure inverse relationship change due to the rising serum phosphate levels. However, the calcium level presented is within normal limits (WNL).

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.

A client is hospitalized for recurrent angina with hypertension and has been started on new medications. When reviewing the admission forms, the nurse should immediately question which prescription? 1. 2 gram sodium diet. 2. Metoprolol 25 mg. P.O. once daily. 3. Potassium 10 meq. P.O. once daily. 4. Diltiazem 120 mg. P.O. once daily. Exhibit: Primary Healthcare Provider Prescriptions: Spironolactone 50 mg. P.O. once daily. Metoprolol 25 mg. P.O. once daily. Diltiazem 120 mg. P.O. once daily. Potassium 10 meq. P.O. once daily. 2 GM. sodium diet.

3. Correct. This client is being treated for recurrent angina with hypertension. The admission prescriptions include spironolactone daily, which is a potassium-sparing diuretic. Therefore, the client should not be taking a daily dose of potassium. Prior to discharge, this client will also need instructions on avoiding additional potassium in the diet such as salt substitutes. 1. Incorrect. A "2-gram sodium diet" would be appropriate for a client with hypertension. 2. Incorrect. Metoprolol is a beta-blocker used to decrease preload, which will also decrease pulse and blood pressure. The dose is appropriate for this client and does not need to be questioned. 4. Incorrect. Diltiazem is a calcium channel blocker which vasodilates the arterial system and reduces recurrent angina by decreasing afterload. Additionally, calcium channel blockers help to decrease blood pressure. This medication and dose are appropriate for this client and would not need to be questioned.

A nurse is caring for a client who had a total hip replacement 2 days ago. What observation would be a priority concern for the nurse? 1. Small amount of red drainage on the surgical dressing. 2. Continues to report pain in hip when being repositioned. 3. Temperature of 101.8°F (38.7°C). 4. Slight swelling in the leg on the affected side.

3. Correct: A low grade fever is normal following hip surgery but a temperature of 101.8ºF (38.7ºC) two days postoperatively is higher than the expected slight increase and should be a priority concern. The development of an infection is one of the major complications for clients following hip surgery. Therefore, fever that persists above 101ºF that is accompanied by chills, diaphoresis, or increasing drainage and odor from the incision should be reported. 1. Incorrect: A small amount of red, bloody drainage on the dressing is expected as part of the normal healing process. 2. Incorrect: Some pain during repositioning after hip surgery is normal and can generally be managed with analgesics. 4. Incorrect: Swelling in the operative leg is a normal part of the postoperative process after hip surgery. Normal swelling is lessened in the morning but tends to re-accumulate throughout the day. This can be minimized by elevating the client's legs or having the client lie down for approximately 45 minutes during the day.

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 is caring for a 5-year old child brought to the Emergency Department by the parents for pain and swelling in the left arm. An x-ray of the arm confirmed a fracture. The parents give conflicting stories about the accident. What action by the nurse is most appropriate? 1. Prepare the child for casting of the arm. 2. Ask the primary healthcare provider to order bone series film. 3. Consult social services. 4. Obtain a history as to how the accident happened.

3. Correct: All states have laws that mandate reporting of child maltreatment. Usually the social service department handles these types of referrals. 1. Incorrect: Casting may be needed, but the most appropriate action is identifying safety issues and possible child abuse. 2. Incorrect: X-rays would be the primary healthcare provider's decision. 4. Incorrect: There is nothing wrong with this answer, but you only have one chance to tell the NCLEX people you know the most important thing to do is to consult social services. This is a safety issue.

What should the nurse do first when caring for a client who is being admitted with a diagnosis of meningococcal meningitis? 1. Assess neuro status. 2. Obtain health history. 3. Institute droplet precautions. 4. Orient client to the room and procedures.

3. Correct: Although all the options are appropriate, the priority is to place the client on droplet precaution to prevent the spread of meningococcal meningitis. 1. Incorrect: Placing client in isolation should be done first (actually prior to arriving to room) since the client has a diagnosis of meningococcal meningitis. Assessment of the neuro status can be done next. 2. Incorrect: The health history can be obtained after placing the client on droplet precautions. 4. Incorrect: Orientation can occur after the initiation of droplet precautions.

A client has been admitted for exacerbation of ulcerative colitis with severe dehydration. What is the best indicator that this client has an actual fluid deficit? 1. Stool count of 10 episodes of diarrhea in 24 hours. 2. Weight increase of 2 kg and a 24 hour output of 1000 mL. 3. Admission weight of 74.3 kg and 2 days later a weight of 72 kg. 4. Daily intake of 2400 mL and an output of 1600 mL, plus diarrheal stools.

3. Correct: Any acute weight gain or loss is fluid. Weight is the best measurement for fluid loss or gain. Acute weight losses correspond to fluid volume deficits. This client has lost 2.3 kg over a 2 day period, indicating a fluid volume deficit (FVD). 1. Incorrect: Although 10 loose stools would result in fluid loss, the stool count of 10 episodes of diarrhea is an inaccurate measurement. The amount of fluid loss can vary depending on the amount of diarrhea, 10 "episodes" does not indicate how much fluid is lost. 2. Incorrect: Weight gains indicate fluid volume retention and excess. This question asks about fluid volume deficit. Also, it does not take into account the client's intake. Only the output is considered, so output has less meaning without being compared to the intake. 4. Incorrect: Daily I&O is good information to have when assessing fluid status, but the diarrhea stools are an inaccurate measurement. The weight remains the best measurement for indicating a fluid deficit.

On the third postoperative day, a client develops a fever of 103.3ºF (39.6ºC) shivering and nausea. The primary healthcare provider writes these prescriptions. Which should the nurse do first? 1. Apply cooling blanket for fever. 2. Give ceftriaxone 1 gram IVPB stat. 3. Draw blood cultures. 4. Give promazine 50 mg po PRN for nausea.

3. Correct: Blood cultures MUST be drawn immediately to identify the causative bacteria. Once the organism is identified, the primary healthcare provider will order organism specific antibiotics. Always draw blood cultures before administering the antibiotic. If antibiotics are given before the blood cultures are drawn, the culture will be inaccurate, and the client cannot be treated appropriately. 1. Incorrect: Application of a cooling blanket is appropriate, but the key in this question is to "fix the problem" ASAP. To treat the infection, the blood cultures must be drawn ASAP and be done before starting the antibiotics. 2. Incorrect: Antibiotics are not given until the cultures have been drawn. Administering the antibiotic first would cause the culture to be inaccurate. 4. Incorrect: Preventing shivering is appropriate, but remember, always pick the answer that is most life-threatening. In this case, treating the bacteria as soon as possible is the priority answer. This requires the culture be obtained ASAP so the antibiotic therapy can be initiated.

A nurse has reinforced teaching to a client about home dressing changes using a clean technique. Which statement made by a client indicates to the nurse that the client understands this technique? 1. "The wound should be cleaned using a washcloth, soap, and water." 2. "Povidone-iodine should be applied to the wound with each dressing change." 3. "It is important that I wash my hands using soap and water before removing my dressing." 4. "I will use sterile gloves to clean my wound and change the dressings."

3. Correct: Clean technique requires washing hands with soap and water prior to removing the dressing. 1. Incorrect: The wound should be cleaned with 4x4's and sterile water. Soap can be very drying to the wound. A washcloth may not be clean as it has been sitting in a cabinet. 2. Incorrect: Povidone-iodine is harsh and damages healthy tissue, so should not be applied to the wound. 4. Incorrect: Sterile gloves are not needed when using clean technique. Clean gloves may be used.

A home health nurse has taught a client about home dressing changes using a clean technique. Which statement made by a client indicates to the nurse that the client understands this technique? 1. "The wound should be cleaned using a washcloth, soap, and water." 2. "Povidone-iodine should be applied to the wound with each dressing change." 3. "It is important that I wash my hands using soap and water before removing my dressing." 4. "I will use sterile gloves to clean my wound and change the dressings."

3. Correct: Clean technique requires washing hands with soap and water prior to removing the dressing. 1. Incorrect: The wound should be cleaned with 4x4's and sterile water. Soap can be very drying to the wound. A washcloth may not be clean as it has been sitting in a cabinet. 2. Incorrect: Povidone-iodine is harsh and damages healthy tissue, so should not be applied to the wound. 4. Incorrect: Sterile gloves are not needed when using clean technique. Clean gloves may be used.

Which task would be appropriate for the LPN/VN to accept from the Labor, Delivery, Recovery, Postpartum (LDRP) charge nurse? 1. Administer IV pain medication to a client three days postopertive cesarean section. 2. Draw a trough vancomycin level on a client 3 days postpartum with bilateral mastitis. 3. Reinforce how to perform perineal care to a primipara who is four hours postpartum. 4. Draw admission labs on a client admitted in final stages of labor.

3. Correct: Client teaching may be reinforced by an LPN/VN on a stable client. 1. Incorrect: Administering IV pain medications is out of the scope of practice of LPN/VN. 2. Incorrect: This client with a severe infection who is only 3 days postpartum is considered an unstable client. Therefore, this client should have the blood drawn and receive care from the RN. 4. Incorrect: Drawing admission labs on a client in the final stages of labor would be inappropriate, because the client is potentially unstable and needs experienced LDRP nursing care.

The nurse is caring for a client diagnosed with type 2 diabetes who was brought to the emergency department in an unresponsive state. A diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is made. The nurse prepares for the administration of which initial therapy? 1. Oxygen by nasal cannula 2. Long-acting IV insulin 3. Normal saline 4. IV dextran

3. Correct: Clients in HHNS diurese due to a high glucose load in the vascular space. The client becomes severely volume depleted and is at risk for developing shock. Therapy is focused on combating shock. 1. Incorrect: Oxygen by nasal cannula is not the priority for this client. Don't pick oxygen as a priority every time. Oxygen does not fix the problem. The problem is shock. 2. Incorrect: The client will be given short-acting insulin. 4. Incorrect: Dextran is contraindicated as this will increase blood sugar even more.

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 nurse is caring for a depressed client. The client has a flat affect, apathy, and slowed physical movement. The client has not bathed in several days and there is a malodorous odor noted. Which intervention would be most appropriate at this time? 1. Explain the rules about daily showers. 2. Leave the client alone since there is slowed movement. 3. Tell the client it is time to take a shower. 4. Ask when he or she would like to take a shower.

3. Correct: Depressed clients often have little energy to do or think. Give short, simple commands during this time. 1. Incorrect: Not very therapeutic. This is difficult to comprehend at this time. Give short, clear, simple commands. 2. Incorrect: Do not ignore the problem. You must do what is best for the client and this would not be the best decision. 4. Incorrect: The client will not want to do anything at this time. It will be put off and depressed client's often have difficulty making decisions.

The nurse is caring for a depressed client. The client has a flat affect, apathy, and slowed physical movement. The client has not bathed in several days and there is a malodorous odor noted. Which intervention would be most appropriate at this time? 1. Explain the rules about daily showers. 2. Leave the client alone since there is slowed movement. 3. Tell the client it is time to take a shower. 4. Ask when he or she would like to take a shower.

3. Correct: Depressed clients often have little energy to do or think. The depression can lead to a lack of self-care as the client lacks motivation and energy. Give short, simple commands during this time. 1. Incorrect: Not very therapeutic. This is difficult for the depressed client to comprehend at this time. Give short, clear, simple commands. 2. Incorrect: Do not ignore the problem. You must do what is best for the client, and this would not be the best decision. Depression does include slowed movement, but being depressed is not a reason for the client to not meet hygiene needs. 4. Incorrect: The client will not want to do anything at this time. It will be put off, and depressed clients often have difficulty making decisions. The depressed client lacks motivation and energy. The depressed client needs short, simple statements.

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.

Two days after a myocardial infarction, a client begins reporting orthopnea and dyspnea. Further assessment reveals bi-basilar crackles, jugular venous distension, an S3 heart sound, a BP of 100/60 mm Hg, and apical pulse of 90 beats per minute. The urine output has steadily declined over the past 12 hours. What should the nurse do first? 1. Notify the primary healthcare provider. 2. Increase the IV rate. 3. Elevate the head of the bed. 4. Observe for cardiac arrhythmias.

3. Correct: Elevate the head of the bed first. The client is reporting inability to breathe. (Orthopnea means the client needs to sit up to breathe better.) With ANY client having difficulty breathing, the first intervention for the nurse is to sit the client up. This client is showing s/s of heart failure. 1. Incorrect: Your next step is to call the primary healthcare provider after you do something to try to fix the problem. 2. Incorrect: Increasing the IV rate is contraindicated and would make the problem worse. 4. Incorrect: After an MI, all clients are observed for cardiac arrhythmias. This, however, does not fix the problem.

A clinic nurse is educating a client diagnosed with Bell's Palsy. What is the most important educational point the nurse must emphasize to the client? 1. Physical therapy will be needed to maintain muscle tone of the face. 2. Massaging the face several times daily using a gentle upward motion. 3. Proper methods of closing eyelids and eye patching. 4. Non-steroidal anti-inflammatory medications are used to alleviate painful muscles.

3. Correct: Even though all are educational points that need to be provided to the client, this is the most important educational point to make. Keratitis, or the inflammation of the cornea, is one of the most dangerous complications for a client with Bell's palsy. As a precautionary measure, the nurse must ensure that the cornea is protected even if the eyelids will not close. 1. Incorrect: Physical therapy will be needed, however care to prevent eye injury takes priority. 2. Incorrect: This can be done once the client's facial sensitivity to touch decreases and the client can tolerate touching the face. Preventing eye injury takes priority. 4. Incorrect: This is true, but again, protecting the eye is the most important point to convey to the client.

Which task would be appropriate for the LPN/VN to complete? 1. Assessing a client who was just admitted to the unit. 2. Administering morphine IV push to a two day post-op client. 3. Feeding a client through a percutaneous endoscopic gastrostomy (PEG). 4. Reinserting a PICC line that was pulled out by the client.

3. Correct: Feeding by way of a PEG tube would be the best assignment for the LPN/VN. This is a nursing action that can be performed by the LPN/VN and does not require verification nor a co-signature by the RN. 1. Incorrect: The LPN/VN can collect data on a new client, but the RN must verify the information and co-sign the assessment. New admits require initial observation and data collection. From this, the RN must evaluate the information and formulate priorities of care. 2. Incorrect: Administering morphine IVP is out of the scope of practice for the LPN/VN. Therefore, this task should not be assigned to the LPN/VN. 4. Incorrect: Reinserting a PICC line is out of the realm of practice for an LPN/VN. Therefore, this task should not be assigned to the LPN/VN.

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.

The clinical specialist is teaching a group of new staff nurses about therapeutic communication. Which statement by one of the staff nurses indicates to the clinical specialist that further teaching is needed? 1. Effective communication involves feedback to let the sender know that the message was understood by the receiver. 2. An effective message should be clear and complete. 3. Therapeutic communication does not include the use of gestures. 4. I must listen with a "third ear" to be aware of what the client is not saying.

3. Correct: Gestures are a type of nonverbal communication which can provide assistance in communicating therapeutically with a client. Other forms of nonverbal communication include facial expression, touch, mannerisms, posture, position, and personal space. 1. Incorrect: This is a correct statement regarding therapeutic communication. 2. Incorrect: This is a correct statement regarding therapeutic communication. 4. Incorrect: This is a correct statement regarding therapeutic communication. The third ear listens for what the client is not saying or picks up on hints as to the real message.

The charge nurse is observing the work of an unlicensed assistive personnel (UAP). Which observation will require the nurse to intervene? 1. Placing soiled linen in a hazardous waste linen bag outside of the client's room. 2. Closing the door when exiting the room of a client diagnosed with tuberculosis (TB). 3. Going between client rooms wearing the same pair of gloves to collect I&O reports. 4. Cleaning a blood pressure cuff with a disinfectant.

3. Correct: Gloves should be removed and hands washed before leaving each client's room. Gloves quickly become contaminated and then become a potential vehicle for the transfer of organisms between clients. 1. Incorrect: No intervention is needed because this is an appropriate action. Do not carry soiled linen down the hall to place in a receptacle. 2. Incorrect: No intervention is required because this is an appropriate action. Clients with tuberculosis (TB) need to be on airborne precautions in a negative pressure room with the door closed. 4. Incorrect: Equipment used against intact skin should be thoroughly cleaned with low level disinfectant between uses to reduce the load of microorganisms to a level that is not threatening to the next client. Therefore, no intervention is needed since the action is appropriate.

When caring for a client with hepatitis A, the nurse should take what special precaution? 1. Wear gloves when handling blood and body fluids. 2. Wear a mask and gown before entering the room. 3. Use gloves when removing the client's bedpan. 4. Use caution when bringing food to the client.

3. Correct: Hepatitis A is transmitted by the fecal/oral route. 1. Incorrect: Hepatitis B is transmitted by contact with blood and body fluids. 2. Incorrect: Masks are not necessary when a client is placed on contact isolation. Hepatitis A is NOT transmitted by airborne or droplet transmission. 4. Incorrect: Use caution in bringing fresh produce to clients placed on reverse isolation.

A client is admitted to the emergency department reporting abdominal discomfort and constipation lasting 3 days. Which abdominal assessment data would the nurse report to the primary healthcare provider? 1. Striae. 2. Borborygmi. 3. High-pitched bowel sounds. 4. Tympany noted on percussion.

3. Correct: High-pitched bowel sounds are indicative of an early bowel obstruction and hypoactive bowel sounds develop as obstruction worsens. The additional signs presented are also clues of a possible obstruction. 1. Incorrect: Striae on the abdomen may be a sign of past weight changes such as those seen with weight gain from pregnancy. These do not create abdominal discomfort nor constipation. 2. Incorrect: Borborygmi are normal, loud, rumbling sounds from gas movement through the intestines or from hunger. These are easily audible bowel sounds. These are not typically associated with constipation but may be present with diarrhea. 4. Incorrect: This is a normal finding in the abdomen. Tympany is usually present in most of the abdomen caused by air in the gut (a higher pitch than the lungs). Tympany would be minimal in this case, dependent upon the degree of constipation, which would lead to a dull sound upon percussion.

The home health nurse is caring for a client with a neurological urinary tract dysfunction. What information should be included when teaching the client how to perform intermittent self catheterization? 1. Performed in an emergency department (ED). 2. Prevents urinary catheter infections. 3. Perform as a clean procedure. 4. Requires using sterile gloves.

3. Correct: Home intermittent catheterization is a clean, not sterile technique when performed in the home environment. Home intermittent catheterization is preferred over continuous use of an indwelling catheter, as an indwelling catheter increases client risk of urinary tract infection (UTI).1. Incorrect: The client can be taught to do self-catheterization at home. The client does not need to go to the emergency department (ED) to perform the self-catheterization procedure.2. Incorrect: Performing intermittent self-catheterization at home is recommended for urinary retention. It does not prevent urinary tract infections.4. Incorrect: Intermittent self-catheterization is a clean procedure, not sterile technique.

What important principle should the nurse reinforce with the client performing intermittent self-catheterization? 1. Inserted in an emergency department. 2. Used to treat urinary catheter infections. 3. Is a clean procedure. 4. Requires use of sterile gloves.

3. Correct: Intermittent catheterization is a clean, not sterile, technique when performed in the home environment. Home intermittent catheterization is preferred over continuous use of a Foley catheter, as a Foley catheter increases client risk of urinary tract infections. 1. Incorrect: The client can be taught to do self-catheterization at home. An intermittent self-catheterization does not need to be performed in an emergency department. 2. Incorrect: Performing intermittent self-catheterization at home is recommended for urinary retention. This procedure does not treat urinary tract infections. 4. Incorrect: This procedure is a clean, not sterile, technique when performed in the home environment. Sterile gloves are not required.

A low income family with children lives in an old, run-down apartment building situated close to a salvage yard in a poor neighborhood. Which area of assessment would be most important for the home health nurse? 1. Immunization status 2. School-related problems 3. Lead poisoning 4. Signs of child abuse

3. Correct: Lead may be found in the soil around rusted cars and can cause lead exposure. Old paint contains lead. Chips of paint may be consumed by young teething children. Old, run-down apartments may also have pipes which contain lead. Exposure to and consuming even small amounts of lead can be harmful. No safe lead level in children has been identified, and lead can affect nearly every system in the body. Mental and physical development can be negatively impacted by lead in the body. 1. Incorrect: Although the nurse does need to check immunizations, the hints in the stem indicate several problems that should direct the focus to lead poisoning, which is the priority. Immunization should be administered if the child is not on schedule, but consequences of lead poisoning is much more serious. 2. Incorrect: There was nothing in the stem indicating school problems. This would not take priority over lead exposure assessment. 4. Incorrect: Although poverty and poor housing conditions have been identified as environmental factors for potential abuse, the stem of this question does not provide additional cues that would indicate abuse. Assessment for lead poisoning would be the priority in this situation based on the environmental issues identified.

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

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

A client is returned to the surgical unit following gastric/esophageal repair of a hiatal hernia, with an IV, NG tube to suction, and an abdominal incision. To prevent disruption of the esophageal suture line, what is most important for the nurse to do? 1. 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 is assisting an unlicensed assistive personnel (UAP) move an obese and dependent client toward the top of the bed. Which action is most important to prevent shearing forces on the skin? 1. Each person puts hands under the client and slides client toward the top of the bed. 2. Apply powder to the sheet before pulling client toward the top of the bed. 3. Place turn sheet under the client and use it to slide the client toward the top of bed. 4. Seek assistance of another person before pulling up in bed.

3. Correct: Placing a turn sheet under the client before moving will prevent friction and shearing forces which may lead to an abrasion or skin tear. Pressure ulcers are more likely to develop in tissues where shear force injury has occurred. 1. Incorrect: This will not prevent shearing forces on the skin and may result in scratches to the skin if the staff are wearing rings or other jewelry. The shearing force is created by gravity pushing down on the client's body, creating a resistance to movement. It creates a downward and forward pressure on tissues beneath the skin. 2. Incorrect: Using powder may actually irritate the skin as it may be abrasive when client's weight pushes against it and the bed. 4. Incorrect: Another person to assist in controlling the head or holding the lower legs would be helpful; however, using three to move up without protecting the skin would not be beneficial to the client. Shearing force injury to the skin could still result.

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 performing CPR on an adult client with facial and neck trauma. Following the administration of rescue breaths, where is the best location for the nurse to assess for a pulse in this client? 1. Apical area 2. Carotid artery 3. Femoral artery 4. Radial artery

3. Correct: Pulses that are best palpated are large and close to the trunk of the body. The femoral artery is large and at the trunk (proximal) of the body. 1. Incorrect: It would take too long to use a stethoscope and listen for an apical pulse on the client. A quicker area of checking the pulse would need to be used. 2. Incorrect: The client has bilateral neck trauma. The carotid artery would not be the best site to assess for a pulse. 4. Incorrect: The radial artery is not as large as the femoral artery and is distal to the femoral artery.

A nurse invites a friend home one evening. On arrival, the friend sees the nurse's large, white, long-haired cat sitting on the couch and begins to experience palpitations, trembling, nausea, shortness of breath, and a feeling of losing control. What should the nurse do first? 1. Stay with the friend until the friend feels better. 2. Have the friend breathe into a paper bag. 3. Remove the cat from the room. 4. Dim the lights in the room.

3. Correct: Remove the source of the panic attack first, then continue to assess the person for symptoms. Removing the cat "fixes" the problem. 1. Incorrect: This is a correct answer, but remove the cat first. 2. Incorrect: This will help hyperventilation if it occurs, but the stem of the question said the client was having "shortness of breath" related to seeing the cat. Remove the cat first as this will fix the problem and alleviate the symptoms. 4. Incorrect: This is a correct answer, but remove the cat first.

A nurse invites a friend home one evening. On arrival, the friend sees the nurse's large, white, long-haired cat sitting on the couch and begins to experience palpitations, trembling, nausea, shortness of breath, and a feeling of losing control. What should the nurse do first? 1. Stay with the friend until the friend feels better. 2. Have the friend breathe into a paper bag. 3. Remove the cat from the room. 4. Dim the lights in the room.

3. Correct: Remove the source of the panic attack first, then continue to assess the person for symptoms. Removing the cat "fixes" the problem. 1. Incorrect: This is a correct answer, but remove the cat first. 2. Incorrect: This will help hyperventilation if it occurs, but the stem of the question said the client was having "shortness of breath" related to seeing the cat. Remove the cat first as this will fix the problem and alleviate the symptoms. 4. Incorrect: This is a correct answer, but remove the cat first.

The nurse is working with the parents of a preschooler to help promote healthy sleep patterns of approximately 8 - 12 hours of sleep per night. Which intervention should assist the parents to achieve adequate sleep for their preschooler? 1. Offer a time of exercise prior to bedtime. 2. Follow a bedtime routine at least three or four nights per week. 3. Spend about 30 minutes with the preschooler prior to bedtime for stories. 4. Encourage preschooler to sleep without a toy.

3. Correct: Rituals help the preschooler to feel secure. Quiet time to read, tell stories, and say prayers prepares the child for sleep. 1. Incorrect: Stimulation of activity before bedtime impedes sleep. 2. Incorrect: The routine should be maintained each night if at all possible. Only through routine does the child feel secure in preparation for bedtime. 4. Incorrect: A special toy helps the child to feel secure and adds to the nighttime routine.

Which statement by a student nurse indicates to the nurse educator that teaching regarding witnessing consent signatures has been successful? 1. "Two people must witness a consent signature." 2. "A RN must witness a consent signature." 3. "Signing as a witness implies that the client willingly signed the consent." 4. "A witness must be over the age of 21."

3. Correct: Signing as a witness implies that the witness has observed the client personally signing the consent form with no coercion. 1. Incorrect: Only one signature is required as a witness. 2. Incorrect: The witness does not have to be an RN. 4. Incorrect: A witness is required to be over the age of 18.

The nurse is performing morning care on a client on the medical unit. What should the nurse do after changing a client's bed linen? 1. Hold the linen close to the body while transporting it to the dirty utility room. 2. Wear a gown and gloves to transport the linen to the biohazard container. 3. Place the linen into a leak proof container sitting outside the room. 4. Place the linen in a pillow case and set it on the floor until client care is completed.

3. Correct: Soiled linen should be placed in a leak proof container for transport off the unit to the laundry. Make sure the linen bags are not overfilled which would prevent complete closure. 1. Incorrect: Linen should be held away from the body to prevent contamination of the nurse's clothes. The linens should be handled as little as possible to avoid possible contamination of air, surfaces and persons. 2. Incorrect: Gloves should always be worn when handling soiled linen. A gown is not necessary. Soiled linen should be carried away from the body with minimal handling to prevent contamination. 4. Incorrect: Soiled linen should not be placed on the floor. All linens should be handled and transported in a way that will minimize contamination and maintain a clean environment for the client, healthcare workers and visitors.

The nurse is caring for a client taking spironolactone. Which needed dietary change should the nurse reinforce to the client? 1. Eat extra helpings of bananas. 2. Increase intake of water. 3. Avoid salt substitutes. 4. Increase intake of green leafy vegetables.

3. Correct: Spironolactone is a potassium sparing diuretic. Salt substitutes have potassium instead of sodium and should be avoided. 1. Incorrect: Bananas have potassium and should be avoided to prevent hyperkalemia and life threatening arrhythmias. 2. Incorrect: Water intake does not affect the use of spironolactone and is not the best answer to the question. 4. Incorrect: Green leafy vegetables contain vitamin K and are not contraindicated. This is a distractor to the answer that could cause the most harm to the client if not chosen.

The nurse is caring for a client taking spironolactone. Which dietary change should the nurse teach the client to make when starting treatment with this medication? 1. Eat extra helpings of bananas. 2. Increase intake of water. 3. Avoid salt substitutes. 4. Increase intake of green leafy vegetables.

3. Correct: Spironolactone is a potassium sparing diuretic. Salt substitutes have potassium instead of sodium and should be avoided. 1. Incorrect: Bananas have potassium and should be avoided to prevent hyperkalemia and life-threatening arrhythmias. 2. Incorrect: Water intake does not affect the use of spironolactone and is not the best answer to the question. 4. Incorrect: Green leafy vegetables contain vitamin K and are not contraindicated. This is a distractor to the answer that could cause the most harm to the client if not chosen.

An elderly male, diagnosed with chronic renal failure and depression, lives alone. Which question should the home health nurse ask first when assessing this client? 1. Have you had suicidal thoughts in the past? 2. How are you feeling today? 3. Have you had thoughts of harming yourself? 4. Do you have guns in your home?

3. Correct: Suicide assessment should begin with direct questions about the presence of suicidal thinking. The nurse should recognize that elderly men are at higher risk for committing suicide, especially those with a history of depression, chronic illness and isolation. 1. Incorrect: This question should be asked, but only after determining if suicidal thinking is present. 2. Incorrect: This question could be an introductory question to establish rapport, but it is not direct enough to use in suicide assessment. 4. Incorrect: This question should be asked if the client is considering using gun as a method of suicide or if he has a history of suicide attempts with a gun.

The nurse is assessing pain after surgery in a 3 year old client with a known developmental delay. Which pain scale should the nurse use to assess this client's pain level? 1. CRIES scale 2. Numeric scale 3. FLACC scale 4. FACES scale

3. Correct: The FLACC scale can be used for pediatric clients from age 2 months to 7 years and is appropriate when clients cannot communicate their pain. 1. Incorrect: The CRIES scale is used with neonates and infants. 2. Incorrect: Not age-appropriate; used for children ages 5 and up.4. Incorrect: Not age-appropriate. The FACES scale is indicated for children ages 3 years and up. When using the FACES scale, the child must be able to understand the difference between pain and being sad. Because this child is only 3 years old (the bottom age for use of the FACES scale), and because the client has a developmental delay, the FLACC scale is a better choice as it is based on nursing observations.

Which assessment finding by a nurse would best indicate a positive Mantoux tuberculin skin test in a client? 1. Formation of a vesicle that is 4 mm in diameter 2. A sharply demarcated region of erythema of 10 mm 3. A central area of induration of 15 mm surrounded by erythema 4. A circle of blanched skin surrounding the injection site

3. Correct: The basis of reading the skin test is the presence or absence of induration, which is a hard, dense, raised formation. This is the area that is measured. Sometimes the site has erythema, a reddening of the skin that can also have swelling. The erythema should NOT be measured. Reactions to the skin test will vary. Measure only the induration. An induration of 15 mm or more is positive in persons with no known risk factors of TB. Reactions larger than 15 mm are unlikely to be due to previous BCG vaccination or exposure to environmental mycobacteria. 1. Incorrect: The basis of reading the skin test is the presence or absence of induration, which is a hard, dense, raised formation. This is the area that is measured. Sometimes the site has erythema, a reddening of the skin that can also have swelling. The erythema should NOT be measured. Reactions to the skin test will vary. For example, this is a very large reaction with blistering, swelling, and redness. Make sure to record blistering, even if no induration is present. Palpate this induration gently, as it may be painful. Measure only the induration. The vesicle may have a different underlying cause. 2. Incorrect: The basis of reading the skin test is the presence or absence of induration, which is a hard, dense, raised formation. This is the area that is measured. Sometimes the site has erythema, a reddening of the skin that can also have swelling. The erythema should NOT be measured. Doing so would result in a false positive test for the client. 4. Incorrect: The basis of reading the skin test is the presence or absence of induration, which is a hard, dense, raised formation. This is the area that is measured. Sometimes the site has erythema, a reddening of the skin that can also have swelling. The erythema should NOT be measured. Reactions to the skin test will vary. The area around the injection site may appear blanched initially, but should resolve. However, blanching should not be measured.

A new admit arrives to the nursing unit with one thousand dollars in cash. What would be the best action by the nurse to safeguard the client's money? 1. Insist the money go home with the client's visitor. 2. Place the money in the client's bedside table drawer. 3. Put itemized cash in envelope and place in hospital safe. 4. Lock money up in narcotic cabinet with client's identity and room number.

3. Correct: The best action by the nurse would be to itemize the valuables, place in an envelope, and put in the hospital safe. 1. Incorrect: This is not the best option. The visitor may not be the best person to take the money. The client also has the right to refuse. 2. Incorrect: This is not a safe option. Anyone could retrieve the money. 4. Incorrect: This is not a safe option. Anyone with access could retrieve the money.

An angry client visits the primary healthcare provider's office and requests a copy of their medical records. The client is angry after being placed on hold several times for over 10 minutes when requesting an appointment. What should the nurse tell this client? 1. All client appointment calls are transferred to the scheduling clerk. 2. The client will have to speak to the primary healthcare provider. 3. A copy of the record may be obtained within 24 hours of the request. 4. Medical records must stay within the facility unless requested by another primary healthcare provider.

3. Correct: The client has the right to the personal medical record. Generally, a period of time is required to get the record copied. The client may be charged for the copy. This assures the client that the request will receive attention. 1. Incorrect: This response dismisses the client's feelings and may only anger the client further. The response does not address the reason for the client's anger. The statement may be true; however, the client does have the right to request and receive a copy of the medical record. 2. Incorrect: The primary healthcare provider does not have to be contacted, as there should be policies in place to grant the request for a copy of the medical record. Also, telling the client to speak to the healthcare provider would not address the reason for the client's anger. This would dismiss the client's feelings. 4. Incorrect: The client has a right to the medical record. Records may also be requested by other providers with consent of the client. The client's feelings should be addressed and the client should be informed that the medical record will be provided as requested.

A client was admitted to the psychiatric unit with delusions and a history of auditory hallucinations. The client reports, "The FBI has been watching my house and are going to raid it and arrest me." What is the nurse's best response? 1. The FBI would not be watching you unless there was a good reason. 2. I don't think that the FBI is watching your house. 3. I believe that your thoughts are very disturbing to you. 4. Tell me more about your thoughts.

3. Correct: The client's delusions can be very distressing. The nurse should empathize with the feelings of the client, but should not validate the belief itself. Empathy displays that the nurse is concerned, interested, and accepts the client but does not support the delusion. 1. Incorrect: Arguing with the client who has delusions only upsets the client and may provoke violence. The client can not understand the logical argument, so the delusional ideas are not dispelled. Also, the argument can interfere with the development of trust. 2. Incorrect: Disagreement may anger the client. The client needs empathy and understanding from the nurse. This is dismissing the client's feelings. The focus should not be on what the nurse thinks. The focus should always be on the client's feelings. 4. Incorrect: In-depth detail of delusions only reinforces the delusion. The nurse should encourage reality based conversation. Interacting about reality is beneficial for the client to move them away from delusional thoughts.

A nurse from an adult unit was reassigned to the pediatric unit. Which client would be least appropriate to assign to this nurse? 1. Ten year old with 2nd and 3rd degree burns. 2. Five year old that was in a MVA and has a femur fracture. 3. Six year old admitted for evaluation of possible sexual abuse by a parent 4. Two month old with bronchopulmonary dysplasia being admitted for reflux.

3. Correct: The least appropriate client to assign the nurse from the adult unit would be the suspected sexual abuse. Caring for an abused child requires skill that must be developed from understanding the dynamics of abuse as well as working with a certain developmental level. 1. Incorrect: A nurse on an adult unit should understand classification of burns and associated care for the burn client. The pediatric burned client would be a similar to the condition adults might acquire, and the nurse's skill level could transfer to these clients. 2. Incorrect: The nurse who works on an adult unit should understand the concepts for caring for a client with a fracture. The pediatric client with the fracture would be a similar condition adults might acquire, and the nurse's skill level could transfer to these clients. 4. Incorrect: The 2 month old with BPD is different, but the concept and care of reflux is similar to that in adult clients.

Two hours following a lumbar puncture, the client stands up to void and reports a headache rated 8 out of 10 on a pain scale. What priority action should the nurse perform? 1. Instruct the client to drink at least 8 ounces (240 mL) of water. 2. Close room blinds to darken the environment. 3. Assist the client into a supine position in bed. 4. Notify primary healthcare provider of client's complaints.

3. Correct: The most frequent cause of headache following a lumbar puncture is loss of, or leaking, of cerebrospinal fluid from the puncture site. Positioning a client is an important nursing responsibility, particularly in this situation since the supine position could help to stop any leaking. Following this, the nurse will pursue additional actions as prescribed by the primary healthcare provider, which may include increasing fluids or even a blood patch. 1. Incorrect: Although increasing fluids may help clients under specific circumstances, it is not the priority action in this situation. Additionally, the primary healthcare provider may order IV fluids rather than PO fluids. 2. Incorrect: A darkened room can be beneficial for clients with severe migraine headaches, but would not be useful to this client. Headaches following a lumbar puncture are caused by the loss of cerebrospinal fluid and would not respond to a quiet, dark environment. So this would not be the priority. 4. Incorrect: Although the primary healthcare provider should indeed be notified of this situation, the nurse's priority action should first focus on stabilizing the client by addressing the cause of this problem and positioning the client.

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 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.

What action should the nurse take after entering the room of a client who becomes agitated and combative? 1. Administer prn sedative. 2. Notify the family of client behavior. 3. Speak softly to the client. 4. Apply wrist restraints.

3. Correct: The nurse needs to present a calm manner and speak quietly to the client. This will build trust and decrease tension and stress in the client. 1. Incorrect: This is a form of restraint. The use of positive nursing actions can reduce the use of chemical (drug therapy) restraints. 2. Incorrect: Do not pick an answer that transfers the client away from the nurse's care. 4. Incorrect: Restraints are a last resort and can make the client more agitated.

Following surgery, a client refuses to ambulate as prescribed. What action should the nurse take? 1. Notify the primary health care provider of client's refusal to ambulate. 2. Offer the client pain medication. 3. Explain complications associated with bed rest. 4. Perform passive range of motion exercises.

3. Correct: The nurse should educate the client about complications that can be prevented with ambulation, such as constipation, pneumonia, or deep vein thrombosis (DVT). 1. Incorrect: The first action should be for the nurse to educate the client so an informed decision can be made. This would put the nurse in an advocacy role and would more likely persuade the client to comply with ambulation. 2. Incorrect: The first action should be for the nurse to educate the client so that he/she can make an informed decision. Offering pain medication would be appropriate if pain is impeding the client's ability to move; however, pain medications may make the client at risk for falls so safety precautions would be priority. 4. Incorrect: The first action should be for the nurse to educate the client so that an informed decision can be made. Passive range of motion would not be the best option at this time.

The nurse prepares a sterile field for a procedure. Fifteen minutes later, the nurse is informed that there will be a 20 minute delay before the primary healthcare provider will arrive. What action should the nurse take? 1. Cover the sterile field with a sterile drape 2. Close and tape the doors so that no one may enter. 3. Monitor the sterile field while awaiting the primary healthcare provider. 4. Take down the sterile field.

3. Correct: The nurse should monitor the sterile field while awaiting the primary healthcare provider. This means keeping the sterile field in your site. 1. Incorrect: Sterile fields should not be covered. Although there are no research studies to support or discount the practice, removing a table cover may result in a part of the cover that was below the table level being drawn above the table level or air currents drawing microorganisms from a nonsterile area to the sterile field. It is important to continuously monitor all sterile areas for possible contamination.​ 2. Incorrect: There is no specified amount of time designated that a room can remain open and not used and the sterile field still be considered sterile. The sterility of an open sterile field is event-related. An open sterile field requires continuous visual observation. Direct observation increases the likelihood of detecting a breach in sterility.​ 4. Incorrect: It is unnecessary to take down the sterile field as the delay is minimal. This is also an added cost to discard materials and redo the sterile field when it has not been contaminated. Sterile fields should be prepared as close as possible to the time of use. The potential for contamination increases with time because dust and other particles present in the ambient environment settle on horizontal surfaces over time. Particulate matter can be stirred up by movement of personnel when opening the room and can also settle on opened sterile supplies.

A 70 year old client was admitted to the vascular surgery unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's BP is 198/94. What would be the best action for the charge nurse to delegate at this time? 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm in 15 minutes. 3. Have the LPN/LVN administer the 0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for pain.

3. Correct: The nurse should recognize the need for measures to reduce the blood pressure. Administering the client's blood pressure medicine is aimed at correcting the problem. It is appropriate to administer the medications at this time in relation to the time that the next dose is due. 1. Incorrect: This is an appropriate action, but does not address the problem of lowering the client's blood pressure. 2. Incorrect: This is an appropriate action, but does not address the problem of lowering the client's blood pressure. 4. Incorrect: This is an appropriate action, but does not address the problem of lowering the client's blood pressure.

To determine the standards of care for the institution, the nurse should consult which document? 1. Organizational Chart 2. Personnel policies 3. Policies and procedure manual 4. Job descriptions

3. Correct: The standard of care for nurses is defined as what a prudent nurse would do in the same situation. The policies and procedure manual defines standards of care for an institution. 1. Incorrect: An organizational chart identifies which departments exist and their relationship with each other. It also lists the chain of command of positions/jobs. 2. Incorrect: Policies for personnel are not standards of care. Personnel policies are pre-established guidelines that are utilized to govern personnel related issues. 4. Incorrect: A job description is a formal written statement of an employee's work responsibilities. This is not related to the standards of care and therefore, doesn't go into detail about standards of care.

The triage nurse in the emergency department (ED) assesses 4 clients. Which client is in need of emergent care? 1. A 52 year old who has a partially amputated finger. 2. A 9 month old with temperature of 103°F (39.4°C). 3. A two year old with excessive drooling and a weak cough. 4. A 28 year old experiencing a migraine headache for three days.

3. Correct: The two year old is exhibiting signs of respiratory difficulty with excessive drooling and a weak cough. Partial airway obstruction is likely and maybe the result of acute epiglottitis in which rapid progression to severe respiratory distress can occur . Airway takes priority over the other clients. 1. Incorrect: The partial amputation would have associated bleeding could be seen next, but airway takes priority. 2. Incorrect: Most fevers in children do not last for long periods and do not have much consequence. Elevated temperature would not take priority over airway. Antipyretics can be given in triage. 4. Incorrect: The migraine is not emergent. Take care of life-threatening illnesses/injuries first. Remember, pain never killed anyone.

The nurse is teaching a client about foods containing tyramine which should be avoided while taking a monoamine oxidase inhibitor (MAOI). Which meal selection by the client would indicate understanding of an acceptable food to eat? 1. Smoked turkey and dressing, sweet peas and carrots and milk. 2. Baked chicken over pasta with parmesan sauce, baked potato and tea. 3. Fried catfish, French fries, coleslaw and apple juice. 4. Liver smothered in gravy and onions, rice, squash and water.

3. Correct: These foods are not high in tyramine. Tyramine is an amino acid that helps in the regulation of blood pressure. MAOIs block the enzyme monoamine oxidase which is responsible for breaking down excess tyramine in the body. Eating foods high in tyramine while on MAOIs can result in dangerously high levels of tyramine in the body. This can lead to a serious rise in blood pressure, creating an emergency situation. Tyramine is found in protein-containing foods and the levels increase as these foods age. Food such as strong or aged cheese, cured meats, smoked or process meats, liver (especially aged liver), pickled or fermented foods, sauces, soybeans, dried or overripe fruits, meat tenderizers, brewer's yeast, alcoholic beverages and caffeine- such as in tea, cokes and coffee are considered to be high in tyramine and should be avoided in clients taking MAOIs. 1. Incorrect: The following foods in the options listed above contain moderate to high levels of tyramine and should be avoided while taking MAOIs: smoked turkey, parmesan cheese, tea and liver. 2. Incorrect: The following foods in the options listed above contain moderate to high levels of tyramine and should be avoided while taking MAOIs: smoked turkey, parmesan cheese, tea and liver. 4. Incorrect: The following foods in the options listed above contain moderate to high levels of tyramine and should be avoided while taking MAOIs: smoked turkey, parmesan cheese, tea and liver.

A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops slurred speech, shuffling gait and drooling. Which prescribed PRN medication would the nurse administer? 1. Lorazepam 2. Atropine 3. Benztropine 4. Chlorpromazine

3. Correct: These signs and symptoms are reflective of pseudoparkinsonism, a form of extrapyramidal side effects which are side effects of the haloperidol. An anticholinergic agent maybe used for treatment. This is an anticholinergic agent that may be used for extrapyramidal side effects. 1. Incorrect: This is a sedative/hypnotic or antianxiety agent. It is not used for treatment of extrapyramidal side effects. 2. Incorrect: This is an anticholinergic agent, but not one commonly used to treat pseudoparkinsonism, a form of extrapyramidal side effects. It is commonly used to treat arrhythmias and preoperatively to decrease secretions. 4. Incorrect: This is another antipsychotic medication.

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.

A client has been prescribed vancomycin 1 gram IV every 12 hours for the treatment of methicillin-resistant staphylococcus aureus (MRSA). Which action by a new nurse when administering this medication would require intervention by the charge nurse? 1. Dilutes medication in NS 100 mL. 2. Delivers medication via an IV pump. 3. Calculates infusion rate at 30 minutes. 4. Monitors IV site every 30 minutes during infusion.

3. Correct: This dose of medication should be delivered over at least 60 minutes to prevent hypotension and ototoxicity. 1. Incorrect: The minimum dilution for 1 gram is 100 mL, so this action does not need intervention. 2. Incorrect: This is a correct action by the new nurse. A pump is required to ensure that medication is not delivered too rapidly. 4. Incorrect: A peripheral IV site should be monitored for pain, redness or swelling prior to initiating the infusion and every 30 minutes until the completion of the infusion.

The nurse is caring for a client who has taken an acetaminophen overdose. Which symptom is the client most likely to exhibit? 1. Expectorating pink frothy sputum 2. Sudden onset of mid-sternal chest pain 3. Jaundiced conjunctiva 4. Diaphoresis and fever

3. Correct: This is a sign of liver damage, which is caused by an overdose of acetaminophen. 1. Incorrect: This is a symptom of pulmonary edema, not liver damage. 2. Incorrect: This is a symptom of myocardial ischemia, not liver damage. 4. Incorrect: Acetaminophen would decrease fever, and fever could cause diaphoresis, so neither of these are expected with acetaminophen overdose.

The nurse is evaluating dietary education provided to a client diagnosed with cholecystitis. The nurse determines that further teaching is necessary when the client chooses which meal to consume? 1. Cup of oatmeal, blueberries, soymilk 2. Whole grain pasta, marinara sauce, baked fish, coffee 3. Spaghetti with meat sauce, peas, garlic French bread, tea 4. Lentil soup, vegetable medley, fruit salad, water

3. Correct: This is not a good choose for this client. Meat is high fat. French bread with butter is low fiber and high fat. 1. Incorrect: This is a good meal choose when on a low fat, high fiber diet. Blueberries are high in fiber and all are low fat. 2. Incorrect: This is a good low fat, high fiber meal choose. Whole grain pasta is high in fiber and low in fat. Fish and marinara sauce are low in fat. 4. Incorrect: These are low fat, high fiber items to consume.

The nurse is providing post-operative care to the craniotomy client. Hourly urinary output increases from 100 mL last hour to 500 mL this hour. What action by the nurse takes priority? 1. Elevate HOB 90 degrees 2. Auscultate apical pulse 3. Obtain a blood pressure 4. Assess Glasgow Coma Score

3. Correct: This is the best answer because we are "worried" this client is going into SHOCK due to diabetes insipidus. So, you better be checking a BP. This is a time where checking the BP is appropriate. If we "assume the worst" I better check a blood pressure. It could have dropped out the bottom. 1. Incorrect: This client is losing too much fluid. We worry about shock. Lower the HOB. 2. Incorrect: Checking the pulse is a good thing, but not as important as checking the BP. 4. Incorrect: If my client is going into shock, the highest priority is to assess the BP.

A client 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 client is hospitalized because of severe malnutrition related to anorexia nervosa. What is the most important goal for this client? 1. Verbalize understanding that eating behaviors are maladaptive. 2. Verbalize the importance of adequate nutrition. 3. Achieve at least 80% of expected body weight. 4. Acknowledge misperception of body image as fat.

3. Correct: Until appropriate weight is gained, the client continues to be at risk for major health complications including hypotension, cardiac arrhythmias, poor muscle tone, increased risk for infection, abnormal liver function, and damaged kidneys. 1., 2. & 4. Incorrect: These are all appropriate goals; however, the most important one is that the client gain adequate weight.

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 nurse is preparing a client for a renal biopsy. Which is most important for the nurse to assess prior to this procedure? 1. BUN and creatinine 2. NPO status and signature on consent 3. Bleeding time and coagulation studies 4. Serum potassium and urine sodium

3. Correct: Yes. Before you insert a needle into an organ for a biopsy, it would be best to know the client's bleeding time because there is a risk of bleeding when the biopsy is performed. 1. Incorrect: Although these are related to renal function, they do not impact the procedure itself. Therefore, they are not essential for the procedure. 2. Incorrect: Although both of these are carried out, they are not the priority over risk of bleeding. Always think what could be life threatening. 4. Incorrect: Although both serum potassium and urine sodium are related to renal function, they do not impact the procedure itself. Therefore, they are not essential for the procedure.

A client with a history of congestive heart failure has an implantable cardioverter defibrillator (ICD) surgically implanted. What teaching points should the nurse reinforce with the client prior to discharge? (SATA) 1. Avoid hot baths and showers. 2. Increase intake of leafy green vegetable products. 3. Avoid magnets directly over the site. 4. Notify primary healthcare provider whenever a shock is delivered by the ICD. 5. Driving is not recommended for 1 year after placement of an ICD.

3., & 4. Correct: Magnets can deactivate the defibrillator. Other transmitter devices should also be avoided. Most arrhythmias need only one shock, but the healthcare provider should be notified when a shock is delivered so that monitoring can increase. 1. Incorrect: Hot baths or showers are not contraindicated with ICDs. 2. Incorrect: Increase of leafy green vegetable products would have no relation to the ICD but should be avoided if the client is on warfarin. 5. Incorrect: The client cannot drive for 6 months after implantation of an ICD and cannot drive for 6 months after any shock therapy from the ICD.

A client with a history of congestive heart failure has an implantable cardioverter defibrillator (ICD) surgically implanted. What teaching points should the nurse provide the client prior to discharge? Select all that apply 1. Avoid hot baths and showers. 2. Increase intake of leafy green vegetable products. 3. Avoid magnets directly over the site. 4. Notify primary healthcare provider whenever a shock is delivered by the ICD. 5. Driving is not recommended for 1 year after placement of an ICD.

3., & 4. Correct: Magnets can deactivate the defibrillator. Other transmitter devices should also be avoided. Most arrhythmias need only one shock, but the healthcare provider should be notified when a shock is delivered so that monitoring can increase. 1. Incorrect: Hot baths or showers are not contraindicated with ICDs.2. Incorrect: Increase of leafy green vegetable products would have no relation to the ICD but should be avoided if the client is on warfarin. 5. Incorrect: The client cannot drive for 6 months after implantation of an ICD and cannot drive for 6 months after any shock therapy from the ICD.

Which assignment would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Select all that apply 1. Obtaining a sterile urine specimen from an indwelling catheter. 2. Inserting an in-and-out catheter on a client postpartum. 3. Taking vital signs on a client 12 hours postpartum. 4. Removing an indwelling catheter on a client postpartum. 5. Perform perineal care on a client with an episiotomy.

3., & 5. Correct: Taking vital signs is within the scope of practice for the UAP, but the nurse is responsible for evaluating the vital signs. Performing perineal care is within the scope of practice for the UAP. The nurse is responsible for assessing the episiotomy and confirming that perineal care is done properly. 1. Incorrect: Invasive procedures are not appropriate tasks for UAP (obtaining sterile specimen from indwelling catheter). 2. Incorrect: Invasive procedures are not appropriate tasks for UAP (inserting catheter). 4. Incorrect: Invasive procedures are not appropriate tasks for UAP (removing indwelling catheter).

Which task would be most appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? (SATA) 1. Obtain a sterile urine specimen from an indwelling catheter. 2. Insert an in-and-out catheter on a postpartum client. 3. Take vital signs on a client 12 hours postpartum. 4. Remove an indwelling catheter on a postpartum client. 5. Perform perineal care on a client with an episiotomy.

3., & 5. Correct: Taking vital signs is within the scope of practice for the UAP, but the nurse is responsible for reviewing the vital signs. Performing perineal care is within the scope of practice for the UAP. The nurse is responsible for assessing the episiotomy and confirming that perineal care is done properly. 1. Incorrect: Invasive procedures are not appropriate tasks for UAP (obtaining sterile specimen from indwelling catheter). 2. Incorrect: Invasive procedures are not appropriate tasks for UAP (inserting catheter). 4. Incorrect: Invasive procedures are not appropriate tasks for UAP (removing indwelling catheter).

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.

A licensed practical nurse (LPN) is utilizing the nursing process to care for assigned clients. Which nursing actions should the LPN relate to the implementation step of the nursing process? (SATA) 1. Collecting client data for a nursing history. 2. Reporting client response to a new medication. 3. Procuring equipment for a planned medical procedure. 4. Assigning client care activities to unlicensed assistive personnel. 5. Delivering skilled nursing care according to an established health care plan.

3., 4., & 5. Correct: The nurse should relate procuring medical equipment, assigning client care activities, and delivering skilled nursing care to the implementation step of the nursing process. Implementation is the third step of the nursing process and consists of delivering nursing care according to an established health care plan and as assigned by the RN or other person(s) authorized by law. 1. Incorrect: This is not the implementation step of the nursing process. LPNs participate in the assessment step of the nursing process by collecting client data for a nursing, psychological, spiritual, and social histories, comparing the data collected to normal values and findings. 2. Incorrect: This is not the implementation step of the nursing process. LPNs participate in the nursing process by reporting client responses to the RN or supervising healthcare provider.

Which clients would be appropriate for the RN to assign to an LPN/LVN? 1. Seventy four year old client with unstable angina who needs teaching for a scheduled cardiac catheterization. 2. Sixty year old client experiencing chest pain scheduled for a graded exercise test. 3. Forty eight year old client who is five days post right-sided cerebral vascular accident (CVA). 4. Eighty four year old client with heart disease and mild dementia. 5. Newly admitted ninety year old client with decreased urinary output, altered level of consciousness, and temperature of 100.8°F (38.2°C) 6. Sixty six year old client with chronic emphysema experiencing mild shortness of breath.

3., 4., 6. Correct: The client who is five days post CVA is one of the most stable clients and could be assigned to the LPN/LVN. There is nothing in the option to indicate that this client is unstable. There is no indication that the eighty-four year old client with heart disease and dementia is unstable so this client can be assigned to the LPN/LVN. The client with chronic emphysema will experience shortness of breath. There is nothing to indicate that this client is unstable. 1. Incorrect: This client is unstable and should be cared for by the RN. Additionally, the RN is responsible for teaching. 2. Incorrect: This client is experiencing chest pain and is thus considered unstable and should be cared for by the RN. 5. Incorrect: This client has s/s that could indicate sepsis, so is considered unstable and should not be assigned to the LPN/LVN.

A client admitted with a myocardial infarction has developed crackles in bilateral lung bases. Which prescription written by the primary healthcare provider should the nurse complete first? 1. Draw blood for arterial blood gases. 2. Place compression hose on legs. 3. Insert indwelling catheter for hourly urinary output. 4. Administer furosemide 20 mg intravenous push (IVP).

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A client comes into the emergency department (ED) and demands to be seen immediately, but refuses to tell the triage nurse the problem. During the assessment, the client starts yelling and shaking their fist. For the nurse's safety, what should be the nurse's initial action? 1. Tell the client to stay calm, and that treatment will be provided soon. 2. Explain that unless the client behaves, they will be sent away from the ED. 3. Notify the client that security will be called if they do not go to the waiting room immediately. 4. Find a safe place away from the client and then notify security.

4

A client diagnosed with a duodenal ulcer is prescribed lansoprazole and sucralfate. What should the nurse teach the client about how to take these medications? 1. Take together immediately before meals. 2. Take together immediately after meals. 3. Take the sucralfate first, wait at least 30 minutes, then take the lansoprazole. 4. Take the lansoprazole first, wait at least 30 minutes, then take the sucralfate.

4

A client experiencing chest pain is prescribed an intravenous infusion of nitroglycerin. After the infusion is initiated, the occurrence of which symptom would prompt the nurse to discontinue the nitroglycerin? 1. Frontal headache 2. Orthostatic hypotension 3. Decrease in intensity of chest pain 4. Cool, clammy skin

4

A client has an order for two units of packed red blood cells (PRBCs) to be administered. The current IV prescribed is D5LR with 20 mEq KCL at 125 mL/hr infusing through a 22 gauge needle to the left hand. What action should the nurse take? 1. Piggyback the PRBCs to the current IV fluid at the lowest port on the tubing. 2. Change the current IV fluid to NS so the blood can infuse through the IV tubing. 3. Disconnect the current IV fluid and connect NS with a y-tubing blood administration set. 4. Start another IV with an 18 gauge needle to the right arm.

4

A client in a psychiatric unit sings over and over, "It is hot, I am a hot tot in a lot, I sit all day on a cot drinking a pop." How should the nurse document this form of thought? 1. Neologisms 2. Dissociation 3. Fugue 4. Clang Association

4

A client was admitted to the medical unit with pneumonia 2 days ago. There is a history of drinking 5-6 martinis every night for the past 2 years. Today, the nurse notes that the client is disoriented to time and place and is seeing imaginary spiders on the ceiling. The nurse cannot understand what the client is saying. What is this client most likely experiencing? 1. Wernicke's Encephalopathy 2. Korsakoff's Psychosis 3. Alcohol Withdrawal 4. Alcohol Withdrawal Delirium

4

A client with cancer of the larynx undergoes radiation therapy for 5 weeks prior to a neck dissection and tumor excision. The client asks the nurse how long the post surgical recovery time will be. How should the nurse reply? 1. "I really don't know. It is different for everyone, but speak to your surgeon." 2. "Your medical insurance will cover the whole length of your stay, so don't worry." 3. "You shouldn't worry about how long you are going to stay. You should focus on getting better." 4. "It may be a little longer than average. The radiation you received sometimes delays tissue healing."

4

A female client taking captopril for hypertension tells the clinic nurse that she is planning to get pregnant. What recommendation should the nurse make? 1. "Captopril can be taken safely during pregnancy, but we will need to decrease your dose so you do not become hypotensive." 2. "We will need to increase your dose of captopril once you become pregnant." 3. "In order to prevent neural tube defects, start taking folic acid." 4. "Captopril can cause serious harm to an unborn baby, so you must prevent pregnancy while taking this medication. "

4

A nurse is at highest risk for blood-borne exposure during which situation? 1. When removing a needle from the syringe. 2. While placing a suture needle into the self-locking foreceps. 3. Prior to inserting the intravenous (IV) line, the client moves causing a needle stick to the nurse. 4. A clean needle sticks the nurse through blood-soiled gloves.

4

A nurse is caring for a client who has developed ventricular fibrillation. Where should the nurse place the conductive electrodes for maximum defibrillation effectiveness? 1. The left lower sternum and the right side of the thorax in the midclavicular line. 2. On the right shoulder and the left side of the sternum just below the rib cage. 3. The left upper chest to the left of the sternum and the lower right half of the sternum. 4. Below the right clavicle to the right of the sternum and just below the left nipple.

4

A nurse is teaching a client about the prescription aripiprazole discmelt. The nurse documents that teaching has been effective when the client makes which statement? 1. "If I start to have shakiness and sweating I need to call my primary healthcare provider at once." 2. "I must be certain to take this medication with food to eliminate vomiting." 3. "If I miss a dose of medication, I need to take an extra dose to make up for the missed dose." 4. "I will allow the tablet to dissolve in my mouth."

4

A parent tells the clinic nurse, "My child has just been diagnosed with attention-deficit/hyperactivity disorder (ADHD). What will be done to help my child?" How should the nurse best respond to the parent? 1. The primary healthcare provider will want to start your child on a central nervous system (CNS) depressant in order to decrease hyperactivity and improve attention. 2. You will need to admit your child to the psychiatric behavioral unit so that group therapy can be initiated. 3. Children are often placed on central nervous system stimulants that improve behavior associated with ADHD. 4. The standard of care for children with ADHD includes central nervous system stimulants along with behavior and family therapy.

4

After reviewing the nursing notes on a client receiving a unit of packed red blood cells, what action should the charge nurse take? Exhibit 1. Decrease the transfusion rate to 50 mL/hour. 2. Assess the client for a transfusion reaction. 3. Check primary healthcare provider prescription for prescribed administration time. 4. Stop the transfusion and send blood bag to the lab.

4

During a conversation with a client on a psychiatric unit the client tells the nurse, "Everyone here hates me." Which response by the nurse is best? 1. No, they do not hate you. 2. What did you do to make others not like you? 3. Just don't pay attention to what others think of you. 4. I can't speak for the other people, but I don't hate you.

4

How would the nurse determine the correct size oropharyngeal airway for a client? 1. Select the same size as the little finger of the victim. 2. Measure from the tip of the lips to the epiglottis. 3. Determine the length from the earlobe to the xiphoid process. 4. Measure from the earlobe to the corner of the mouth.

4

The charge nurse observes a staff nurse caring for a new mother with oral herpes simplex type I. Which action by the nurse indicates that further instruction on transmission of this disease is needed? 1. Instructs the new mother that she should not kiss the newborn. 2. Wears gloves during the perineal and lochia assessment. 3. Washes hands before and after each client contact. 4. States that the newborn may contract herpes from the birth canal.

4

The nurse is caring for a client while fluorouracil is being infused. The client reports burning at the intravenous (IV) site. What should the nurse do first? 1. Apply warm compresses. 2. Slow the infusion. 3. Inspect the IV site. 4. Stop the infusion.

4

The nurse is caring for a client with hypothyroidism. Which dietary consideration is most important for the nurse to teach this client? 1. Increase carbohydrate intake. 2. Decrease fluid intake. 3. Avoid shellfish. 4. Increase fiber.

4

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

4

The nurse is preparing to administer nadolol to a hospitalized client. Which client data would indicate to the nurse that the medication should be held and the primary healthcare provider notified? 1. Blood pressure 102/68 2. Glucose 118 3. UOP 440 mL over previous 8 hour shift. 4. Heart rate 56/min

4

The nurse should question which prescription for a client diagnosed with acute heart failure? 1. 2 gram of sodium (Na) diet. 2. Digoxin 0.25 mg IV q 4 hours times 3 doses. 3. Furosemide 40 mg IVP stat. 4. Start IV with NS at 125 mL/hr.

4

The nurse will be admitting a client from the operating room following a left total pneumonectomy for adenocarcinoma. Which type of chest drainage should the nurse anticipate that the client will have? 1. Bilateral chest tubes. 2. One chest tube on the operative side 3. Two chest tubes on the operative side 4. No chest drainage will be necessary.

4

The nursing supervisor notified the charge nurse on a pediatric unit that a child with a history of developmental delays is being admitted with shingles. The nurses on the floor have the following assignments. It would be inappropriate for the charge nurse to assign the new admit to which nurse? 1. A nurse caring for clients with nephritis, irritable bowel syndrome, and appendectomy. 2. A new nurse just out of orientation caring for clients diagnosed with RSV, asthma, and anorexia nervosa. 3. A nurse caring for clients diagnosed with spina bifida, Hirschsprung's Disease, and irritable bowel syndrome. 4. A pregnant nurse caring for clients with cystic fibrosis, myelomeningocele, and rheumatoid arthritis.

4

The occupational health nurse is caring for an employee after a chemical explosion at the local tire factory. The client reports a foreign body in the right eye. The right eye is watery, and the client reports photophobia. Which nursing action takes priority? 1. Evert eyelid and examine for foreign body. 2. Measure visual acuity. 3. Notify the receiving hospital immediately for transfer of the client. 4. Place an eye shield over eye.

4

What is most important for the nurse to do prior to initiating peritoneal dialysis? 1. Aspirate for placement. 2. Have the client void. 3. Irrigate the catheter for patency. 4. Warm the dialysate fluid.

4

What is most important for the nurse to have at the client's bedside when inserting a large orogastric tube for rapid gastric lavage? 1. Emesis basin 2. Portable x-ray machine 3. Oxygen 4. Suction equipment

4

What medication should the nurse anticipate giving to a client in preterm labor to stimulate maturation of the baby's lungs? 1. Magnesium sulfate 2. Terbutaline 3. Methotrexate 4. Betamethasone

4

When preparing a client for surgery, the nurse realizes the operative permit has not been signed. The client tells the nurse he understands the procedure, but received his preoperative medication approximately 10 minutes ago. What would be the appropriate action by the nurse? 1. Have the client sign the permit, as he verbalizes understanding. 2. Witness the form after having the client sign it. 3. Have his wife sign the form as she witnessed his statement that he understands. 4. Call the surgical area and explain that the surgery will have to be cancelled.

4

Which client admitted to the emergency department should the nurse assess first following shift report on assigned clients? 1. Client reporting inability to void and a distended bladder on palpation. 2. Client diagnosed with a confirmed closed fracture of the tibia. 3. Client who has a suspected corneal laceration. 4. Client with abdominal discomfort and a rigid abdomen on palpation.

4

Which snack selection by a client receiving chemotherapy would indicate to the nurse that teaching has been successful? 1. Fresh salad with cucumbers, carrots, and tomatoes. 2. Orange slices with yogurt. 3. Strawberries with whipped cream. 4. Milk shake with a packet of instant breakfast added.

4

Which actions by the nurse, working in the recovery room, should be performed to prevent injury from a needle stick? 1. Recap the needle after use to prevent injury. 2. Reinsert the sylet if it becomes loose in the vascular assess device. 3. After drawing up saline to flush an intravenous (IV) line, place the syringe in a pocket to prevent possible injury. 4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible.

4,5

Which client admitted to the emergency department should the nurse assess first following shift report on assigned clients? 1. Client reporting inability to void and a distended bladder on palpation. 2. Client diagnosed with a confirmed closed fracture of the tibia. 3. Client who has a suspected corneal laceration. 4. Client with abdominal discomfort and a rigid abdomen on palpation.

4. Correct. A rigid abdomen may indicate bleeding or other causes of peritonitis which takes priority over the other three, more stable clients. This could lead to shock in this client. Conditions requiring immediate treatment include cardiac arrest, anaphylaxis, multiple trauma, shock, poisoning, active labor, drug overdose, severe head trauma, and severe respiratory distress. 1. Incorrect. Although this condition may be uncomfortable and could lead to renal problems if not resolved, it does not take priority over a client who is bleeding. 2. Incorrect. This person is likely experiencing pain, but this client does not take priority over a client who has peritonitis and may be going into shock from bleeding or third spacing into the peritoneum. Remember, pain never killed anyone. 3. Incorrect. This client with a corneal laceration would be experiencing pain and needs attention to avoid vision loss. However, this client does not take priority over a client who has peritonitis and may be going into shock from bleeding or third spacing in the peritoneum. Remember, ascites is fluid in the peritoneal cavity.

Family members have been asking triage nurses if loved ones were admitted to the hospital during a national emergency situation with massive casualties. What response should be made by the nurses? 1. Tell the family members that information about clients cannot be provided. 2. Ask for the victims' permission before talking with the family members. 3. Instruct the family to wait for public announcements about victims. 4. Inform them if their family members have been admitted.

4. Correct. The national emergency situation allows waivers for the Health Insurance Portability and Accountability Act (HIPAA) provisions. Due to the emergency situation, the nurse may inform the family members about the status of their loved ones. 1. Incorrect. During a national disaster declared by the President, information may be given to families without client consent.2. Incorrect. There is no need to make the family more worried if information is known. Waivers for certain elements of HIPAA are allowed during the emergency period.3. Incorrect. The nurse may legally give information to the family. The triage nurse may provide information concerning their family members.

The nurse is providing care to a client who has returned to the long-term facility following cataract surgery. Which finding would indicate a possible complication? 1. Minimally swollen eyelid 2. Mild discomfort of the eye 3. Slight red appearance of the eye 4. Extreme pain in the eye

4. Correct. The postoperative cataract client usually experiences little to no pain, and it can be managed with mild analgesics. If the pain is severe, there may be an increase in intraocular pressure, hemorrhage, or infection, and the surgeon should be notified. 1. Incorrect. Slight swelling of the eyelid is considered a normal finding following cataract surgery. 2. Incorrect. The postoperative cataract client usually experiences little to no discomfort following surgery. This is a normal finding. 3. Incorrect. Slight redness is an expected finding. Pay attention to the word "slight". Increased redness is cause for concern. Compare it to the non-operative eye.

A client has sustained a major head injury as a result of a motor vehicle accident. The emergency department nurse is assessing the client's neurological status every 15 minutes. Which sign would the nurse recognize as an early indicator of an increased intracranial pressure (ICP)? 1. Dilated and unresponsive pupils 2. Cheyne-Stokes respirations 3. Cushing's triad 4. Change in level of consciousness (LOC)

4. Correct: A change in LOC is one of the earliest indicators of an elevated ICP. 1. Incorrect: Loss of pupillary reflexes is a late sign of increased ICP. Earlier pupil changes would include gradual dilation and pupils become sluggish in response to light. 2. Incorrect: This is a late sign of increased ICP. This pattern of respirations is characterized by an increase in depth and rate of respirations followed by a gradual reduction. 3. Incorrect: Cushing's triad is a very late presentation of brain stem dysfunction and manifest as bradycardia, hypertension, and bradypnea. It is seen when cerebral blood flow decreases significantly. This is a grave sign for a client with a head injury. It is related to a significant increase in ICP. Therefore, it is not one of the earliest indicators of an elevated ICP. It is a late sign and if intervention is not initiated, herniation of the brain stem is imminent, with death likely.

A nurse is at highest risk for blood-borne exposure during which situation? 1. When removing a needle from the syringe. 2. While placing a suture needle into the self-locking forceps. 3. Prior to inserting the intravenous (IV) line, the client moves causing a needle stick to the nurse. 4. A clean needle sticks the nurse through blood-soiled gloves.

4. Correct: A clean needle that moves through blood-soiled gloves to stick the nurse is considered to be potentially contaminated and results in a blood-borne exposure. All other answers are considered a clean stick. 1. Incorrect: This is considered a clean stick. The needle is sterile initially and has not been contaminated prior to removal of the needle from the syringe. 2. Incorrect: This is considered a clean stick since the suture needle has not been inserted into the client prior to the needle stick. 3. Incorrect: This is considered a clean stick. The IV insertion device is sterile and has not been contaminated since it was not inserted into the client.

The nurse makes selections from the hospital menu for a client who is confused and suspicious of others. Which menu choice is best? 1. Ham and vegetable casserole 2. Cheese and crackers 3. Caffeine free tea 4. Packaged sugar free Jell-O

4. Correct: A client who is suspicious of others needs foods that are packaged and can see them opened. 1. Incorrect: A client who is suspicious of others needs to be able to identify the ingredients in the food that is being eaten. A casserole contains many ingredients, and the client may fear that something has been added to the food. 2. Incorrect: Finger foods are best for clients that are manic. 3. Incorrect: Drinks and foods with no caffeine are okay for the confused and suspicious client, but this menu choice is not the best choice from the list here.

The nurse makes selections from the hospital menu for a client who is confused and suspicious of others. Which menu choice is best? 1. Ham and vegetable casserole 2. Cheese and crackers 3. Caffeine free tea 4. Packaged sugar free Jell-O

4. Correct: A client who is suspicious of others needs foods that are packaged and can see them opened. 1. Incorrect: A client who is suspicious of others needs to be able to identify the ingredients in the food that is being eaten. A casserole contains many ingredients and the client may fear that something has been added to the food. 2. Incorrect: Finger foods are best for clients that are manic. 3. Incorrect: Drinks and foods with no caffeine are okay for the confused and suspicious client but this menu choice is not the best choice from the list here.

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.

Which nursing intervention should the nurse include when caring for a client with Alzheimer's disease being admitted to a long term care facility? 1. Offer multiple environmental stimuli at the same time to provide distraction. 2. Encourage the client to participate in activities such as board games. 3. Restrain the client in a chair to prevent falls when sundowning occurs. 4. Involve the client in supervised walking as a routine.

4. Correct: A regular routine and physical activity help clients with Alzheimer's disease maintain abilities for a longer period of time. Physical activities promote strength, agility, and balance. The client's walking should be supervised for client safety issues. 1. Incorrect: Environmental stimuli should be limited with clients with Alzheimer's disease. The client can become agitated and/or more disoriented with an increase in environmental stimuli. 2. Incorrect: Board games would not be appropriate due to the client's cognitive and memory impairment. Board games require complex cognitive actions. 3. Incorrect: Restraints should be avoided because they increase agitation. The client may become agitated by the restriction of the restraints. Also the client may perceive the restraints as a threat.

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 reviewing the nursing notes on a client receiving a unit of packed red blood cells, what action should the charge nurse take? 1. Decrease the transfusion rate to 50 mL/hour. 2. Assess the client for a transfusion reaction. 3. Check primary healthcare provider prescription for prescribed administration time. 4. Stop the transfusion and send blood bag to the lab. Exhibit: Nursing Notes: 1200: NS hung to y-tubing for administration of one unit of PRBCs. Initial vital signs taken. Afebrile. Client informed of signs/symptoms of reactions to report. Informed client that vital signs will be taken every 15 minutes for 1 hour. 1205: Unit of PRBCs checked with M. Nurse, RN as compatible. Unit #12345 hung via pump at 25 mL per hour. 1220: No signs/symptoms of reaction to blood transfusion. Vital signs stable. Afebrile. IV rate increased to 50 mL per hour. 1620: PRBCs continue to infuse. IV rate increased to 125 mL per hour.

4. Correct: All blood from each unit of packed red blood cells must be completed within a 4 hour time frame due to risk of hemolysis and bacterial invasion. If the unit of blood is not completed in a 4 hour time frame, the blood must be sent to the lab to be discarded. Keep in mind that the time frame for administering platelets and fresh frozen plasma differs (20-30 min). 1. Incorrect: This blood has been hanging for 4 hours and must be discontinued. 2. Incorrect: The problem is that the blood has been hanging too long. It must be taken down. There is no indication that a transfusion reaction is occurring. Transfusion reaction symptoms include back pain, dark urine, chills, fainting or dizziness, fever, flank pain, skin flushing, shortness of breath. 3. Incorrect: The problem is that the blood has been hanging too long. It must be taken down. It cannot be hung for a longer period of time due to risk of hemolysis and bacterial invasion.

A hysterical college student arrives in the emergency department in bloody soiled clothing. The nursing assessment reveals facial bruising and multiple contusions consistent with the client's report of being raped. Which initial nursing intervention takes priority at this time? 1. Notify police of the alleged rape. 2. Allow the client privacy to wash self. 3. Remove clothing and bag for evidence. 4. Encourage client to express fears and anxiety.

4. Correct: Although there are specific protocols that must be followed when dealing with rape clients, it is important to remember that this client had all control taken away during the attack. The emotional effects of rape are as traumatizing as the physical injuries. Allowing the client to first express emotions, such as fear or anxiety, returns a small amount of control to a situation in which the client has little or none. 1. Incorrect: The police will indeed be notified of the situation by the hospital personnel, but the nurse's initial priority is to focus on the client's needs, both physical and emotional. 2. Incorrect: The client will not be permitted to clean self until all evidence has been collected per protocol. However, initial contact between nurse and client should focus on more than just the physical aspects of the situation. 3. Incorrect: Collection of all evidence for the police is a crucial part of treating rape clients and will be completed according to protocols. But it is more important to remember that this client has already been violated during the attack. Removing clothing before addressing emotional needs may further exacerbate that sense of violation.

A client diagnosed with alcoholism was admitted to the medical unit with substance-withdrawal delirium. Two days later, the client decides to leave the hospital against medical advice. What action should the nurse take? 1. Hide the client's clothes so that the client cannot leave. 2. Administer the ordered sedative. 3. Place restraints on the client. 4. Determine why the client wants to leave.

4. Correct: Always assess why the client wishes to leave first. This is the only way to fix the problem. 1. Incorrect: By confining a client against his or her wishes, and outside of an emergency situation, the nurse may be charged with false imprisonment. Actions that may invoke these charges include locking an individual in a room, taking a person's clothes for the purposes of detainment, and restraining in mechanical restraints a competent, voluntary client who demands to be released. 2. Incorrect: By confining a client against his or her wishes, and outside of an emergency situation, the nurse may be charged with false imprisonment. Actions that may invoke these charges include locking an individual in a room, taking a person's clothes for the purposes of detainment, and restraining in mechanical restraints a competent, voluntary client who demands to be released. 3. Incorrect: By confining a client against his or her wishes, and outside of an emergency situation, the nurse may be charged with false imprisonment. Actions that may invoke these charges include locking an individual in a room, taking a person's clothes for the purposes of detainment, and restraining in mechanical restraints a competent, voluntary client who demands to be released.

How would the nurse determine the correct size oropharyngeal airway for a client? 1. Select the same size as the little finger of the victim. 2. Measure from the tip of the lips to the epiglottis. 3. Determine the length from the earlobe to the xiphoid process. 4. Measure from the earlobe to the corner of the mouth.

4. Correct: An airway of proper size will extend from the corner of the client's mouth to the tip of the earlobe on the same side of the client's face. 1. Incorrect: The size of the client's little finger does not determine the size of the oral airway that should be used. This would result in an inappropriate size oropharyngeal airway to be selected. 2. Incorrect: The epiglottis is an internal body part thus making it impossible to correctly measure it. In addition, the measurement would not determine the appropriate size oropharyngeal airway to use. 3. Incorrect: Measuring from the client's earlobe to the client's xiphoid process would make the oral airway too long.

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.

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.

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.

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.

What medication should the nurse anticipate giving to a client in preterm labor to stimulate maturation of the baby's lungs? 1. Magnesium sulfate 2. Terbutaline 3. Methotrexate 4. Betamethasone

4. Correct: Betamethasone is used to stimulate maturation of the baby's lungs in case preterm birth occurs. This medication is given to help prevent respiratory distress syndrome (RDS) by improving storage and secretion of surfactant that helps to keep the alveoli from collapsing. 1. Incorrect: Magnesium sulfate is given to stop preterm labor, however, if delivery is imminent, then Betamethasone should be given to stimulate maturation of the baby's lungs. 2. Incorrect: Terbutaline is contraindicated in preterm labor, however, if delivery is imminent, then Betamethasone should be given to stimulate maturation of the baby's lungs. 3. Incorrect: Methotrexate is used to stop the growth of the embryo in ectopic pregnancy so that the fallopian tube can be saved. It is not an agent used in the management of preterm labor.

A female client taking captopril for hypertension tells the clinic nurse that she is planning to get pregnant. What recommendation should the nurse make? 1. "Captopril can be taken safely during pregnancy, but we will need to decrease your dose so you do not become hypotensive." 2. "We will need to increase your dose of captopril once you become pregnant." 3. "In order to prevent neural tube defects, start taking folic acid." 4. "Captopril can cause serious harm to an unborn baby, so you must prevent pregnancy while taking this medication. "

4. Correct: Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy. 1. Incorrect: Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy. 2. Incorrect: Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy. 3. Incorrect: Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy. The problem being presented in the stem is not related to general prevention of neural tube defects. Folic acid would not prevent the harm to the fetus caused by captopril.

A client in a psychiatric unit sings over and over, "It is hot, I am a hot tot in a lot, I sit all day on a cot drinking a pop." How should the nurse document this form of thought? 1. Neologisms 2. Dissociation 3. Fugue 4. Clang Association

4. Correct: Clang association involves the choice of words governed by sounds, often taking the form of rhyming even though the words themselves don't have any logical reason to be grouped together. 1. Incorrect: The psychotic person invents new words, or neologisms, that are meaningless to others but have symbolic meaning to the psychotic person. 2. Incorrect: Dissociation is the splitting off of clusters of mental contents from conscious awareness. It is a mental process that leads to a lack of connection in the client's thoughts, memory and sense of identity. In its mild form, it is similar to daydreaming. In a more severe form, it can be manifested as multiple personalities. 3. Incorrect: Fugue is sudden, unexpected travel away from home or customary place of daily activities, with inability to recall some or all of one's past. The person is unaware that anything has been forgotten. Following recovery, there is no memory of the time during the fugue.

Which snack selection by a client receiving chemotherapy would indicate to the nurse that teaching has been successful? 1. Fresh salad with cucumbers, carrots, and tomatoes. 2. Orange slices with yogurt. 3. Strawberries with whipped cream. 4. Milkshake with a packet of instant breakfast added.

4. Correct: Clients with cancer often experience a combination of increased energy expenditure but the nutritional intake is decreased and inadequate to meet the caloric and protein needs. The decreased intake may be, in part, due to the side effects of the chemo. Cold drinks, like shakes, can be soothing, especially if the client has no desire to eat solid foods or is experiencing mouth pain. Shakes will also offer more calories for the client and more protein if a packet of instant breakfast or protein powder is added. Cold, high protein foods are generally tolerated better and have less offensive odors than hot foods. 1. Incorrect: Although raw vegetables are full of fiber, vitamins and minerals, this is not the best option because they can contribute to foodborne illness, especially in a person who is immunosuppressed from receiving chemotherapy. Their immune system is weakened. To minimize the risk of infection, vegetables should be cooked for these clients. It is recommended that all fruits and vegetables be washed thoroughly in cold water and dried on a clean paper towel. 2. Incorrect: Oranges, grapefruits, and tangerines should be avoided in favor of softer, blander fruits such as bananas. Mouth sores are a common side effect of chemo treatment which can be extremely painful when even the blandest food rubs up against the sore. The citrus nature of oranges can cause discomfort if stomatitis is present. 3. Incorrect: Raw fruit with rough texture such as strawberries and raspberries should not be eaten. The rough texture on the strawberries can hide dirt and other contaminants that washing can not clean well enough.

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.

Which is a risk factor for developing breast cancer in women? 1. Menopause before the age of 50 2. Drinking one glass of wine daily 3. Multiparity 4. Menarche at age 10

4. Correct: Early menarche, before age 12, is a known risk factor for breast cancer. The increased risk of breast cancer linked to a younger age at the first period is likely due, at least in part, to the amount of estrogen a woman is exposed to in her life. A higher lifetime exposure to estrogen is linked to an increase in breast cancer risk. The earlier a woman starts having periods, the longer her breast tissue is exposed to estrogens released during the menstrual cycle, and the greater her lifetime exposure to estrogen. 1. Incorrect: Studies show women who go through menopause after age 50 have increased risk of breast cancer. The risk for breast cancer increases as the time period between menarche and menopause increases. 2. Incorrect: There is a small increase in risk with moderate alcohol consumption, not one glass of wine daily. Drinking low to moderate amounts of alcohol, however, may lower the risks of heart disease, high blood pressure, and death. But, drinking more than one drink per day (for women) and more than two drinks per day (for men) has no health benefits and many serious health risks, including breast cancer. Alcohol can change the way a woman's body metabolizes estrogen (how estrogen works in the body). This can cause blood estrogen levels to rise. Estrogen levels are higher in women who drink alcohol than in non-drinkers. These higher estrogen levels may, in turn, increase the risk of breast cancer. 3. Incorrect: Nulliparity (no pregnancies) is a known risk factor for breast cancer. Factors that increase the number of menstrual cycles also increase the risk of breast cancer, probably due to increased endogenous estrogen exposure.

What should the nurse calculate as the estimated due date of a pregnant client, whose last menstrual period started on August 31st? 1. July 1st 2. May 6th 3. May 31st 4. June 7th

4. Correct: Estimated date of delivery is calculated by counting back 3 months, adding seven days, and adding a year if needed. August 31st - 3 months would be May 31st. Add seven days. The estimated date of delivery would be June 7th. 1. Incorrect: Estimated date of delivery is calculated by counting back 3 months, adding seven days, and adding a year if needed. 2. Incorrect: Estimated date of delivery is calculated by counting back 3 months, adding seven days, and adding a year if needed. 3. Incorrect: Estimated date of delivery is calculated by counting back 3 months, adding seven days, and adding a year if needed.

The nurse is reinforcing teaching to a client who has been prescribed glucocorticoids for the treatment of Addison's disease. What points should the nurse emphasize? 1. Be aware of the development of hypoglycemia. 2. Test the urine for albumin or other proteins. 3. Take the medication 30 minutes prior to bedtime. 4. Maintain the prescribed dose without interruption in therapy.

4. Correct: Glucocorticoids should not be abruptly discontinued due to the risk of adrenal suppression with prolonged use. Doses should be tapered before being discontinued. 1. Incorrect: Increased blood sugar is an adverse effect associated with glucocorticoid therapy, not hypoglycemia. 2. Incorrect: Protein in the urine is not associated with glucocorticoid therapy. 3. Incorrect: Insomnia is an adverse effect associated with glucocorticoid therapy. Daily dosing of glucocorticoids should be done in the morning to decrease this effect.

The nurse is teaching a client who has been prescribed daily glucocorticoids for the treatment of Addison's disease. What teaching points should the nurse emphasize? 1. Be aware of the development of hypoglycemia. 2. Test the urine for albumin or other proteins. 3. Take the medication 30 minutes prior to bedtime. 4. Maintain the prescribed dose without interruption in therapy.

4. Correct: Glucocorticoids should not be abruptly discontinued due to the risk of adrenal suppression with prolonged use. Doses should be tapered before being discontinued.1. Incorrect: Increased blood sugar is an adverse effect associated with glucocorticoid therapy, not hypoglycemia.2. Incorrect: Protein in the urine is not associated with glucocorticoid therapy.3. Incorrect: Insomnia is an adverse effect associated with glucocorticoid therapy. Daily dosing of glucocorticoids should be done in the morning to decrease this effect.

The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given? 1. "The action of the medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you do not break a bone." 4. "Glycopyrrolate will decrease stomach secretions."

4. Correct: Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease the risk of aspiration. 1. Incorrect: The client has a right to be told the reason the drug is given. This is a nontherapeutic communication response. The nurse should not refuse the client's desire to understand their medications. 2. Incorrect: Glycopyrrolate blocks the secretions in the mouth, throat, airway and stomach. The medication does not prevent the client from having a seizure. The ECT will induce a seizure, which is the desired action. 3. Incorrect: This is not the drug's purpose, so this would be incorrect information to give to the client.

The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given? 1. "The action of the medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you do not break a bone." 4. "Glycopyrrolate will decrease stomach secretions."

4. Correct: Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease the risk of aspiration. 1. Incorrect: The client has a right to be told the reason the drug is given. This is a nontherapeutic communication response. The nurse should not refuse the client's desire to understand their medications. 2. Incorrect: Glycopyrrolate blocks the secretions in the mouth, throat, airway and stomach. The medication does not prevent the client having a seizure. The ECT will induce a seizure, which is the desire. 3. Incorrect: This is not the drug's purpose so this would be incorrect information to give to the client.

During a conversation with a client on a psychiatric unit the client tells the nurse, "Everyone here hates me." Which response by the nurse is best? 1. No, they do not hate you. 2. What did you do to make others not like you? 3. Just don't pay attention to what others think of you. 4. I can't speak for the other people, but I don't hate you.

4. Correct: Here the nurse is speaking only for the nurse. The nurse cannot legitimately speak for anyone else. The nurse must model the process of not speaking for anyone else. The response also lets the client know that the nurse cares about the way the client feels. 1. Incorrect: This is arguing and defending which are non-therapeutic communication techniques. The nurse does not know how the others on the unit feel about the client, so this may not be a true statement. Arguing with a client's belief can further upset or anger the client and leads to mistrust of the nurse. 2. Incorrect: This is agreeing with the client that everyone hates the client. It also puts the client on the defense by implying that the client is at fault for doing something that made everyone hate the client. This response reinforces the client's false belief. 3. Incorrect: This is using denial. This is where the nurse denies that a problem exists and blocks the discussion with the client. This avoids helping the client identify and explore the problem. This also dismisses the client's feelings.

The nurse is caring for a client with hyperemesis gravidarum. What electrolyte imbalance is most likely? 1. Hypocalcemia 2. Hypomagnesemia 3. Hyponatremia 4. Hypokalemia

4. Correct: Hyperemesis gravidarum is characterized by persistent, severe pregnancy related nausea and vomiting. There is a large amount of potassium in the upper GI tract. A client with prolonged vomiting will lose potassium in the emesis. Additionally, the client is unable to replace the lost potassium due to the persistent nausea and vomiting. 1. Incorrect: Hypocalcemia results from any condition that causes a decrease in the production of parathyroid hormone (PTH). Hyperemesis gravidarum does not affect PTH levels. 2. Incorrect: The lower GI tract has a lot of magnesium. Therefore, this client is at risk for hypomagnesemia, but not more than hypokalemia. The client with hyperemesis gravidarum is losing upper GI contents. 3. Incorrect: The client with hyperemesis gravidarum is at high risk for being dehydrated. The electrolyte imbalance associated with dehydration is hypernatremia, not hyponatremia. Remember, this client's blood will be concentrated, and concentrated makes numbers go up (i.e. sodium, hematocrit, and specific gravity).

A nurse attaches a client to continuous cardiac monitoring due to a potassium level of 2.8 mEq (2.8 mmol). The nurse should monitor for which dysrhythmia? 1. Third degree heart block 2. Atrial fibrillation 3. Premature atrial contractions 4. Premature ventricular contractions

4. Correct: Hypokalemia is reflected by the EKG. The earliest EKG change is often premature ventricular contractions (PVCs) which can deteriorate into ventricular tachycardia or fibrillation (VT/VF) without appropriate potassium replacement. 1. Incorrect: Atrial-ventricular blocks are not often seen initially with hypokalemia.2. Incorrect: Atrial fibrillation is not often seen with hypokalemia.3. Incorrect: PACs are not often seen initially with hypokalemia.

The occupational health nurse is caring for an employee after a chemical explosion at the local tire factory. The client reports a foreign body in the right eye. The right eye is watery, and the client reports photophobia. Which nursing action takes priority? 1. Evert eyelid and examine for foreign body. 2. Measure visual acuity. 3. Notify the receiving hospital immediately for transfer of the client. 4. Place an eye shield over eye.

4. Correct: If a foreign body is the result of explosion or blunt or sharp trauma, the eye should be protected from further damage by placing an eye shield over the eye (or if a shield is not available, a paper cup to prevent rubbing of the eye). Then make arrangements to transport the client for emergency care by an ophthalmologist. If movement of the unaffected eye creates movement in the affected eye, it may be necessary to cover the unaffected eye also to prevent further injury to the eye from movement. 1. Incorrect: Everting the eyelid and examining for a foreign body are not measures that should be performed before placement of eye shield. You should never attempt to remove a foreign body, so examination would not be needed at this point. 2. Incorrect: Measuring visual acuity is not a priority and is not performed before placement of eye shield. The goal is to protect the eye from further injury and reduce movement of the eye. The shield will help accomplish this goal. 3. Incorrect: Notifying immediately for transfer should not be done before placement of eye shield. The eye should be protected first to reduce further injury.

The nurse is caring for a client who has been diagnosed with dissociative identity disorder. What is the most appropriate short term goal? 1. Recovery of memory deficits. 2. Demonstration of the ability to perceive stimuli correctly. 3. Elimination of causative phobia. 4. Verbal recognition of the existence of multiple personalities.

4. Correct: In order for therapy to be successful, the client must first acknowledge that there are multiple personalities within the client's personality. 1. Incorrect: This is related to a client with dissociative amnesia. 2. Incorrect: This is related to a client with disturbed sensory perception. 3. Incorrect: This outcome would not be related to this client.

A client, admitted in Sickle Cell Crisis, is started on oxygen at 2L/NC and given a narcotic analgesic for pain control. What additional prescription is a priority for the nurse to initiate? 1. A high protein, low fat diet 2. Administration of a thrombolytic, such as streptokinase 3. Implementation of bleeding precautions 4. Administration of IV fluids for hydration

4. Correct: Increasing hydration status via the administration of IV fluids is indicated in sickle cell crisis to increase that volume in the vascular space and subsequently decrease the vaso-occlusion from the sickling effects of the RBCs. The increased volume separates the sickled cells to reduce the clumping together of the cells. 1. Incorrect: While beneficial for many clients, a high protein, low fat diet provides no benefit during the crisis phase of sickle cell disease. Hydration to improve circulation is a priority due to the impairment or obstruction of blood flow caused by the sickled cells clumping together. 2. Incorrect: Thrombolytics are indicated for the lysis of existing clots and do not have a primary role in the treatment or management of sickle cell disease. The issue in sickle cell crisis is not clot formation but rather a clumping together of sickled cells that impairs or blocks circulation. 3. Incorrect: Sickle cell disease is characterized by sickling of RBCs, causing them to clump together and obstruct capillary blood flow, causing ischemia and possible tissue infarction. Increased risk of bleeding is not a concern.

The charge nurse was notified that a client with 2nd degree burns is being admitted to the floor. Which nurse should be assigned this client? 1. A nurse caring for clients with spina bifida and acute gastroenteritis. 2. The new nurse, out of orientation for 2 months, caring for clients diagnosed with tonsillitis and anorexia nervosa. 3. The pregnant nurse caring for clients with cystic fibrosis and staph infection. 4. A nurse caring for clients with irritable bowel syndrome and post op appendectomy.

4. Correct: It would be best to assign the client to this nurse because the clients this nurse is caring for do not have anything contagious, which will decrease the risk of the burn client becoming infected. 1. Incorrect: This nurse is caring for a client with infection: acute gastroenteritis. 2. Incorrect: This nurse is caring for a client with infection: tonsillitis. 3. Incorrect: This nurse caring for a client with infection: staph infection.

The nurse is teaching a diabetic client who has been prescribed Lispro insulin about avoiding hypoglycemia. What administration teaching is priority? 1. Take insulin 30 minutes before bedtime 2. Take insulin twice daily in AM and PM 3. Take insulin one hour before meals 4. Take insulin with meals

4. Correct: Lispro is a rapid-acting insulin that should only be taken with food or within 15 minutes of a meal.1. Incorrect: Lispro is a rapid-acting insulin and should not be taken without food.2. Incorrect: Lispro is a rapid-acting insulin and should not be taken without food.3. Incorrect: Lispro is a rapid-acting insulin and should not be taken without food. Giving an hour before eating is too early and would put the client at risk for hypoglycemia.

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 client has an intestinal obstruction and a NG tube to low suction. Blood gases are ph 7.54, pCO2 40, HCO3 35. The client is weak, shaky, and reports tingling of the fingers. The nurse knows that this client is most likely in which acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4. Correct: Metabolic alkalosis happens when there is a loss of acid or a gain in bicarbonate. Metabolic alkalosis occurs from gastric losses via vomiting, NG tubes to suction, or lavage, and potent diuretics. Signs and symptoms include n/v, sensorium changes, tremors, and convulsions. pH > 7.45, pCO2 normal between 35-45, HCO3 > 26. 1. Incorrect: This is not a respiratory related acid-base imbalance 2. Incorrect: This is not a respiratory related acid-base imbalance 3. Incorrect: This is not acidosis. There is loss of gastric acid from the stomach due to the NG tube to low suction.

The nurse is assigned to care for a client who has developed intestinal obstruction and has had an NG tube inserted to low suction. Blood gases are pH 7.54, pCO2 52, HCO3 35. Assessment of the client by the nurse reveals that the client is weak, shaky, and reporting tingling of the fingers. The nurse determines that this client is in which acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4. Correct: Metabolic alkalosis occurs from gastric losses via vomiting, NG tubes to suction, or lavage, and potent diuretics. Signs and symptoms include n/v, sensorium changes, tremors, convulsions. pH > 7.45, pCO2 > 45, HCO3 > 27. 1. Incorrect: Not a respiratory related acid/base imbalance. 2. Incorrect: Not a respiratory related acid/base imbalance. 3. Incorrect: Not acidosis. There is loss of gastric acid.

Which pain scale should the nurse use to monitor the pain level of a 3-year old client after surgery? 1. Numerical scale 2. Verbal descriptive scale 3. Visual analog scale 4. FACES scale

4. Correct: Monitoring pain in children requires special techniques. The nurse should use the FACES scale as a tool to assess this client's pain level. Children as young as 3 years of age can use the FACES scale to communicate their pain level to the medical team. The scale has six faces ranging from smiling face to sad, tearful face. 1. Incorrect: Not age appropriate. This scale uses numbers. 2. Incorrect: Not age appropriate. Young children may not understand the word pain. 3. Incorrect: Not age appropriate. This scale requires reading.

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.

A client comes into the emergency department (ED) and demands to be seen immediately, but refuses to tell the triage nurse the problem. During the assessment, the client starts yelling and shaking their fist. For the nurse's safety, what should be the nurse's initial action? 1. Tell the client to stay calm, and that treatment will be provided soon. 2. Explain that unless the client behaves, they will be sent away from the ED. 3. Notify the client that security will be called if they do not go to the waiting room immediately. 4. Find a safe place away from the client and then notify security.

4. Correct: Self-protection is a priority. There is no advantage to protecting others if medical caregivers are injured. Security officers and police must gain control of the situation first, and then care is provided. 1. Incorrect: This does not provide safety for the nurse and might increase the client's anger. 2. Incorrect: This is not a true statement and does not provide immediate safety for the nurse. Clients seeking treatment are not refused care in the ED. 3. Incorrect: This is not the initial action. Finding a safe place is the first action for the nurse's safety. Also, the angry client does not need to be sent to the waiting room around other clients at this time.

Post cataract removal, a client reports nausea and severe pain in the operative eye. Which nursing intervention takes priority? 1. Administer morphine and ondansetron. 2. Reposition client to non-operative side. 3. Massage the canthus to unblock the lacrimal duct. 4. Notify the primary healthcare provider.

4. Correct: Severe pain and nausea indicate an increase in intraocular pressure and must be reported at once. Eye damage can result if not resolved quickly. The primary healthcare provider may prescribe medications or take the client back to surgery. 1. Incorrect: This is not the priority, as severe pain and nausea indicate an increase in intraocular pressure and must be reported at once. 2. Incorrect: Repositioning will not fix the problem. Severe pain with nausea indicate an increase in intraocular pressure and must be reported at once. 3. Incorrect: The problem is an increase in intraocular pressure which needs to be reported to the primary healthcare provider.

Post cataract removal a client reports nausea and severe pain in the operative eye. Which nursing intervention takes priority? 1. Administer morphine and ondansetron. 2. Reposition client to non-operative side. 3. Massage the canthus to unblock the lacrimal duct. 4. Notify the primary healthcare provider.

4. Correct: Severe pain with nausea indicates an increase in intraocular pressure and needs to be reported at once. Eye damage can result if not resolved quickly. The primary healthcare provider may prescribe medications or take the client back to surgery. 1. Incorrect: This is not the priority as severe pain and nausea indicates an increase in intraocular pressure and needs to be reported at once. 2. Incorrect: Repositioning will not fix the problem. Severe pain with nausea indicates an increase in intraocular pressure and needs to be reported at once. 3. Incorrect: The problem is an increase in intraocular pressure which needs to be reported to the primary healthcare provider.

Which nursing action is likely to improve client satisfaction and demonstrate acts of beneficence? 1. Allowing clients to make their own decisions about care 2. Answering all questions posed by client in an honest manner 3. Reporting faulty equipment to the proper departments 4. Sitting at the bedside and listening to an elderly client

4. Correct: Sitting and listening demonstrates kindness and compassion that are consistent with the ethical term "beneficence." Beneficence is taking positive action to help others and a desire to do good which is the core principle of client advocacy. 1. Incorrect: Autonomy is the ethical principle illustrated here by supporting independent decision making with clients. 2. Incorrect: Fidelity is the ethical principle illustrated here and refers to the concept of keeping a commitment. It is based upon the virtue of caring. 3. Incorrect: Reporting faulty equipment is an act to promote nonmaleficence or to do no harm. This is the core of nursing ethics.

Which nursing action is likely to improve client satisfaction and demonstrate acts of beneficence? 1. Allowing clients to make their own decisions about care 2. Answering all questions posed by client in an honest manner 3. Reporting faulty equipment to the proper departments 4. Sitting at the bedside and listening to an elderly client

4. Correct: Sitting and listening demonstrates kindness and compassion that are consistent with the ethical term "beneficence." Beneficence is taking positive action to help others and desiring to do good which are the core principles of client advocacy. 1. Incorrect: Autonomy is the ethical principle illustrated here by supporting independent decision making with clients. 2. Incorrect: Fidelity is the ethical principle illustrated here and refers to the concept of keeping a commitment. It is based upon the virtue of caring. 3. Incorrect: Reporting faulty equipment is an act to promote nonmaleficence or to do no harm. This is the core of nursing ethics.

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.

A client diagnosed with arachnophobia is prescribed alprazolam 0.5 mg orally three times daily. The nurse knows that reinforcement of teaching about this medication is successful when the client makes what statement? 1. Alprazolam will take up to two weeks to start working. 2. The drug does not cause drowsiness, so my daily activities will not suffer. 3. This medication cannot be taken with food. 4. I should not stop taking alprazolam suddenly.

4. Correct: Suddenly stopping alprazolam could produce serious withdrawal symptoms, such as depression, insomnia, anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, and delirium. 1. Incorrect: Alprazolam works relatively quickly. 2. Incorrect: Drowsiness, confusion, and lethargy are the most common side effects. The client should not drive or operate dangerous machinery while taking the medication. 3. Incorrect: If the client experiences nausea and vomiting, take with food or milk.

A client diagnosed with arachnophobia is prescribed alprazolam 0.5 mg orally three times daily. The nurse knows that teaching about this medication is successful when the client makes what statement? 1. Alprazolam will take up to two weeks to start working. 2. The drug does not cause drowsiness, so my daily activities will not suffer. 3. This medication cannot be taken with food. 4. I should not stop taking alprazolam suddenly.

4. Correct: Suddenly stopping could produce serious withdrawal symptoms, such as depression, insomnia, anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, and delirium. 1. Incorrect: Alprazolam works relatively quickly. 2. Incorrect: Drowsiness, confusion, and lethargy are the most common side effects. The client should not drive or operate dangerous machinery while taking the medication. 3. Incorrect: If the client experiences nausea and vomiting, take with food or milk.

A client, admitted to the medical unit with persistent vomiting, reports weakness and leg cramps. The spouse states that the client is irritable. The primary healthcare provider has prescribed lab work and blood gases. Based on this assessment, the nurse anticipates which acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4. Correct: Symptoms of 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 acid base imbalance. 2. Incorrect: Not respiratory related acid base imbalance. 3. Incorrect: Not acidosis. There is loss of gastric acid and K with persistent vomiting.

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.

The nurse is caring for a Native American client who has returned to the surgical floor following abdominal surgery. The nurse is concerned about the level of discomfort that the client is experiencing. Which comment is the nurse likely to hear upon assessment? 1. "The pain is getting worse. I can't stand it." 2. "I need something for pain as soon as possible." 3. "I hope that the pain will go away soon." 4. "I am doing okay. The pain is not bad."

4. Correct: The Native American client is likely to be quiet and less expressive of pain. Native Americans tend to tolerate high levels of pain. 1. Incorrect: This comment is likely to come from the dominant American culture where pain is considered something to be treated. 2. Incorrect: Native Americans tend to tolerate high levels of pain. Abdominal surgery usually results in sensations of pain for most people. 3. Incorrect: The Native American client is likely to be very quiet about the pain being experienced.

The nurse should question which prescription for a client diagnosed with acute heart failure? 1. 2 gram of sodium (Na) diet. 2. Digoxin 0.25 mg IV q 4 hours times 3 doses. 3. Furosemide 40 mg IVP stat. 4. Start IV with NS at 125 mL/hr.

4. Correct: The client is in fluid overload and does not need the normal saline (NS) at 125 mL/hr. NS is an isotonic solution. It goes in the vascular space and stays there without shifting out to the cells. This could cause additional overload in the vascular space as well as cause the BP to increase. The other prescriptions are acceptable. 1. Incorrect: This is an appropriate measure Na restricted diet will help to lower the serum Na and decrease H2O retention. This does not need questioning. 2. Incorrect: Digoxin is a digitalis glycoside. It slows conduction and strengthens the force of contraction of the heart. Therefore, this medication that increases cardiac contractility and reduces the heart rate does not need questioning. 3. Incorrect: Furosemide is a diuretic. It enhances renal excretion of Na and H2O and reduces systemic and pulmonary congestion. This medication prescription does not need questioning.

When preparing a client for surgery, the nurse realizes the operative permit has not been signed. The client tells the nurse he understands the procedure, but received his preoperative medication approximately 10 minutes ago. What would be the appropriate action by the nurse? 1. Have the client sign the permit, as he verbalizes understanding. 2. Witness the form after having the client sign it. 3. Have his wife sign the form as she witnessed his statement that he understands. 4. Call the surgical area and explain that the surgery will have to be cancelled.

4. Correct: The client must sign the operative permit or any other legal document prior to taking preoperative drugs that can affect judgment and decision-making capacity. 1. Incorrect: The client's verbal understanding does not override the fact that he has received medication that can alter thought processes and decision-making. 2. Incorrect: Witnessing would not make this document legal. The consent would not be valid because the client has already received the pain medication that could alter the thought process. 3. Incorrect: When a client is of legal age (unless an emancipated minor) and of sound mind, it would be inappropriate for the spouse to sign the form for surgery. In order to be valid it must be the client who signs it, unless there is a legal power of attorney, durable power of attorney, or healthcare surrogate.

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

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

The nurse is preparing to make an occupied bed. Which action by the nurse is important to preserve client's self-esteem during this procedure? 1. Remove the top sheet first and replace with a clean one. 2. Inform the client that they will be uncovered only for a short time. 3. Ask the client to relax as the top sheet is removed and the bottom sheet is changed. 4. Cover the client with a bath blanket before removing any of the sheets on the bed.

4. Correct: The client should not be exposed during the bed change. Cover with a bath blanket as the top sheet is removed. 1. Incorrect: The client's self-esteem will not be preserved if uncovered during the procedure. Being exposed to the nurse is very troubling for most clients. 2. Incorrect: The client should be covered throughout the procedure. 3. Incorrect: The client's self-esteem will not be preserved by relaxing. Being exposed is anxiety provoking, and exposure is unnecessary.

The nurse is preparing the sterile field to assist the primary healthcare provider with a procedure. Which flap of the sterile pack should the nurse open first? 1. Closest to the nurse. 2. To the left of the nurse. 3. To the right of the nurse. 4. Farthest from the nurse.

4. Correct: The flap farthest from the nurse should be opened first so that the nurse's arm or hand does not cross the sterile field. 1. Incorrect: The flap closest to the nurse should be opened last so that the sterile field is not crossed by the nurse's arm or hand. 2. Incorrect: The sides should be opened in the 2nd and 3rd steps so that the nurse's hand does not cross the sterile field. 3. Incorrect: The sides should be opened in the 2nd and 3rd steps so that the nurse's hand does not cross the sterile field.

Which client could the charge nurse assign to an LPN/VN? 1. Eight year old in diabetic ketoacidosis (DKA) 2. Six year old in sickle cell crisis 3. Two month old with dehydration 4. Five year old in skeletal traction

4. Correct: The fracture would be most appropriate for an LPN/VN and is within the scope of practice. This LPN/VN would need minimal assistance from the RN. Possibly, the other clients could have intravenous fluid (IVF) needs and medications that would require skill from an RN. 1. Incorrect: The child with DKA is in metabolic acidosis. The child is also at risk for other problems such as dehydration and electrolyte disturbances. Therefore, the child will need close observation and the RN's assessment skills. 2. Incorrect: IV fluid management is crucial for clients in a sickle cell crisis Assessment of the child's cardiovascular status, tissue perfusion and neuro status are priorities. Pain management is also very important in these clients. Therefore, the child with sickle cell will need close observation and the RN's assessment skills. 3. Incorrect: The baby with dehydration will need close observation and the RN's assessment skills, including monitoring for impending shock. Renal function and electrolyte levels should be monitored closely. The care of the child will likely involve IV fluids.

A client with heart failure and pulmonary edema is given furosemide intravenously. Which assessment indicates that the furosemide has achieved the desired effect? 1. Weight has decreased 2 pounds. 2. Systolic blood pressure has decreased. 3. Urinary output has increased. 4. Lungs have fewer rales on auscultation.

4. Correct: The goal for diuretic therapy in this client is to prevent/relieve fluid accumulation in the lungs. This answer addresses the most life-threatening sequelae with HF. The number one thing to worry about in clients with HF is pulmonary edema, because this is what can kill the client. 1. Incorrect: Weight loss is a good assessment of fluid loss or gain, especially acute weight changes. The stem of the question, however, asks which is the desired effect? The desired effect is to decrease fluid in the lungs and weight loss alone does not ensure that the lungs are clearing. 2. Incorrect: Lowered blood pressure is an expected finding, but treatment of pulmonary edema is the primary goal. 3. Incorrect: Increased urinary output is an expected finding, but treatment of pulmonary edema is the primary goal.

The nursing supervisor notified the charge nurse on a pediatric unit that a child with a history of developmental delays is being admitted with shingles. The nurses on the floor have the following assignments. It would be inappropriate for the charge nurse to assign the new admit to which nurse? 1. A nurse caring for clients with nephritis, irritable bowel syndrome, and appendectomy. 2. A new nurse just out of orientation caring for clients diagnosed with RSV, asthma, and anorexia nervosa. 3. A nurse caring for clients diagnosed with spina bifida, Hirschsprung's Disease, and irritable bowel syndrome. 4. A pregnant nurse caring for clients with cystic fibrosis, myelomeningocele, and rheumatoid arthritis.

4. Correct: The information does not let you know if any of the nurses have had chickenpox or not. If a nurse has not had chickenpox, then they should not care for the client with shingles. The varicella zoster virus is responsible for chickenpox and shingles. The virus is lying dormant in the nerve ganglia and under certain conditions erupts (for example: stress). With the information you have, it would be best not to assign the new admit to the nurse who is pregnant. The other set of nurses and clients have no identified contraindications to taking care of the client with shingles. 1. Incorrect: This is an appropriate assignment. There are no identified contraindications for the nurse or clients to prevent the nurse from caring for a client with shingles. 2. Incorrect: This is an appropriate assignment. There are no identified contraindications for the nurse or clients to prevent the nurse from caring for a client with shingles. 3. Incorrect: This is an appropriate assignment. There are no identified contraindications for the nurse or clients to prevent the nurse from caring for a client with shingles.

The client states, "I really do not want to have surgery. I have told my children this, but they still want me to go through with the surgery. I do not know what to do." What is the best response for the nurse as client advocate? 1. "Your children are concerned about you. The surgery is the best thing for your health." 2. "You have some genuine concerns about the surgery, and you feel as if your children are not addressing your concerns. You and your family will need to resolve this before you go to surgery." 3. "I can contact your primary healthcare provider so that you can discuss your concerns regarding surgery." 4. "You have some genuine concerns about the surgery, and you feel as if your children are not addressing your concerns. Tell me more about your concerns."

4. Correct: The nurse has a duty to advocate for the client if there is a discrepancy between the care or proposed care and the client's wishes regarding treatment. It is important to acknowledge the client's feelings and to demonstrate compassion and a willingness to understand. This presents an opportunity for additional communication to help answer some of the client's questions or set up a client-family conference with the client, the client's family, and the primary healthcare provider. 1. Incorrect: When the nurse agrees with the client's children, the nurse ignores the client's feelings and does not address the issue of the client's treatment wishes. 2. Incorrect: When the nurse restates the client's comment without investigating the client's concerns, the issue goes unresolved. 3. Incorrect: Offering only to contact the primary healthcare provider is an incomplete solution and hints of the nurse not taking responsibility to investigate the client's concerns. The client may be uncomfortable addressing concerns with the primary healthcare provider before resolving the issue of treatment wishes with family members.

A client diagnosed with Celiac disease is on a gluten-free diet. What statement by the client would indicate to the nurse that reinforcing of diet instructions is needed? 1. "I will still have occasional abdominal discomfort." 2. "I may need to take iron or vitamin supplements." 3. "I can have eggs but no wheat toast for breakfast." 4. "I should avoid fresh apples and strawberries."

4. Correct: The nurse is evaluating client statements for any lack of understanding and the need to provide further instruction. With Celiac disease, intestinal villi become inflamed whenever gluten is introduced to the gut through food intake. However, fresh fruits and vegetables do not contain gluten; therefore, fresh apples and strawberries would definitely be acceptable foods for this client. This statement by the client is inaccurate, indicating the need for reinforcing diet instructions by the nurse. 1. Incorrect: The client correctly acknowledges that some episodes of abdominal discomfort may still occur, since it is nearly impossible to totally eliminate gluten. Despite buying "gluten-free" products, occasionally small amounts of gluten may contaminate foods and cause symptoms to resurface. Eating in a restaurant may also be a challenge for those with Celiac disease. The client recognizes these possible symptoms. 2. Incorrect: This is an accurate statement by the client about Celiac disease. Because inflammation of the intestinal villi may lead to poor absorption of nutrients or anemia, clients may, indeed, need to take supplements for extended periods of time. This response does not indicate any problems with the client's comprehension of diet. 3. Incorrect: It is important for a client with Celiac disease to eat as healthy and diverse a diet as possible, since malnutrition occurs secondary to poor nutrient absorption in the bowel. Protein is a vital component in the diet, including such choices as eggs, dairy, and beans. Those foods creating the worst symptoms include grains like wheat, rye, and barley as well as the "malt barley" used as a thickening agent in certain products. The client has precisely stated that a breakfast including eggs but minus the wheat toast would be appropriate, evidence the client understands the diet.

Upon receiving a diagnosis of Stage 4 lung cancer, an elderly client expresses regret for having chosen to smoke. Which response by the nurse would best help the client cope at this time? 1. "You are lucky to have lived a very long life." 2. "We have younger clients in worse shape than you." 3. "The doctor will make sure to treat any pain." 4. "You are regretting your decision to smoke."

4. Correct: The nurse responds with an open-ended statement that reflects back to what the client has stated. This allows the client to continue expressing concerns and feelings about the diagnosis or past choices. At this time, encouraging the client to verbalize is the best choice to help with coping. 1. Incorrect: This is a closed-ended statement that diminishes the client's feelings about the diagnosis or possible personal choices that may have led to this situation. The response infers that the client should be grateful for the life lived and belittles the client's response. 2. Incorrect: Such a non-therapeutic statement does not address the client's feelings and, in fact, devalues the client by comparing this situation to that of other clients. The nurse should focus on helping the client to cope at this time by encouraging the expression of feelings. 3. Incorrect: Rather than allowing the client to verbalize concerns or emotions, the nurse has responded with a close-ended statement that addresses a topic not initiated by the client's comments. This option does nothing to help the client cope, but rather may instill fear by referring to pain that may or may not occur.

Upon receiving a diagnosis of Stage 4 lung cancer, an elderly client expresses regret for having chosen to smoke. Which response by the nurse would best help the client cope at this time? 1. "You are lucky to have lived a very long life." 2. "We have younger clients in worse shape than you." 3. "The doctor will make sure to treat any pain." 4. "You are regretting your decision to smoke."

4. Correct: The nurse responds with an open-ended statement that reflects back what the client has stated. This allows the client to continue expressing concerns and feelings about the diagnosis or past choices. At this time, encouraging the client to verbalize is the best choice to help with coping. 1. Incorrect: This is a closed-ended statement that diminishes the client's feelings about the diagnosis or possible personal choices that may have led to this situation. The response infers that the client should be grateful for the life lived and belittles the client's response. 2. Incorrect: Such a non-therapeutic statement does not address the client's feelings and in fact devalues the client by comparing this situation to that of other clients. The nurse should focus on helping the client to cope at this time by encouraging the expression of feelings. 3. Incorrect: Rather than allowing the client to verbalize concerns or emotions, the nurse has responded with a close-ended statement that addresses a topic not initiated by the client's comments. This option does nothing to help the client cope, but rather may instill fear by referring to pain that may or may not occur.

The nurse monitors a multigravida who is four hours postpartum. Findings include that fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The lochia is moderately heavy and bright red. Which nursing intervention has priority? 1. Massage the fundus. 2. Administer intravenous oxytocin. 3. Document these normal findings. 4. Assist the client up to void.

4. Correct: These findings are caused by a full bladder, which prevents the uterus from contracting down and achieving homeostasis. Once the bladder is empty, the fundus will contract adequately and return to its normal location at level of umbilicus or 1 finger breadth below the umbilicus and in the midline. A distended bladder will displace the uterus, usually to the right. 1. Incorrect: The nurse may check fundus after client voids to ensure that this fixes the problem. 2. Incorrect: Administering oxytocin is not the first intervention for this issue. 3. Incorrect: These are not normal findings, so this would be incorrect information for the nurse to document.

The nurse assesses a multigravida who is four hours postpartum. Findings include that fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The lochia is moderately heavy and bright red. Which nursing intervention has priority? 1. Massage the fundus. 2. Administer intravenous oxytocin. 3. Document these normal findings. 4. Assist the client up to void.

4. Correct: These findings are caused by a full bladder, which prevents the uterus from contracting down and achieving homeostasis. Once the bladder is empty, the fundus will contract adequately and return to its normal location at level of umbilicus or 1 finger breadth below the umbilicus and in the midline. A distended bladder will displace the uterus, usually to the right. 1. Incorrect: The nurse may check fundus after client voids to ensure that this fixes the problem. 2. Incorrect: Administering oxytocin is not the first intervention for this issue. 3. Incorrect: These are not normal findings so this would be incorrect information for the nurse to document.

The nurse is caring for a client 28 weeks pregnant who reports swollen hands and feet. Which additional sign or symptom would cause the greatest concern? 1. Nasal congestion 2. Hiccups 3. Blood glucose of 130 4. Muscle spasms

4. Correct: This client could have preeclampsia and would be at risk for seizures. 1. Incorrect: This is a common occurrence during pregnancy and is not the greatest concern. 2. Incorrect: Hiccups would be the second best answer, indicating nerve/muscle irritation, but not a common symptom associated with preeclampsia. 3. Incorrect: Not the greatest concern with presenting signs and symptoms of swelling. The blood glucose is elevated, but the priority data is the possibility of muscle spasms which may progress to seizures due to eclampsia.

The nurse is preparing to administer nadolol to a hospitalized client. Which client data would indicate to the nurse that the medication should be held and the primary healthcare provider notified? 1. Blood pressure 102/68 2. Glucose 118 3. UOP 440 mL over previous 8 hour shift. 4. Heart rate 56/min

4. Correct: This is a beta blocker. It slows the heart rate. If a client's heart rate is less than 60 beats per minute, notify the primary healthcare provider and ask if the client should receive this medication. Administering a beta blocker to a client who has a heart rate less than 60 could possibly cause the client to develop symptomatic bradycardia and hypotension. 1. Incorrect: If the client's BP drops below 90/60, this beta blocker should be held and the primary healthcare provider notified. The BP in this option is high enough to administer the medication, but the BP in clients on beta blockers should be monitored and the client should be taught about signs and symptoms of hypotension. 2. Incorrect: This is a normal glucose level. If the client is a diabetic, beta blockers can mask the signs of hypoglycemia. There diabetics on beta blockers should monitor their blood sugar carefully. 3. Incorrect: Urinary output is adequate. Beta blockers do not alter renal function. However, if pulse and BP are reduced too much, renal perfusion could ultimately be affected.

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 cancer of the larynx undergoes radiation therapy for 5 weeks prior to a neck dissection and tumor excision. The client asks the nurse how long the post surgical recovery time will be. How should the nurse reply? 1. "I really don't know. It is different for everyone, but speak to your surgeon." 2. "Your medical insurance will cover the whole length of your stay, so don't worry." 3. "You shouldn't worry about how long you are going to stay. You should focus on getting better." 4. "It may be a little longer than average. The radiation you received sometimes delays tissue healing."

4. Correct: This is the best, most accurate response. Radiation can cause tissue trauma and changes that can delay wound healing. 1. Incorrect: On NCLEX®, the nurse should know not to put work off on someone else. This answer avoids responsibility and does not provide the client with the information requested. 2. Incorrect: This answer assumes the client has financial concerns, but this is not the question the client asked. It also dismisses the client by being told not to worry. 3. Incorrect: This answer brushes off the client. Never pick an answer that brushes off the client's concern.

A client with cancer refuses treatment and asks about options for hospice home care. The client's daughter asks the nurse to talk the client into agreeing to cancer treatment. The nurse explains to the daughter that this violates which client right? 1. Advocacy 2. Ability to decline participation in experimental treatments. 3. Expectation of reasonable continuity of care. 4. To make decisions about the plan of care

4. Correct: Under the Patient Self-Determination Act (PSDA), healthcare institutions provide clients with a summary of their rights when making health care decisions as well as the facility's policies regarding recognition of advanced directives. The client is advised of the right to consent to or refuse treatment. Client rights refer to such matters as access to care, dignity, confidentiality, and consent to treatment. The competent adult client has the right to participate in the plan of care, to refuse a proposed treatment, and to accept alternative care and treatment. Documentation should be made that the client fully understands the risks and benefits of their decision. 1. Incorrect: The right to advocacy relates to the right to have another person present during interviews or examinations. This right would not be violated by the nurse if attempts were made to convince the client to have cancer treatment. 2. Incorrect: The right to decline participation in research or experimental studies is incorrect because no research or experimental treatment is proposed to the client. 3. Incorrect: The right to expect reasonable continuity of care appears to be a possible correct answer, but is incorrect because the client has not been transferred to hospice home care. Attempting to convince the client to agree to cancer treatment would not be pertinent to continuity of care in this situation.

A client diagnosed with a duodenal ulcer is prescribed lansoprazole and sucralfate. What should the nurse teach the client about how to take these medications? 1. Take together immediately before meals. 2. Take together immediately after meals. 3. Take the sucralfate first, wait at least 30 minutes, then take the lansoprazole. 4. Take the lansoprazole first, wait at least 30 minutes, then take the sucralfate.

4. Correct: When prescribed any medication along with sucralfate, the client should avoid taking the medication at the same time with sucralfate. Sucralfate can make it harder for the body to absorb lansoprazole because it forms a "coating" or "barrier" on the stomach lining. Therefore, the client should wait at least 30 minutes after taking the lansoprazole before taking sucralfate. 1. Incorrect: Taking sucralfate and lansoprazole at the same time will decrease the effects of lansoprazole because the sucralfate coats the stomach lining and reduces the absorption of the lansoprazole. 2. Incorrect: Taking sucralfate and lansoprazole at the same time will decrease the effects of lansoprazole because the sucralfate coats the stomach lining and reduces the absorption of the lansoprazole.. 3. Incorrect: Sucralfate can make it harder for your body to absorb lansoprazole because of the barrier created on the stomach lining.

The nurse, caring for an 8 month old infant, should recognize which major stressor of hospitalization for this infant? 1. Fear of unknown 2. Loss of daily routine 3. Body image disturbance 4. Separation anxiety

4. Correct: Yes, they are afraid of being without the caregiver. Separation anxiety develops after a child gains an understanding of object permanence. The infant may become unsettled after the parent leaves. Although some babies display object permanence and separation anxiety as early as 4 to 5 months of age, most develop more robust separation anxiety at around 8 months. Separation anxiety can be worse if the infant is hungry, tired, or not feeling well. 1. Incorrect: Fear of the unknown is not a concern at this age, but rather between the age of 2-3 years. Separation anxiety is their immediate concern. 2. Incorrect: Keeping family routines and providing quality time with trusted adults is reassuring once the child reaches the age of 2. 3. Incorrect: The preschooler fears mutilation resulting in body image disturbance.

Which foods should the nurse encourage a client to avoid when prescribed a diet limiting purine rich foods? (SATA) 1. Peanut butter 2. Potatoes 3. Apples 4. Venison 5. Scallops

4., & 5. Correct: Purines are found in many foods and produced naturally by the body. Meats such as liver, bacon, veal, and venison are high in purine and should be avoided. Seafood such as sardines, mussels, codfish, scallops, trout, and haddock are high in purine and should be avoided. 1. Incorrect: Peanut butter is low in purine and allowed on a diet limiting purine rich foods. 2. Incorrect: Potatoes are allowed on low purine diet. 3. Incorrect: All fruit and fruit juices are low in purine. So apples can be eaten on a diet limiting purine rich foods.

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.

TEF

4Cs' Coughing, Choking, Cyanosis, Continous Drooling

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

Huntington's Chorea

50% genetic, autosomal dominant disorder S/S: chorea --> writhing, twisting, movements of face, limbs and body -gait deteriorates to no ambulation -no cure, just palliative care

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

An antacid should be given to a mechanically ventilated patient with an NG tube if the pH of the aspirate is

<5.0. Aspirate should be checked at least every 12 hours.

APGAR

A = appearance ( color all pink, pink and blue, blue (pale)) P = pulse (>100, <100, absent) G = grimace ( cough, grimace, no response) A = activity (flexed, flaccid, limp) R = respirations (strong cry, weak cry, absent)

Multiple Sclerosis is

A chronic, progressive disease with demyelinating lesions in the CNS which affect the white matter of the brain and spinal cord Motor S/S: limb weakness, paralysis, slow speech Sensory S/S: numbness, tingling, tinnitus Cerebral S/S: nystagumus, ataxia, dysphagia, dysarthria

734. The nurse is caring for four clients who are on the rehabilitation unit, which client should the nurse assess first? A. A client with an above-the-knee amputation who is complaining of phantorn pain. B. A client who is receiving a continuous tube feeding and is now vomiting. C. A client with left hemiplegia who is scheduled for hemodialysis today. D. A client with pneumonia who is scheduled for pulmonary function studies.

A client who is receiving a continuous tube feeding and is now vomiting.

798. The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first? A. A client with congestive heart failure who reports a 3 pound weight gain in the last two days B. An immobile client with a stage 3 pressure ulcer on the coccyx who is having low back pain C. A client diagnosed with chronic obstructive pulmonary disease (COPD) who is short of breath D. A terminally ill older adult who has refused to eat or drink anything for the last 48 hours

A client with congestive heart failure who reports a 3 pound weight gain in the last two days.

What should a community health nurse include when planning a presentation on prevention and early detection of colon cancer?

A diet high in vegetables, fruits, and whole grains has been linked with a decreased risk of colorectal cancer; exercise regularly The guaiac-based fecal occult blood test detects blood in the stool through a chemical reaction. This test is done yearly.

660. When organizing home visits for the day, which older client should the home health nurse plan to visit first? a. A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools. b. A man who receives weekly injections of epoetin (Procrit) for a low serum iron level c. A man with emphysema who smokes and is complaining of white patches in his mouth d. A frail woman with heart failure who reported a 2 pounds' weight gain in the last week.

A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools. Rationale: A serious side effect of naproxen is GI bleeding, so the dark, tarry stools, a sign of GI bleeding should be assessed first and possible referred to the physician.

Lumbar puncture

AFTER the procedure, the client should be placed in the supine position for 4 to 12 hrs as prescribed

A little trick regarding potassium

ALKALOSIS: K is LOW Acidosis is just the opposite: K is High

NEVER check the monitor or a machine as a FIRST ACTION. ALWAYS assess the CLIENT FIRST!

ALWAYS ASSESS THE CLIENT FIRST

an answer that delays care or treatment is

ALWAYS wrong

Managing stress in a patient with adrenal insufficiency (addison's) is paramount because if the adrenal glands are stressed further it could result in

Addisonian crisis. Blood pressure is the most important assessment parameter, as it causes severe hypotension.

Meniere's disease

Admin diuretics to decrease endolymph in the cochlea, restrict Na, lay on affected ear when in bed. Triad: 1)Vertigo 2)Tinnitus 3)N/V

743. A male client is admitted with a severe asthma attack. For the last 3 hours he has experienced increased shortness of breath. His arterial blood gas results are: pH 7.22 PaCO2 55 mmHg; HCO3 25 mEq/L or mmol/L (SI). Which intervention should the nurse implement? A. Space care to provide periods of rest B. Instruct client to purse lip breathe C. Administer PRN dose of albuterol D. Position client for maximum comfort

Administer PRN dose of albuterol.

781. The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply.) A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy D. Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperative E. Start the second blood transfusion for a client twelve hours following a below knee amputation

Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty. Perform daily surgical dressing change for a client who had an abdominal hysterectomy.

771. A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously schedules. What action should the nurse take? A. Advise the UAP to resume positioning the client on schedule B. Encourage the UAP to provide comfort care measures only C. Assume total care of the client to monitor neurologic function D. Assign a practical nurse to assist the UAP in turning the client

Advise the UAP to resume positioning the client on schedule.

687. A female client with chronic urinary retention explains double voiding technique to the nurse by stating she voids partially, hold the remaining urine in her bladder for three minutes, then voids again to empty her bladder fully. How should the nurse respond?

Advise the client to empty her bladder fully when she first voids.

664. The nurse provides feeding tube instructions to the wife of a client with end stage cancer. The client's wife performs a return demonstration correctly, but begins crying and tells the nurse, "I just don't think I can do this every day." The nurse should direct further teaching strategies toward which learning domain? A. Cognitive B. Affective C. Comprehension D. Psychomotor

Affective.

751. A client arrives in the emergency center with a blood alcohol level of 500 mg/dl. When transferred to the observation unit, the client becomes demanding, aggressive, and shouts at the staff. Which assessments finding is most important for the nurse to identify in the first 24 hours? A. Decreased appetite B. Nausea and elevated blood pressure C. Difficulty walking D. Agitation and threats to harms staff

Agitation and threats to harms staff.

A hysterical college student arrives in the emergency department in bloody soiled clothing. The nursing assessment reveals facial bruising and multiple contusions consistent with the client's report of being raped. Which initial nursing intervention takes priority at this time? 1. Notify police of the alleged rape. 2. Allow the client privacy to wash self. 3. Remove clothing and bag for evidence. 4. Encourage client to express fears and anxiety.

Allowing the client to first express emotions, such as fear or anxiety, returns a small amount of control to a situation in which the client has little or none. The police will indeed be notified of the situation by the hospital personnel, but the nurse's initial priority is to focus on the client's needs, both physical and emotional.

What should the nurse do first when caring for a client who is being admitted with a diagnosis of meningococcal meningitis?

Although all the options are appropriate, the priority is to place the client on droplet precaution to prevent the spread of meningococcal meningitis.

when aspirin is given once a day it acts as

An Antiplatelet

TB drugs are liver toxic. (Does your patient have hepB?)

An adverse reaction is peripheral neuropathy.

766. Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN)?

An elderly female client with cancer whose children who are trying to decide whether to change to palliative care measures or continue disease control.

691. Which class of drugs is the only source of a cure for septic shock? a- Antihypertensives b- Antiinfectives c- Antihistamines d- Anticholesteremics.

Antiinfectives. Rationale: Antiinfective agents, such as antibiotics, are the only drugs that eliminate bacteria. The only to halt destruction to organ system in septic shock is to eliminate the production of endotoxins by bacterial invaders. A is contraindicated due to the low cardias output which in low blood pressure and occurs in late septic shock. While C may reduce some of the destructive effects of massed cell release occurring with the inflammatory response that may occur, endotoxin release would not be stopped. D has no therapeutic effect relevant to septic shock.

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client?

Anxiety

772. The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain? A. Degree of skin elasticity B. Appearance of wound C. Bilateral pedal pulse force D. Onset of any bleeding

Appearance of wound.

606. A client present at the clinic with blepharitis. What instructions should the nurse provide for home care? a- Use bilateral eyes patches while sleeping to prevent injury to eyes. b- Wear sunglasses when out of doors to prevent photophobia c- Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo d- Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo.

Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo.

711. The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and the interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, "She says it is OK." What action should the nurse take next? a- Have the interpreter co- sign the consent to validate client understanding b- Have the client sign the consent and the nurse witness the signature c- Ask for a full explanation from the interpreter of the witnessed discussion. d- Clarify the client's consent through the use of gestures and simple terms.

Ask for a full explanation from the interpreter of the witnessed discussion.

708. After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication? a- Ask the client about gastrointestinal pain b- Auscultate for bowel sounds in all quadrants c- Measure the client's fluid intake and output d- Monitor the client's serum electrolyte levels.

Ask the client about gastrointestinal pain. Rationale: Proton pump inhibitor suppress gastric acid secretion, relieving the symptoms of peptic ulcer disease and GERD. To evaluate the effectiveness of PPIs, the client should be asked about the relief of symptoms such as gastrointestinal discomfort.

654. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive...medication therapy, the nurse notices the client has more energy, is giving her belongings...mood. Which intervention is best for the nurse to implement? a- Support the client by telling her what wonderful progress she is making. b- Ask the client if she has had any recent thoughts of harming herself. c- Reassure the client that the antidepressant drugs are apparently effective d- Tell the client to keep her belongings because she will need hem at discharge.

Ask the client if she has had any recent thoughts of harming herself.

659. An older female client tells the nurse that her muscles have gradually been getting weak...what is the best initial response by the nurse? a- Explain that this is an expected occurrence with aging. b- Observe the lower extremity for signs of muscle atrophy c- Review the medical record for recent diagnosis test results. d- Ask the client to describe the changes that have occurred

Ask the client to describe the changes that have occurred.

717. A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement? a- Obtain the results for STAT serum cardiac biomarkers b- Asses for contraindications for thrombolytic therapy c- Measure ST-segment height and waveform changes. d- Transfer for percutaneous coronary intervention (PCI)

Asses for contraindications for thrombolytic therapy. Rationale: ST segment elevation myocardial infarction (STEMI) usually occurs with complete occlusion of an epicardial coronary artery which requires early reperfusion therapy. Screening the client for fibrinolytic therapy (B) is most important to determine PCI option for rapid reperfusion. If the client is not a candidate for fibrinolytic therapy, then transfer to a PCI unit or facility is indicated. Reperfusion therapy should be delayed in STEMI (A). (C) is of significant concern in ECG interpretation with ST-segment depression, not STEMI

755. A preoperative client states he is not allergic to any medications. What is the most important nursing action for the nurse to implement next? A. Record "no known drug allergies" on preoperative checklist B. Assess client's allergies to non-drug substances C. Assess client's knowledge of an allergy response D. Flag "no known drug allergies" on the front of the chart

Assess client's knowledge of an allergy response.

640. Which nursing intervention has the highest priority for a multigravida who delivered... a. Maintain cold packs to the perineum for 24 hrs. b. Assess the client pain level frequently c. Observe for appropriate interaction with the infants. d. Assess fundal tone and lochia flow

Assess fundal tone and lochia flow.

A long-term care nurse is planning care for a newly admitted client diagnosed with Alzheimer's disease. What should the nurse include in the plan of care?

Assess the client's ability to perform activities of daily living and allow client to perform alone if capable. Maintain stimuli such as a clock, newspaper, calendar, and/or weather status. Encourage family to visit to maintain socialization. Plan for staff to spend some time talking and listening to the client.

A client who has been on bed rest for several days is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last.

Assess the client's orientation. Assist the client to sit on the side of the bed for 1-2 minutes. Apply a gait belt to the client's waist. Have the client stand by the side of the bed for a few seconds. Ambulate in the room

665. A male client with rheumatoid arthritis is schedule for a procedure in the morning. The...unable to complete the procedure because of early morning stiffness. Which intervention...implement?

Assign a UAP to assist the client with a warm shower early in the morning.

780. A confused, older client with Alzheimer's disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement? A. Instruct the client to use the call button when a bedpan is needed B. Apply adult diapers after each attempt to void C. Check residual urine volume using an indwelling urinary catheter D. Assist the client's to a bedside commode every two hours

Assist the client's to a bedside commode every two hours.

The nurse is caring for a client with possible hepatic failure. The nurse asks the client to sign a permit for a procedure. The nurse recalls the client's admission signature as legible, but, now observes a jerky, illegible signature. What should the nurse suspect is the cause of this handwriting change? 1. Fetor 2. Ataxia 3. Apraxia 4. Asterixis

Asterixis is a tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. Yes, the liver flap, which is an abnormal muscle tremor, is usually found in clients with diseases of the liver. This is an indication that the hepatic failure is worsening and needs to be documented.

793. While removing staples from a male client's postoperative wound site, the nurse observes that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, what action should the nurse implement? a- Encourage the client to continue verbalize his anxiety b- Attempt to distract the client with general conversation c- Explain the procedure in detail while removing the staples d- Reassure the client that this is a simple nursing procedure.

Attempt to distract the client with general conversation.

800. Oxygen at 5l/min per nasal cannula is being administered to a 10 year old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider? A. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen? B. Avoid administration of oxygen at high levels for extendedperiods. C. Increase oxygen rate during sleep to compensate for slower respiratory rate. D. Oxygen is less toxic when it is humidified with a hydration source.

Avoid administration of oxygen at high levels for extended periods.

608. The nurse is teaching a client with atrial fibrillation about a newly prescribed medication, dronedarone. Which information should the nurse include in client interactions? (Select all that apply) a- Discontinue medication when palpitation subside. b- Avoid eating grapefruit or drinking grapefruit juice. c- Report changes in the use of daily supplements d- Notify your health care provider if your skin looks yellow e- If a dose is missed, the next dose should be double.

Avoid eating grapefruit or drinking grapefruit juice. Report changes in the use of daily supplements. Notify you heal care provider if your skin looks yellow.

649. Which instruction is most important for the nurse to provide a client who is being discharge following treatment for Guillain-Barre syndrome? A. Avoid exposure to respiratory infections B. Use relaxation exercises when anxious C. Plan short, frequent rest periods D. Continue physical therapy at home

Avoid exposure to respiratory infections.

The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse? A. A 12-year-old with complaints of neck and lower back discomfort B. An 11-year-old with a headache, nausea, and projectile vomiting C. A 6-year-old with multiple superficial lacerations of all ectremities D. An 8-year-old with a full leg air splint for a possible broken tibia

B. An 11-year-old with a headache, nausea, and projectile vomiting

26. A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? A. Abnormal responses for cranial nerves I and II B. Persistent coughing while drinking C. Unilateral facial drooping D. Inappropriate or exaggerated mood swings

B. Persistent coughing while drinking

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. What action should the nurse take first?

Begin manual ventilation immediately.

Interpersonal model (sullivan)

Behavior motivated by need to avoid anxiety and satisfy needs Infancy 0-18 months others will satisfy needs Childhood <6 years learn to delay need gratification Juvenile 6-9 years learn to relate to peers Preadolescence 9-12 years learns to relate to friends of opposite sex Early adolescence 12-14 years learn independence and how to relate to opposite sex Late adolescence 14-21 years develop intimate relationship with person of opposite sex

With low back aches,

Bend knees to relieve pain

Which symptoms would the nurse be likely to observe in the client who overdosed on diazepam?

Benzodiazepines are central nervous system (CNS) depressants. Diazepam is a benzodiazepine. They will slow respirations (bradypnea) and the heart rate (bradycardia). Somnolence (extreme, prolonged drowsiness) would be seen.

729. A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?

Blood pressure 90/76 mm Hg.

768. A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? A. Bone marrow transplantation B. Blood transfusion C. Chemotherapy D. Immunosuppressive therapy

Bone marrow transplantation.

hydrocephalus

Bossing Sign (prominent forehead)

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take?A. Ask the UAP to take the blood pressure in the other arm B. Tell the UAP to use a different sphygmomanometer. C. Review the client's serum calcium level D. Administer PRN antianxiety medication.

C. Review the client's serum calcium level

Definitive diagnosis for abdominal aortic aneurysm (AAA)

CT scan

779. The unit clerk reports to the charge nurse that a healthcare provider has written several prescriptions that are illegible and it appears the healthcare provider used several unapproved abbreviations in the prescriptions. What actions should the charge nurse take? A. Complete and file an incident (variance) report Call the healthcare provider who wrote the prescription C. Contact the healthcare provider review board for instructions D. Report the situation to the house supervisor

Call the healthcare provider who wrote the prescription. Report the situation to the house supervisor.

Edema is in the INTERSTITIAL SPACE and NOT in the:

Cardiovascular space

The primary healthcare provider prescribes nafcillin 0.6 gram every 12 hours IM. Available is a vial labeled 200 mg per 1 mL. How many mL should the nurse give? Round your answer to the nearest whole number.

Changing 0.6 g to mg equals 600 mg. Then 200 mg : 1 mL = 600 mg : x mL 200x = 600 x = 3

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

Check client's vital signs after ambulating. Obtain a stool specimen.

689. When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? A. Massage the urterus to decrease atony B. Review the hemoglobin to determine hemorrhage C. Increase IV infusion D. Check for a distended bladder

Check for a distended bladder.

761. An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which intervention is most important for the nurse to implement? A. Prepare for emergent oral intubation B. Offer sips of favorite beverages C. Clarify end of life desires D. Initiate comfort measures

Clarify end of life desires.

A primary healthcare provider prescribed KCL 40 mEq in 100 mL NS to infuse over 30 minutes. What action should the nurse take? 1. Administer the KCL through the lowest IV line port. 2. Clarify the prescription with the primary healthcare provider. 3. Mix KCL 40 mEq into the present infusing bag of NS when it reaches 100 mL. 4. Set the infusion pump to 100 mL / hour.

Clarify the prescription with the primary healthcare provider. Potassium chloride should be diluted and administered to infuse no faster than 40 mEq per hour. So this prescription would infuse too quickly and may lead to life threatening arrhythmias.

Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching of proper diet was understood?

Client needs low sodium and increased proteins. ex.Scrambled eggs, sliced turkey, biscuit, whole milk

765. The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mother? (Select all that apply)

Close car windows and use air conditioner. Avoid sudden changes in temperature. Keep away from pets with long hair. Stay indoors when grass is being cut.

It's okay to have abdominal cramps , blood tinged outflow and leaking around site if the peritoneal dialysis catheter (tenkhoff) was placed in the last 1-2 weeks. What's not normal ?

Cloudy outflow NEVER NORMAL

702. Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning? a- Slow weight loss b- Muscle weakness c- Cold sensitivity d- Leg numbness

Cold sensitivity.

623. A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next? A. Measure the child's abdominal girth B. Perform an ostoscopic examination C. Collect a urine specimen for routine urinalysis D. Obtain a blood specimen for serum electrolytes

Collect a urine specimen for routine urinalysis.

789. A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instructions should the nurse give to this client? A. Remain on clear liquids until the vomiting subsides B. Come to the clinic to be seen by a healthcare provider C. Make an appointment at the clinic if a fever occurs D. Take nothing by mouth until there is no more nausea

Come to the clinic to be seen by a healthcare provider.

666. The nurse is caring for a client following a myelogram. Which assessment finding should the nurse report to the healthcare provider immediately?

Complain of headaches and stiff neck.

630. An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior? A. addiction B. phobia C. compulsion D. obsession

Compulsion.

Amyotrophic lateral sclerosis (ALS) is a

Condition in which there is a degeneration of motor neurons in both the upper and lower motor neuron systems.

VRSA

Contact AND airborne precaution (Private room, door closed, negative pressure)

726. A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse make? a- Contact the healthcare provider immediately to report the laboratory value regardless of the advice. b- Call the lab to draw an additional blood sample for a repeat evaluation of the potassium level STAT. c- Flag the client's medical record to alert the healthcare provider immediately upon arrival to the unit. d- Ask the charge nurse to contact the healthcare provider with the laboratory results by mid-morning.

Contact the healthcare provider immediately to report the laboratory value regardless of the advice. Rationale: A serum potassium level of 2 mEq/L or mm/L (SI) is dangerous low and requires immediate intervention A to prevent potentially fatal cardiac dysrhythmias, regardless of the charge nurse concern regarding disturbing the healthcare provider, B, C and D may result in a potentially fatal delay in responding to the hypokalemia.

604. The nurse is assessing the thorax and lungs of a client who is having respiratory difficulty. Which finding is most indicative of respiratory distress? a- Contractions of the sternocleidomastoid muscle. b- Respiratory rate of 20 breath/mints c- Downward movement of diaphragm with inspiration d- A pulse oximetry reading of SpO2 95%

Contractions of the sternocleidomastoid muscle.

670. A client is complaining of intermittent, left, lower abdominal pain that began two days ago...implement the following interventions?

Correct orders: (DPIA) 1. Determine when the client had last bowel movement. 2. Position client supine with knees bent. 3. Inspect abdominal contour. 4. Auscultate all four abdominal quadrants.

799. A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most import for successful adherence to the diabetic diet? A. Knows that insulin must be given 30 min before eating B. Frequently eats fruits and vegetables at meals and between meals/ C. Has someone available who can prepare and oversee the diet D. Demonstrates willingness to adhere to the diet consistently

Demonstrates willingness to adhere to the diet consistently.

697. An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms?

Destruction of joint cartilage.

645. A newly hired home health care nurse is planning the initial visit to an adult client who has had multiple sclerosis (MS) for the past 20 years and is currently bed-bound and is lifted by a hoist. And unlicensed caregiver provides care 8 hours/ daily, 5 days/week. During the initial visit to this client, which intervention is most important to the nurse to implement? a. Determine how the client is cared for when caregiver is not present. b. Develop a client needs assessment and review with the caregiver c. Evaluate the caregiver's ability to care for the client's needs. d. Review with the care giver the interventions provided each day.

Determine how the client is cared for when caregiver is not present.

638. An adult male who lives alone is brought to the Emergency Department by his daughter who is unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and...Which nursing intervention has the highest priority? a. Offer to notify the client's minister of his condition. b. Determine if the client has an executed living will c. Provide the family with information about palliative care d. Explore the possibility of organ donation with the family.

Determine if the client has an executed living will.

721. During a clinic visit, a client with a kidney transplant ask, "What will happen if chronic rejection develops?" which response is best for the nurse to provide? a- The immunosuppressant medication will be increased until the rejection subside b- Dialysis may be necessary until the chronic rejection can be reversed. c- Dialysis would need to be resumed if chronic rejection becomes a reality d- A different combination of immunosuppressant medications will be implemented.

Dialysis would need to be resumed if chronic rejection becomes a reality. Rationale: Chronic rejection is managed conservatively by treating the symptoms until dialysis is needed. Immunosuppressant medication dosage are not increased when chronic rejection occurs, but are during acute rejection.

795. The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation? A. Determine the presence of hematemesis as the UAP irrigates the NGT B. Instruct the UAP to bring an antiemetic to the nurse at the bedside C. Assess the appearance of the emesis while the UAP checks bowel sounds D. Direct the UAP to measure the emesis while the nurse irrigates the NGT

Direct the UAP to measure the emesis while the nurse irrigates the NGT.

601. During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement? A. Notify the pediatrician immediately. B. Teach the parents about congenital heart defects. C. Document the finding in the infant's record. D. Apply oxygen per nasal cannula at 3 L/min.

Document the finding in the infant's record.

685. While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client's pain?

Does your pain occur when walking short distances?

What could cause bronchopulmonary dysplasia?

Dysplasia means abnormality or alteration. Mechanical ventilation can cause it. Premature newborns with immature lungs are ventilated and over time it damages the lungs. Other causes could be infection, pneumonia, or other conditions that cause inflammation or scarring.

DO NOT delegate what you can EAT!

E - evaluate A - assess T - teach

Apgar measures HH, RR, Muscle tone, Reflexes, Skin color

Each 0-2 point. 8-10 OK. 0-3 RESUSCITATE

746. The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply)

Ease the client to the floor. Loosen restrictive clothing. Note the duration of the seizure.

794. A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first? A. Ensure client takes a diuretic q AM B. Obtain serum creatinine levels daily C. Measure ankle circumference D. Monitor daily sodium intake

Ensure client takes a diuretic q AM.

719. A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care? a- Monitor deep vein blood flow using Doppler b- Evaluate daily blood clotting factors. c- Apply antiembolism stockings. d- Maintain strict bed rest.

Evaluate daily blood clotting factors. Rationale: Monitoring clotting factors is the most important intervention to include in this client's plan of care following oxygen administration, IV fluids and heparin administration to prevent clot enlargement. Ac and D should be included in the client's plan of care, but these interventions do not have the priority of B

651. A male client with impaired renal function who takes ibuprofen daily for chronic arthritis...gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70, and his renal output is 20 ml / hour. Which intervention should the nurse include in hours? a. Maintain the client NPO during the diuresis phase b. Evaluate daily serial renal laboratory studies for progressive elevations. c. Observe the urine character for sedimentation and cloudy appearance. d. Monitor for onset of polyuria greater than 150ml/hr.

Evaluate daily serial renal laboratory studies for progressive elevations.

720. The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first? a- Administer schedule medications b- Offer the client PRN anxiolytic c- Assess the lungs for wheezing d- Evaluate the oxygen saturation.

Evaluate the oxygen saturation. Rationale: The client is exhibiting symptoms of an acute exacerbation of a chronic obstructive lung disease such as emphysema. The client... baseline oxygen level should be compared to the current level to determine if respiratory decompensation is occurring. Schedule medications can be administered after completing the oxygen saturation assessment. Respiratory distress often makes a client anxious, which may worsen the symptoms, so should be considered after implementing D. Assessing the lung for wheezing does not reveal further respiratory compromise

Four side rails up is considered a form of restraint.

Even in LTC facility when a client is a fall risk, keep lower rails down, and one side of the bed against the wall, lowest position, wheels locked

679. The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzheimer's disease. What action should the nurse take? a- Explain that memory loss and confusion are common with vitamin B12 deficiency. b- Ask if the client is experiencing any changes in bowel habits c- Determine if the client is taking iron and folic acid supplements d- Encourage the husband to bring the client to the clinic for a complete blood count.

Explain that memory loss and confusion are common with vitamin B12 deficiency. Rationale: Pernicious anemia is related to the absence of intricic factor in gastric secretions, leading to malabsorption of vit B12, and commonly causes memory loss, confusion and cognitive problems, and GI manifestations. The nurse should reassure the husband that the client's signs are consistent with the primary disease. Although B, C and D provide additional information about the client's compliance and response to therapy, a quick and dramatic response can occur after 72 hrs. of B12 injections.

656. The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based clean...tray to the room. The UAP rub both hands thoroughly for 2 minutes while standing at the...should the nurse take? a. Encourage the UAP to remain in the client's room, until completed b. Explain that the hand rub can be completed in less than 2 minutes. c. Inform the UAP that handwashing helps to promote better asepsis. d. Determine why the UAP was not wearing gloves in the client's room

Explain that the hand rub can be completed in less than 2 minutes.

704. A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first?

Explore the client's reasons for wanting to be discharged.

602. Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests? a- Expresses an understanding of the procedure. b- NPO for 6 hrs. c- No known drug allergies d- Intravenous access intact.

Expresses an understanding of the procedure.

Glasgow Coma Scale (GCS)

Eye opening: 1) none, 2) to pain, 3) to verbal command, 4) spontaneous Verbal response: 1) none, 2) incomprehensible sounds, 3) inappropriate words, 4) disoriented/confused, 5) oriented Motor response: 1) none, 2) decerebrate, 3) decorticate, 4) withdraws to pain, 5) localizes pain, 6) obeys commands If below 8, you are in a coma Max 15

756. During a visit to the planned parenthood clinic, a young woman tells the nurse that she is going to discontinue taking the oral contraceptives she has taken for three years because she wants to get pregnant. History indicates that her grandfather has adult onset diabetes and that she was treated for chlamydia six months ago, which factor in this client's history poses the greatest risk for this woman's pregnancy? A. Family history of adult onset diabetes. B. Treatment for chlamydia in the past year C. Client's age and previous sexual behavior D. Three year history of taking oral contraceptives

Family history of adult onset diabetes. Three year history of taking oral contraceptives.

A primary healthcare provider informs the nurse to prepare for an amniotomy on a client who's labor has not progressed. What should the nurse assess for prior to the primary healthcare provider performing this procedure?

Fetal engagement is important prior to rupturing the membranes so that the umbilical cord cannot prolapse. Fetal engagement is when the fetus is at station 0 (level of mom's ischial spines).

705. The nurse is assessing a primigravida a 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider? a- Complain of early morning heart burn b- Report intermittent low back pain c- Fetal heart rate of 200 beats/minute d- Maternal hemoglobin of 11.0 grams

Fetal heart rate of 200 beats/minute.

The charge nurse on the pediatric unit is reviewing the protocol for blood administration with a staff nurse. Which actions by the staff nurse indicate understanding of blood administration?

Filters are used when infusing blood. Two nurses must check the blood product label and blood group. Vital signs are checked frequently during a blood transfusion. For example: A baseline set of vital signs are taken, then again 5 minutes after the initiation of the transfusion, then 15 minutes after transfusion started and every 15 minutes for one hour, then every 30 minutes for one hour, then hourly until infusion is complete.

Place the steps in order that the nurse should take to administer a subcutaneous injection. Perform hand hygiene Apply gloves and locate the injection site Cleanse site with antiseptic swab Remove the needle cap by pulling it straight off Hold syringe and pinch the skin with nondominant hand Inject the needle and administer the medication Dispose the syringe in sharps container

First perform hand hygiene. Then apply gloves and locate injection site using anatomical landmarks. Start at the center of the site and rotate outward in a circular direction to cleanse the site. Remove the needle cap by pulling the cap straight off. Next, hold the syringe and pinch the skin with nondominant hand. Inject the needle quickly then administer the medication slowly. Finally, dispose of the syringe in the sharps container.

In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last. Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. Clean around Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's over surgical wound and Penrose drain. Apply abdominal dressing pad.

First, apply clean gloves. Second, remove soiled dressings. Third, discard soiled dressings and clean gloves in red bag. Fourth, don sterile gloves. Fifth, clean surgical wound with moistened sterile 4x4's. Sixth, clean around Penrose drain using circular pattern inside to outside. Seventh, place dry, sterile 4x4's over surgical wound and Penrose drain. Eighth, apply abdominal dressing pad.

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 comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client?

Flushing, nausea and vomiting, palpitations, tachycardia, psychosis are signs of disulfiram-type reaction seen when using products containing alcohol (cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking metronidazole. Antibiotic: take metronidazole on an empty stomach

757. When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? (Select all that apply). A. Fresh turkey slices and berries B. Fresh vegetables with mayonnaise dip C. Soda crackers and peanut butter D. Chicken bouillon soup and toast E. raw unsalted almonds and apples

Fresh turkey slices and berries. Chicken bouillon soup and toast. Raw unsalted almonds and apples.

744. A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first? A. Enalapril B. Furosemide C. Acetaminophen D. Promethazine

Furosemide.

736. A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression, after another minute of compression , the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor, at this point , what is the priority intervention for the nurse? A. Prepare for transcutaneous pacing B. Administer IV epinephrine per ACLS protocol C. Give IV dose of adenosine rapidly over 1-2 seconds. D. Deliver another defibrillator shock.

Give IV dose of adenosine rapidly over 1-2 seconds.

741. During a staff meeting, a nurse verbally attacks the nurse manager conducting the meeting, stating, "you always let your favorites have holidays off give then easier assignments. You are unfair and prejudiced" how should the nurse-manager respond? A. I would prefer to discuss this with you privately. B. Give me specific examples to support your statements. C. Does anyone else on the staff fell the same way D. Your remarks are not true and are very unkind

Give me specific examples to support your statements.

695. The healthcare provider prescribes carboprost tromethamine (Hemabate) 250 mcg IM for a multigravida postpartum client who is experiencing heavy, bright red vaginal bleeding. Prior to administering this medication, which interventions should the RN implement? A. Obtain a second IV access. B. Decrease the room temperature. C. Give the prescribed antiemetic. D. Insert an indwelling catheter.

Give the prescribed antiemetic.

Rhogam

Given at 28 weeks, 72 hours post partum; given IM. Only given to Rh NEGATIVE mothers. If the indirect Coomb's test is POSITIVE, then you DO NOT need to give Rhogam because she has antibody; only give if NEGATIVE Coombs.

The nurse is teaching a client who has been prescribed daily glucocorticoids for the treatment of Addison's disease. What teaching points should the nurse emphasize?

Glucocorticoids should not be abruptly discontinued due to the risk of adrenal suppression with prolonged use. Doses should be tapered before being discontinued.

The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given? 1. "The action of the medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you do not break a bone." 4. "Glycopyrrolate will decrease stomach secretions."

Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease the risk of aspiration.

Fluids are the most important intervention with ______ as well as ______, so get fluids going first. With HHNS there is no ketosis, and no acidosis. Potassium is low in HHNS (d/t diuresis)

HHNS DKA

When caring for a client with hepatitis A, the nurse should take what special precaution?

Hepatitis A is transmitted by the fecal/oral route. Use gloves when removing the client's bedpan.

anaphylactic reaction to baker's yeast is contraindication for

Hepatitis B vaccine

653. When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform? a. Hold the thermometer in place. b. Place the disposable pad under buttocks c. Instruct the client to breathe deeply d. Return the probe to the charger.

Hold the thermometer in place.

DVT

Homan's Sign (pain in calf when bending foot up while supine)

The home health nurse is caring for a client with a neurological urinary tract dysfunction. What information should be included when teaching the client how to perform intermittent self catheterization?

Home intermittent catheterization is a clean, not sterile technique when performed in the home environment. Home intermittent catheterization is preferred over continuous use of an indwelling catheter, as an indwelling catheter increases client risk of urinary tract infection (UTI).

731. A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications? A. Regular insulin. B. Hydrocortisone C. Broad spectrum antibiotic D. Potassium chloride

Hydrocortisone.

Which electrolyte imbalance would be the nurse's priority concern in the burn client?

Hyperkalemia Good job. When the cells lyse they release potassium, and then the serum potassium goes up. And if the kidneys stop, we are in real trouble.

Which signs and symptoms, if noted by the nurse, would indicate that the client with hyperthyroidism is experiencing thyroid crisis?

Hyperkinesis - muscle spasm Hypertension Restlessness Confusion

613. A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse? A. Hypernatremia B. Excessive thirst C. Elevated heart rate D. Poor skin turgor

Hypernatremia. Rationale: A deficiency of antidiuretic hormone (ADH) is the underlying cause of DI, which results in... hypotonic urine.

Trousseau and Tchovoski signs observed in

Hypocalcemia

A nurse attaches a client to continuous cardiac monitoring due to a potassium level of 2.8 mEq (2.8 mmol). The nurse should monitor for which dysrhythmia?

Hypokalemia is reflected by the EKG. The earliest EKG change is often premature ventricular contractions (PVCs) which can deteriorate into ventricular tachycardia or fibrillation (VT/VF) without appropriate potassium replacement.

642. A newly graduated female staff nurse approaches the nurse manager and request reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide? a. I have to call the supervisor o get someone else to transfer to this unit to care for him. b. I know you are good nurse and can handle this client in a professional manner. c. I'll talked to the client about his sexual harassment and I'll insist that he stop it immediately. d. I'll change your assignment, but let's talk about you a nurse should respond to this kind of client.

I'll change your assignment, but let's talk about you a nurse should respond to this kind of client.

Cushing's triad related to

ICP in BRAIN hypertension, bradycardia, irregular respirations

never give K+ in

IV push

Let's say every answer in front of you is an abnormal value.

If potassium is there you can bet it is a problem they want you to identify, because values outside normal can be life threatening. Even a BUN of 50 doesn't override a potassium of 3.0 in a renal patient in priority.

What risk factors should the nurse include when conducting a class about type 2 diabetes mellitus? SATA 1. Fat distribution greater in abdomen than in hips. 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. 5. Polycystic ovary syndrome.

If the body stores fat primarily in the abdomen, risk of type 2 diabetes is greater than if body stores fat elsewhere, such as hips and thighs. Women with polycystic ovary syndrome have increased risk of diabetes.

If one nurse discovers another nurse has made a mistake it is always appropriate to speak to her before going to management.

If the situation persists, then take it higher.

If you can remove the white patches from the mouth of a baby it is just formula.

If you can't, its candidiasis.

A client who has been on bed rest for several days is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last. Monitor the client's orientation. Assist the client to sit on the side of the bed for 1-2 minutes. Apply a gait belt to the client's waist. Have the client stand by the side of the bed for a few seconds. Ambulate in the room.

In order to keep a client safe, the nurse should first check the client's orientation to determine the client's ability to follow instructions. Second, to avoid orthostatic hypotension, the nurse should assist the client to sit on the side of the bed. Third, apply the gait belt to ensure safety while ambulating. Fourth, assist the client to stand for a few seconds. The fifth action is to ambulate in the room.

What is an intraosseous infusion?

In pediatric life-threatening emergencies, when iv access cannot be obtained, an osseous (bone) needle is hand-drilled into a bone (usually the tibia),where crystalloids, colloids, blood products and drugs can be administered into the marrow. It is a temporary, life-saving measure. When venous access is achieved it can be d/c'd. One medication that cannot be administered by intraosseous infusion is isoproterenol, a beta agonist.

A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What should the nurse suggest to reduce this side effect?

Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet.

699. A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate? a- Ineffective coping related to denial b- Anxiety related to treatment of choice c- Decisional conflict related to stress d- Deficient knowledge related to lifestyle changes.

Ineffective coping related to denial.

A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?

Inform her that some antianxiety medications are safe to take while breastfeeding

Family members have been asking triage nurses if loved ones were admitted to the hospital during a national emergency situation with massive casualties. What response should be made by the nurses?

Inform them if their family members have been admitted. The national emergency situation allows waivers for the Health Insurance Portability and Accountability Act (HIPAA) provisions. Due to the emergency situation, the nurse may inform the family members about the status of their loved ones.

792. A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics. Which intervention should the nurse implement first? (Please scroll and view each tab's information in the client's medical record before selecting the answer.) A. Infuse 0.9 % sodium chloride 500 ml bolus B. Insertnasogastrictubetointermittentsuction. C. Maintain head of bed at 45 degrees D. Document strict intake and output

Infuse 0.9 % sodium chloride 500 ml bolus.

673. Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated and his bloods pressure drops to 60/40. Which intervention should the nurse implement?

Infuse a rapid IV normal saline bolus.

603. A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L or 12 mmol/L (SI), and blood glucose is 310 mg/dl or 17.2 mmol/L (SI). Which action should the nurse implement? a- Infuse sodium chloride 0.9% (normal saline) b- Prepare an emergency dose of glucagon c- Determine the last time the client ate d- Check urine for ketone bodies with a dipstick

Infuse sodium chloride 0.9% (normal saline).

760. A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. What intervention should the nurse implement first? A. Give the infant 5% dextrose in water orally B. Insert a nasogastric tube for feeding C. Initiate a prescribed IV for parental fluid D. Feed the infant 3 ounces of Isomil

Initiate a prescribed IV for parental fluid.

742. An adult is admitted to the emergency department following ingestion of a bottle of antidepressants secondary to chronic paint. A nasogastric tube and a left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds procedure should the nurse prepare for first? A. Insertion of a left- sided chest tube. B. Placement of an endotracheal tube. C. Retraction of the nasogastric tube D. Setup of patient- controlled analgesia

Insertion of a left- sided chest tube.

Order of assessment

Inspection, Palpation, Percussion and Ausculation. EXCEPT with abdomen because you don't wanna mess with the bowels and their sounds so you Inspect, Auscultate, Percuss then Palpate (same with kids, I suppose since you wanna go from least invasive to most invasive sine they will cry BLOOD MURDER ! Gotta love them kids !)

710. A client with pneumonia has arterial blood gases levels at: PH 7.33; PaCO2 49 mm/hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results? a- Instruct the client to breath into a paper bag. b- Prepare to administer sodium chloride fluids c- Institute coughing and deep breathing protocols d- Initiate oxygen administration at 2 to 3 L per nasal cannula

Institute coughing and deep breathing protocols. Rationale: Pulmonary hygiene measures will clear the respiratory tract of mucus and purulent drainage, thereby improving ventilation, since these ABG's reveal respiratory acidosis, and treatment should be directed to improving ventilation. A would be good for respiratory alkalosis, B for metabolic alkalosis A paO2 of 95 is within normal limits do D is not necessary

The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? A. Instruct the mother to change the child's diaper more often. B. Encourage the mother to apply lotion with each diaper charge C. Tell the mother to cleanse with soap and water at each diaper change D. Ask the mother to decrease the infant's intake of fruits for 24 hours.

Instruct the mother to change the child's diaper more often

657. An adolescent's mother calls the clinic because the teen is having recurrent vomiting and...Combative in the last 2 days. The mother states that the teen takes vitamins, calcium, mag...With aspirin. Which nursing intervention has highest priority? a. Advise the mother to withhold all medications by mouth. b. Instruct the mother to take the teen to the emergency room c. Recommend that the teen withhold food and fluids for 2 hours d. Suggest that the adolescent breath slowly and deeply.

Instruct the mother to take the teen to the emergency room.

776. The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. What action should the charge nurse take? A. Plan to observe the secured IV site after the insertion procedure B. Confirm that the nurse has gathered the necessary supplies C. Remind the nurse to tape the gauze dressing securely in place D. Instruct the nurse to use a transparent dressing over the site

Instruct the nurse to use a transparent dressing over the site.

652. The health care provider prescribes atenolol 50 mg daily for a client with angina pectoris...to the health care provider before administering this medication? A. Irregular pulse B. Tachycardia C. Chest pain D. Urinary frequency

Irregular pulse.

The nurse is caring for a client who has taken an acetaminophen overdose. Which symptom is the client most likely to exhibit?

Jaundiced conjunctiva This is a sign of liver damage, which is caused by an overdose of acetaminophen.

There is an association between low set ears and renal anomalies. If the nurse notices low set or asymmetrical ears in the neonate, there is a good reason to investigate renal functioning.

Kidneys and ears develop around the same time in utero. Shaped similarly.

measles

Koplik's spots (clustered white lesions on buccal mucosa)

LITHIUM

L-level of therapeutic effect is 0.5-1.5 I-indicate nausea T-toxic level is 2-3, N/V/D, tremors H-hydrate 2-3L of water/day I-increased urine output and dry mouth U-uh oh; give mannitol and diamox if toxic s/s are present M-maintain Na intake of 2-3g/day

723. A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse? a- Pale pink urine output b- Dark red clot in urine c- Leakage around catheter insertion site d- Urinary output greater than 90 ml/hour.

Leakage around catheter insertion site. Rationale: After genitourinary surgery, the client is at risk for blood clots and mucus fragments occluding the catheter. Leakage of urine around the suprapubic insertion site indicates blockage of the catheter that causes urine back-up resulting in bladder distention and overflow leakage around the catheter. Pink urine and clots are normal finding

745. When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement? A. Ignore the behavior and hang the IV antibiotic B. tell the client to stop the inappropriate behavior C. Leave the room and close the door quietly D. Complete an unusual occurrence report

Leave the room and close the door quietly.

621. The daughter of an older female client tells the clinic nurse that she is no longer able to care for her mother since her mother has lost the ability to perform activities of daily living (ADLs) due to aging. Which options should the nurse discuss with the daughter?(Select all that apply) A. Home hospice agency B. Long-term care facility C. Rehabilitation facility D. Independent senior apartment E. Home health agency

Long-term care facility. Home health agency.

with L side in adults

Look for CORONARY complications

Unusual positional tip

Low-fowlers recommended during meals to prevent dumping syndrome. Limit fluids while eating

701. A client is admitted for cellulitis surrounding an insect bite on the lower, right arm and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture? a- Lower the right arm below the level of the heart b- Elevate both arms on two pillows c- Lower the left arm below the level of the heart d- Apply a tourniquet above the right antecubital fossa

Lower the left arm below the level of the heart. Rationale: Since the client has an infection in the right lower arm, the IV should be started in the opposite arm, and the nurse should lower the left arm to dilate the vessels and facilitate cannulation of a vein. May be elevate the affected arm should help but not both arms.

Burning sensation in the mouth and brassy taste are adverse reaction to

Lugol solution (for hyperthyroid). Report to the MD

A client with heart failure and pulmonary edema is given furosemide intravenously. Which assessment indicates that the furosemide has achieved the desired effect? 1. Weight has decreased 2 pounds. 2. Systolic blood pressure has decreased. 3. Urinary output has increased. 4. Lungs have fewer rales on auscultation.

Lungs have fewer rales on auscultation. The goal for diuretic therapy in this client is to prevent/relieve fluid accumulation in the lungs. This answer addresses the most life-threatening sequelae with HF. The number one thing to worry about in clients with HF is pulmonary edema, because this is what can kill the client. 1. Incorrect: Weight loss is a good assessment of fluid loss or gain, especially acute weight changes. The stem of the question, however, asks which is the desired effect? The desired effect is to decrease fluid in the lungs and weight loss alone does not ensure that the lungs are clearing. 2. Incorrect: Lowered blood pressure is an expected finding, but treatment of pulmonary edema is the primary goal. 3. Incorrect: Increased urinary output is an expected finding, but treatment of pulmonary edema is the primary goal.

MAOI's that are used as antidepressants - pirates (arrrr) take MAOI's when they're depressed

MAOIs used for depression all have an arrrr sound in the middle Parnate Marplan Nardil

Transmission Based Precautions - Contact

MRS. WEE M- multidrug resistant organism R - respiratory infection S - skin infections* W - wound infection E - enteric infection - C. Diff E - eye infection - conjunctivitis Skin Infections VCHIPS V - varicella zoster C - cutaneous diptheria H - herpes simplex I - impetigo P - pediculosis S - scabies

Hyperactive deep tendon reflexes, vision changes, fatigue and spasticity are all symptoms of

MS

Hyperkalemia

MURDER - muscle weakness, urine (oliguria/anuria), respiratory depression, decreased cardiac contractility, ECG changes, reflexes

Transmission Based Precautions - Airborne

MY = measles CHICKEN = chicken pox/varicella HEZ = herpez zoster/shingles TB or MTV = Airborne Measles TB Varicella - Chicken Pox/Herpes Zoster - Shingles Private room - negative pressure with 6-12 air exchanges/hour Mask, N95 for TB

655. An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue...Medications. Which medication provides the greatest threat to this client? a. Magnesium hydroxide (Maalox). b. Birth control pills c. Cough syrup containing codeine d. Cold medication containing alcohol

Magnesium hydroxide (Maalox).

752. A male client who had a small bowel resection acquired methicillin- resistant Staphylococcus aureus (MRSA) while hospitalized. He was treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention? a- Maintain contact transmission precaution b- Review white blood cell (WBC) count daily c- Instruct visitors to gown and wash hands d- Collect serial stool specimens for culture

Maintain contact transmission precautions. Rationale" The client may have residual postoperative MRSA infection, a resistant and highly contagious healthcare-associated infection (HAI), that requires strict contact precautions (A), as recommend by the Center for Disease Control (CDC).

Which nursing intervention should receive priority after a client has returned from having had eye surgery?

Maintain head of bed at 35°. Maintaining head of bed in an elevated position will help to decrease intraocular pressure. Do not lie the client supine as this will increase intraocular pressure. If the intraocular pressure increases too much, damage to the eye structures, including the retina and optic nerve, with resulting loss of vision, may result.

610. A 16-year-old male is admitted to the pediatric intensive care unit after being involved in a house fire. He has full thickness burns to his lower torso and extremities. Before a dressing change to his legs, which intervention is most important for the nurse to implement? a- Encourage the parents to stay at the bedside b- Use distraction techniques to reduce pain. c- Maintain strict aseptic technique d- Place a drape over the pubic area.

Maintain strict aseptic technique. Rationale: Full thickness burns cause destruction of the epidermis, dermis... minimize post burn colonization of the wound with gram-negative opportunistic organism is necessary to maintain strict aseptic technique is essential during dressing changes.

692. A 59-year-old male client comes to the clinic and reports his concern over a lump that, "just popped up on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is not overlying tissue inflammation. What do these findings suggest? A. Malignancy B. Bacterial infection C. Viral infection D. Lymphangitis

Malignancy Rationale: Rapid enlargement of a lymph node, particularly the subclavian node with no tenderness of inflammation is suggestive of malignancy. Lymphangitis is characterized by pain and inflammation. Infectious processes C and D the involved nodes become warm and tender to touch.

777. An adult client comes to the clinic and reports his concern over a lump that "just popped up on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, non-tender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these finding suggest? A. Bacterial infection B. Lymphangitis C. Malignancy D. Viral infection

Malignancy.

669. What is the nurse's priority goal when providing care for a 2-year-old child experiencing seizure... A. Stop the seizure activity B. Decrease the temperature C. Manage the airway D. Protect the body from injury

Manage the airway.

Head injury medication

Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use filter needle

airborne precautions

Measles, Chicken Pox, and TB; client's need private room, negative airflow w/ 6-12 air exchanges/hr, and N95 usage

Which foods should the nurse teach a client to avoid when prescribed a diet limiting purine rich foods?

Meats: liver, bacon, veal, and venison are high in purine and should be avoided. Seafood: sardines, mussels, codfish, scallops, trout, and haddock are high in purine and should be avoided.

736. A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care? A. Identify local support HIV support groups. B. Assess for symptoms of AIDS dementia. C. Observe for adverse drug reaction. D. Monitor for secondary infections.

Monitor for secondary infections.

612. A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply) A. Monitor heart, lung, and kidney function. B. Notify healthcare provider of serum amylase and lipase levels. C. Review client's abdominal ultrasound findings. D. Position client on abdomen to provide organ stability E. Encourage an increased intake of clear oral fluids

Monitor heart, lung, and kidney function. Notify healthcare provider of serum amylase and lipase levels. Review client's abdominal ultrasound findings.

605. After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement? a- Send stool specimen to the lab b- Measure abdominal girth c- Encourage increased fiber in diet. d- Monitor mental status.

Monitor mental status.

786. A male client with an antisocial personality disorder is admitted to an in-patient mental health unit for multiple substance dependency. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior this client's history is most likely to include which finding? A. Phobias and panic attacks when confronted by authority figures. B. Suicidal ideations and multiple attempts/ C. Multiple convictions for misdemeanors and class B felonies. D. Delusions of grandiosity and persecution

Multiple convictions for misdemeanors and class B felonies.

What symptoms would the nurse anticipate in a client being admitted to the hospital with a calcium level of 3.2 mg/dL (0.80 mmol/L)?

Muscle rigidity and cramping. Positive Chvostek's sign. Seizures Laryngospasms Normal serum calcium is 8.7 - 10.3 mg/dL (2.18 - 2.58 mmol/L). The client with a calcium level of 3.2 mg/dL (0.80 mmol/L) is hypocalcemic. With hypocalcemia, the muscle tone is rigid and tight. Therefore, the client may report muscle cramping. A hallmark sign of hypocalcemia is a positive Chvostek's sign, which is a twitching of facial muscles following tapping in the area of the cheekbone, indicative of hyperirritability. The client may be at risk of having seizures due to the neuromuscular irritability. Prolonged contraction of the respiratory and laryngeal muscles causes laryngospasm and stridor and may result in cyanosis

Give neostigmine to clients with

Myesthenia Gravis about 45 min. before eating, so it will help with chewing and swallowing.

Demerol for pancreatitis

NOT morphine sulfate

Cardiac cath

NPO 8-12 hours. empty bladder, pulses, tell pt may feel heat, palpitations or desire to cough with injection of dye. Post: V.S.--keep leg straight. bedrest for 6-8 hr

646. A client with urticaria due to an environmental allergies is taking diphenhydramine... Which complaint should the nurse identify to the client as a side effect of the OTC medication? A. Nausea and indigestion. B. Hypersalivation C. Eyelid and facial twitching D. Increased appetite

Nausea and indigestion.

Hemoglobin

Neonates 18-27 3 months 10.6-16.5 3 years 9.4-15.5 10 years 10.7-15.5

698. When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client's GCS score has been 14. What does this GCS finding indicate about the client? a- Neurologically stable without indications of an increased ICP b- Insertion of ICP monitoring device is necessary c- Rehabilitative prognosis is an expected full recovery d- Risk for irreversible cerebral damage related to increased ICP

Neurologically stable without indications of an increased ICP. Rationale: The GCs is valid and reliable neurologic assessment scale that is used to identify early changes in ICP, determine severity of TBI direct treatment, and provide prognostic information. A repeated score of 14 indicates the client is not awake, but not experiencing increase ICP (A) ICP monitoring devices provide a precise quantitative pressure reading, but insertion of such a device B is not indicated at this time. Although preliminary assessment date is used to predict survival of TBI, expectation of a full recovery C is a premature assumption. The GCS is used to guide therapy, but it does not measure outcomes, such as function or cognitive ability (D)

If you gave a toddler a choice about taking medicine and he says no, you should leave the room and come back in five minutes, because to a toddler it is another episode.

Next time, don't ask.

To remember how to draw up INSULIN think:

Nicole Richie RN Air into NPH, then air into regular, draw up regular then draw up NPH

pemphigus vulgaris

Nikolsky's sign (separation of epidermis caused by rubbing of the skin)

What traction is used in a school-age kid with a femur or tibial fracture with extensive skin damage?

Ninety, ninety. The name refers to the angles of the joints. A pin is placed in the distal part of the broken bone, and the lower extremity is in a boot cast. A kid's hinder should clear the bed when in Bryant's traction (also used for femurs and congenital hip for young kids)

Angina (low oxygen to heart tissues):

No DEAD heart tissue. MI = dead heart tissue present

When o2 deprived, as with a PE, the body compensates by causing hyperventilation (resp alkalosis). Should the patient breathe into a paper bag?

No. If the PaO2 is well below 80 they need oxygen. Look at all your ABG values. As soon as you see the words PE, you should think oxygen first.

785. An adult male with schizophrenia who has been noncompliant in taking oral antipsychotic medications refuses a prescribed IM medication. Which action should the nurse take? A. Notify the healthcare provider of the client's refusal B. Administer an oral PRN medication for agitation C. Ask for staff assistance with administering the injection D. explain that oral medications will no longer be required

Notify the healthcare provider of the client's refusal.

713. A client with hyperthyroidism who has not been responsive to medications is admitted for evaluation. What action should the nurse implement? (Click on each chart tab for additional information. Please scroll to the bottom right corner of each tab to view all information contained in the client's medical record.) a- Give acetaminophen 650 mg PO b- Obtain a STAT 12 lead electrocardiogram c- Encourage the client to rest d- Notify the healthcare provider

Notify the healthcare provider. a- Notify the healthcare provider Rationale: The client TSH assay reveals a decreased serum TSH and elevated free thyroxine (T4) and triiodothyronine (T3) which are indicative of a hyperthyroid state. An increase in 1 to 2 degree of temperature within a 2-hour period is indicative of a thyroid storm, which is a life-threatening medical emergency, so the health care provider should be notified immediately (D). The client temperature is not elevated enough to warrant using acetaminophen (A) as an antipyretic. Although an electrocardiogram may be needed, (B) ignores the important warning signs of a thyroid storm. C is not indicated at this time.

A nurse who has never had varicella has been exposed to a client diagnosed with herpes zoster. What actions should the nurse take?

Notify the person responsible for infection control to get post-exposure treatment initiated within a timely manner. For persons who are susceptible, the varicella-zoster immune globulin should be given within 96 hours of exposure. The infection of herpes zoster is contagious until the crusts have dried and fallen off the skin.

For HIV kids avoid

OPV and Varicella vaccinations (live), but give Pneumococcal and influenza. MMR is avoided only if the kid is severely immunocompromised. Parents should wear gloves for care, not kiss kids on the mouth, and not share eating utensils.

796. A preschooler with constipation needs to increase fiber intake. Which snack suggestion should the nurse provide? A. soft pretzels B. fruit-flavored yogurt C. oatmeal cookies D. low fat cheese sticks

Oatmeal cookies.

661. A client is admitted for type 2 diabetes mellitus (DM) and chronic Kidney disease (CKD)...which breakfast selection by the client indicates effective learning? a. Scrambled eggs, bacon, one slice of whole wheat toast with butter and jam. b. Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces' coffee. c. Banana pancake with maple syrup, sausage links, half grapefruit, and low -fat milk d. Orange juice, yogurt with berries, cold cereal with milk, bran muffin with margarine.

Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces coffee. Rationale: The diet for those with type 2 DM limit simplex sugars while allowing moderate complex... and increased dietary fiber. The diet for those with CKD limits protein, water, sodium and... provides dietary fiber in the oatmeal, without simple carbohydrates, and fresh strawberries.

647. In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, The nurse assesses that the client in lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minutes. What assessment should the nurse perform next? A. Note the appearance and patency of the client's peripheral IV site. B. Palpate the volume of the client's right radial pulse C. Auscultate the client's breath sounds bilaterally. D. Observe the amount and dose of morphine in the PCA pump syringe.

Observe the amount and dose of morphine in the PCA pump syringe.

662. A client with a postoperative wound that eviscerated yesterday has an elevated temperature...most important for the nurse to implement? a. Initiate contact isolation b. Obtain a wound swab for culture and sensitivity c. Assess temperature q4 hours d. Use alcohol-based solutions for hand hygiene.

Obtain a wound swab for culture and sensitivity. Rationale: Exposure viscera increases the client's risk for wound infection related to a variety ... (HAI) such as MRSA, which requires selective treatment. Nurse should swab the wound and send the specimen to the lab to determine the primary infectious organism, so the healthcare provider can prescribe a medication.

788. A client who has a suspected brain tumor is schedules for a computed (CT) scan. When preparing the client for the client for the CT scan, which intervention should the nurse implement? A. Determine if the client has had a knee or hip replacement B. Immobilize the client's neck before moving onto stretcher C. Give an antiemetic to control nausea D. Obtain the client's food allergy history

Obtain the client's food allergy history.

pathological jaundice

Occurs before 24 hours and lasts 7 days.

690. A-12-year old boy has a body mass index (BMI) of 28, a systolic pressure and a glycosylated hemoglobin (HBA1C) of 7.8%. Which selection indicated that his mother understands the management of his diet?

One whole-wheat bagel with cream cheese, two strips of bacon, six ounces of orange juice. Rationale: Diet - Foods high in carbohydrates and fiber, low fat. No honey, no ham, no high sugar, no frost food, avoid all whole wheat products.

722. The nurse enters a client's room and observe the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first? a- Provide the gloves for the UAP to apply b- Offer to help reposition the client c- Instruct the UAP to raise the bed level d- Place the side rails in an up position

Place the side rails in an up position. Rationale: To maintain the client safety, it is most important for the nurse to place the side rails in a up position to reduce the risk of falls and injury. A, B and C can then be completed.

790. The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats / minute. Which action should the nurse take? A. Continue the insertion since this is a typical response B. pause and monitor for a continues drop of the heart rate C. Insert the feeding tube into the infant's nasal passage D. Postpone the feeding until the infant's vital signs and stable

Postpone the feeding until the infant's vital signs and stable.

When giving Kayexalate we need to worry about dehydration because

Potassium has inverse relationship with Sodium

Extra insulin may be needed for a patient taking

Prednisone (remember, steroids cause increased glucose).

preload vs afterload

Preload affects amount of blood that goes to the R ventricle. Afterload is the resistance the blood has to overcome when leaving the heart.

The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat through a non-tunneled central venous catheter lumen with no other medication or fluid infusing. In what order should the nurse administer this prescription? Cleanse access port Connect 10 mL normal saline to access port Gently aspirate for blood Flush saline using push-pause method Administer phenytoin Flush with normal saline, then with heparin

Proper administration of medication through a non-tunneled central venous catheter: First, cleanse the access port. Failure to cleanse the port first would increase the risk of infection from contamination when the port is accessed. Second, connect 10 mL normal saline to access port. This 10 mL syringe will be connected to first check patency and then for flushing prior to medication administration. At least 10 mL of normal saline is used to flush central lines. Third, gently aspirate for blood. Fourth, flush saline using push-pause method. This method is utilized to help clear the catheter of blood or drugs that could potentially adhere to the internal surface of the central line catheter. This creation of turbulent flow from pausing then pushing causes swirling of the fluid and theoretically removes blood and medications from the walls of the catheter, which reduces the risk of occlusion in the catheter. Fifth, administer phenytoin. Sixth, flush with normal saline, then with heparin. Standard flushing solutions used most frequently for central venous access devices include normal saline and/or heparinized sodium chloride. Low dose heparin flushes are generally used to fill the lumen of the central line between use in order to prevent thrombus formation and maintain patency of the catheter for a longer period of time.

A clinic nurse is educating a client diagnosed with Bell's Palsy. What is the most important educational point the nurse must emphasize to the client?

Proper methods of closing eyelids and eye patching. Even though all are educational points that need to be provided to the client, this is the most important educational point to make. Keratitis, or the inflammation of the cornea, is one of the most dangerous complications for a client with Bell's palsy. As a precautionary measure, the nurse must ensure that the cornea is protected even if the eyelids will not close.

A client has been on the mental health unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do?

Protocols on the unit must be followed when someone is requesting to leave AMA. The first step is to call the primary healthcare provider about the client's desire to leave AMA. wrong: 2. Make arrangements for a commitment hearing, as soon as possible. 3. Tell the client the primary healthcare provider must discharge the client prior to leaving. 4. Call the primary healthcare provider and request a discharge order. 2. Incorrect: The client is not suicidal; however, the primary healthcare provider needs input into their decision to leave AMA. It is not appropriate to prepare for a commitment hearing. 3. Incorrect: If the client is not a threat or potential threat to self or others, the client may leave. The nurse may discuss the decision to leave; however, this statement is not accurate. 4. Incorrect: The nurse should call the primary healthcare provider and discuss the situation. The primary healthcare provider should have input into this decision.

611. While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition? A. Tinea corporis B. Herpes zoster C. Psoriasis D. Drug reaction

Psoriasis.

714. While taking vital signs, a critically ill male client grabs the nurse's hand and ask the nurse not to leave. What action is best for the nurse to take? a- Allow the client to hold the nurse's hand until the vital signs can be completed b- Reassure the client that the nurse will return after all vital signs are taken c- Tell the client that he must release the nurse's hand. d- Pull up a chair and sit beside the client's bed

Pull up a chair and sit beside the client's bed. Rationale: The critically ill client is most likely pleading for the presence of another person. D is the action that a compassionate nurse would implement. A, B, C do not demonstrate the compassion of D

The nurse is performing CPR on an adult client with facial and neck trauma. Following the administration of rescue breaths, where is the best location for the nurse to assess for a pulse in this client?

Pulses that are best palpated are large and close to the trunk of the body. The femoral artery is large and at the trunk (proximal) of the body.

620. The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin shock...medication? a- Dilute the Dextrose in one liter of 0.9% Normal Saline solution. b- Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml. c- Push the undiluted Dextrose slowly through the currently infusion IV. Ask the pharmacist to add the Dextrose to a TPN solution

Push the undiluted Dextrose slowly through the currently infusion IV. Rationale: To reverse life-threatening insulin shock, the nurse should administer the 50% Dextrose infusing IV.

Cor Pulmonale (s/s: fluid overload) is:

RIGHT sided heart failure caused by PULMONARY DISEASE; may also occur with BRONCHITIS or EMPHYSEMA.

When drawing up regular insulin & NPH together, remember:

RN (regular comes before NPH)

Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching of proper diet was understood? You answered this question Correctly 1. Pancakes with whipped butter, syrup, bacon, apple juice 2. Scrambled eggs, sliced turkey, biscuit, whole milk 3. Grits, fresh fruit, toast, coffee 4. Bagel with jelly, hash browns, tea

Rationale 2. Correct: Client needs low sodium and increased proteins. 1. Incorrect: This selection is too high in sodium and fats. 3. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine. 4. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine.

The nurse receives new healthcare provider prescriptions on a client diagnosed with Addison's disease. Which prescriptions should the nurse recognize as being inappropriately written and requiring clarification from the prescriber? You answered this question Incorrectly 1. Weigh QD 2. IV of normal saline at 125 mL/hr 3. MRI of pituitary gland 4. Fludrocortisone acetate 0.1 mg by mouth T.I.W. 5. Dehydroepiandrosterone DHEA sulfate 5 mg by mouth every other day

RationaleStrategies 1. & 4. Correct: Use "daily" or "every day". QD is an unapproved abbreviation. T.I.W. stands for three times a week; however, it is an unapproved abbreviation. Use "three times a week". 2. Incorrect: This is a correct action and is written properly. 3. Incorrect: The primary healthcare provider may suggest an MRI scan of the pituitary gland if testing indicates the client might have secondary adrenal insufficiency. This is an approved abbreviation. 5. Incorrect: This is written correctly and may be given to women to treat androgen deficiency.

The nurse is caring for a client following spinal surgery. The client is placed on methylprednisolone. What additional drug therapy would the nurse expect to be prescribed with methylprednisolone? You answered this question Correctly 1. Pantoprazole 2. Phenytoin 3. Imipramine HCI 4. Aminocaproic acid

RationaleStrategies 1. Correct: A potential side effect of methylprednisolone is a peptic ulcer. The primary healthcare provider will prescribe a proton pump inhibitor or H2 blocker to prevent this side effect. 2. Incorrect: Phenytoin is an anticonvulsant. Seizures are not a side effect of methylprednisolone. 3. Incorrect: Imipramine HCI is an antidepressant which is not routinely given with methylprednisolone (Although mood changes can occur with steroid administration, anti-depressants are not routinely given). 4. Incorrect: Aminocaproic acid is given when clients are bleeding. Bleeding is not a side effect of methylprednisolone.

A nurse is preparing a lecture about suicide. Which target audience would be most appropriate? You answered this question Correctly 1. High school teachers 2. Girl Scout leaders 3. Support group of divorced parents 4. Hispanic immigrant farm workers

RationaleStrategies 1. Correct: Among those who commit suicide, young men between the ages of 15-24 are more likely to commit suicide than young girls and women. The best line of defense is to teach about the warning signs of suicide to high school teachers, students, and parents of teens and young adults, particularly male. 2. Incorrect: Although teenage girls may attempt suicide, they are less likely than males to use a lethal method. Additionally, participation in groups such as the scouts will provide support for girls. 3. Incorrect: Joining a support group will help eliminate stress of being a single parent. Young males are more likely to attempt suicide by lethal means. 4. Incorrect: Hispanics have a lower suicide rate than Caucasians.

A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most important nursing measure to include in the nursing care plan for this client? You answered this question Correctly 1. Observation and support of ventilation 2. Insertion of indwelling urinary catheter 3. Nasogastric suctioning 4. Frequent assessments of level of consciousness

RationaleStrategies 1. Correct: Guillain-Barre syndrome is an acquired inflammatory disease that results in demyelinization of the peripheral nerves. It is usually ascending in nature and can lead to respiratory paresis or paralysis. 2. Incorrect: Insertion of an indwelling urinary catheter may in fact be necessary but does not prioritize higher than support of ventilation. 3. Incorrect: Nasogastric suctioning is not a need identified with Guillain-Barre syndrome. Guillain-Barre does not affect the LOC. 4. Incorrect: The client's cognitive function remains intact, and there is no data in the stem of the question that indicates otherwise; therefore, ventilation is the priority.

A client has been on the mental health unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do? You answered this question Correctly 1. Inform the primary healthcare provider that the client wishes to leave. 2. Make arrangements for a commitment hearing, as soon as possible. 3. Tell the client the primary healthcare provider must discharge the client prior to leaving. 4. Call the primary healthcare provider and request a discharge order.

RationaleStrategies 1. Correct: Protocols on the unit must be followed when someone is requesting to leave AMA. The first step is to call the primary healthcare provider about the client's desire to leave AMA. 2. Incorrect: The client is not suicidal; however, the primary healthcare provider needs input into their decision to leave AMA. It is not appropriate to prepare for a commitment hearing. 3. Incorrect: If the client is not a threat or potential threat to self or others, the client may leave. The nurse may discuss the decision to leave; however, this statement is not accurate. 4. Incorrect: The nurse should call the primary healthcare provider and discuss the situation. The primary healthcare provider should have input into this decision.

A 72 year old client admitted with a diagnosis of bleeding ulcers has been prescribed ranitidine 50 mg IVPB every 8 hours and omeprazole 10 mg po every morning. Based on this data what intervention should the nurse take first?​ Exhibit You answered this question Incorrectly 1. Stop the infusion of ranitidine. 2. Send the client for a CT scan of the head. 3. Provide oxygen at 2L/NC. 4. Notify the primary healthcare provider. exhibit: 0900 Client alert and oriented. Denies abdominal pain, discomfort, or nausea and vomiting. Active bowel sounds in all quadrants. Abdomen soft, non-tender to palpation. Ranitidine 50 mg IVPB hung to IV line of NS at 100 mL per hour. No redness or edema noted at IV site. 0930 Client confused to place and time. Oxygen sat 95%. Lungs clear bilaterally. Denies pain. BP 118/78, HR 84/min, RR - 20/min, Temp. - 97.8 F (36.55 C).

RationaleStrategies 1. Correct: Ranitidine can cause confusion in the elderly as well as agitation. Stop the infusion, then notify the primary healthcare provider. 2. Incorrect: Confusion is a side effect of ranitidine, so the medication should be stopped and then the healthcare provider notified. 3. Incorrect: The oxygen saturation is not low at 95%. Providing oxygen will not correct the confusion. 4. Incorrect: The primary healthcare provider should be notified after stopping the ranitidine.

A staff nurse decides to go to lunch with a friend instead of meeting with a study group for a certification exam. The staff nurse informs the clinical specialist, "Studying more will not do any good anyway." What defense mechanism does the clinical specialist understand that the staff nurse is exhibiting? You answered this question Correctly 1. Rationalization 2. Denial 3. Regression 4. Reaction formation

RationaleStrategies 1. Correct: Rationalization is the mind's way of justifying behavior by offering an explanation other than a truthful response. This is often used to avoid embarrassment. 2. Incorrect: Denial is the unconscious refusal to acknowledge painful realities, feelings, or experiences. It offers a temporary escape from an unpleasant event. 3. Incorrect: Regression is a reversion to immature patterns of behavior. 4. Incorrect: Reaction formation is behaving in a way that is exactly opposite of one's true feelings.

The client had a thoracentesis with removal of 2500 mL of fluid from the chest cavity. What is the priority nursing assessment for this client? You answered this question Correctly 1. Vital signs 2. Pain 3. O2 sat 4. Signs of infection

RationaleStrategies 1. Correct: That's right. Should be watching the vital signs for shock, tachycardia, and hypotension because a lot of fluid has just been removed from the body. 2. Incorrect: Not priority; remember, pain never killed anyone. 3. Incorrect: We will watch but isn't highest priority. 4. Incorrect: Monitoring vital signs would show signs of infection.

The nurse is searching for information about the nursing care of a client receiving an experimental drug for the treatment of obesity. Which database is most likely to address this issue? You answered this question Correctly 1. Cumulative Index for Nursing and Allied Health Literature (CINAHL) 2. Cochrane Library 3. Health and Wellness Resource Center 4. MEDLINE

RationaleStrategies 1. Correct: The Cumulative Index for Nursing and Allied Health Literature (CINAHL) is a source for reviewing nursing and allied health information. It is also located in other healthcare data bases. 2. Incorrect: Cochrane Library includes evidence based medicine databases. 3. Incorrect: The Health and Wellness Resource Center provides access to a variety of journal articles, magazines, and pamphlets. 4. Incorrect: MEDLINE is one of the major sources for biomedical information.

Which nursing task would be appropriate to delegate to an LPN/VN? You answered this question Incorrectly 1. Obtain a wound culture from a client. 2. Administer regular insulin IV to a client in diabetic ketoacidosis. 3. Monitor a client's closed drainage unit (CDU) for tidaling. 4. Assess a client for tactile fremitus.

RationaleStrategies 1. Correct: The LPN/VN has the knowledge and skill to obtain a wound culture. This is within the scope of practice for the LPN/VN. 2. Incorrect: The LPN/VN cannot administer IV medications to an unstable client. This client needs the RN for close monitoring. 3. Incorrect: The LPN/VN can monitor a chest tube and closed drainage unit, however we don't know whether the client is unstable or not. The LPN can definitely obtain a wound culture. 4. Incorrect: Assessment is the task of an RN. LPN/VN's can collect data, observe, and monitor the client.

A client is reporting pain rated an 8 out of 10 on the numeric pain scale. The nurse administers an oral pain medication to the client and starts a CD of the client's favorite relaxing music. Fifteen minutes later, the client rates the pain as 2 out of 10 on the numeric pain scale. What type of nonpharmacologic pain relief intervention has the nurse used? You answered this question Correctly 1. Distraction 2. Biofeedback 3. Progressive relaxation 4. Cutaneous stimulation

RationaleStrategies 1. Correct: The nurse uses distraction in the form of music while the oral analgesic takes effect. 2. Incorrect: Biofeedback is a behavioral therapy that trains individuals to take control of the physiological responses to stressors. 3. Incorrect: Progressive relaxation uses a combination of breathing exercises and muscle group contractions and relaxation. 4. Incorrect: Cutaneous stimulation uses stimulation of the skin through heat, cold, or even electrical nerve stimulation to decrease or eliminate pain.

Which task should the nurse perform first? You answered this question Correctly 1. Suctioning the tracheostomy. 2. Changing a colostomy bag that is leaking. 3. Performing an admission assessment on a client. 4. Administering pain medication to a postoperative client.

RationaleStrategies 1. Correct: The tracheostomy tube must be suctioned to keep the client's airway open. Suctioning the tracheostomy should take priority. Remember, airway first. 2. Incorrect: The client may be uncomfortable from the colostomy bag leaking. This task can be delegated. The suctioning of the client does not have priority over airway. 3. Incorrect: Important, but not priority over airway. There is no indication from the question that the new client is in distress. The priority intervention is to maintain the airway. 4. Incorrect: Important, but it does not take priority over airway.

The nurse is preparing to administer iron dextran IM. Which injection site would be best for administration? You answered this question Incorrectly 1. Ventrogluteal site 2. Vastus lateralis site 3. Rectus Femoris site 4. Deltoid site

RationaleStrategies 1. Correct: This site would be used for Z track IM injections. Iron preparations are administered by the Z track technique, preferably in a large, deep muscle such as the ventrogluteal muscle. 2. Incorrect: The vastus lateralis site could be used in adults with enough muscle mass, but ventrogluteal is preferred site. 3. Incorrect: The rectus femoris site can be used in adults when other sites are no longer accessible. It is not the preferred site. 4. Incorrect: The deltoid is a small muscle that is not well developed in many clients. It is not a recommended site for Z track medication administration.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which clients should the charge nurse assign to the medical-surgical nurse? You answered this question Correctly 1. Total abdominal hysterectomy 2. Breast reduction 3. Vaginal delivery with fetal demise 4. 32 week gestation with lymphoma 5. Post-partal with HELLP syndrome

RationaleStrategies 1., & 2. Correct: Though the clients are females, their postoperative care has similarities to the standard postoperative clients. 3. Incorrect: This client needs specialized care. This postpartum client had a vaginal delivery. A nurse who has experience caring for a client who delivered a stillborn should be assigned to this client. 4. Incorrect: This client needs specialized care. The client is at 32 weeks gestation. A nurse with obstetrical experience, should be assigned to this client. 5. Incorrect: No, the monitoring is too specific for the medical-surgical nurse. Hemolysis Elevated Liver enzymes Low Platelet count (HELLP) syndrome is a form of preeclampsia with severe liver damage. The medical-surgical nurse should not be assigned to this client.

What risk factors should the nurse include when conducting a class about type 2 diabetes mellitus? You answered this question Correctly 1. Fat distribution greater in abdomen than in hips. 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. 5. Polycystic ovary syndrome.

RationaleStrategies 1., & 5. Correct: If the body stores fat primarily in the abdomen, risk of type 2 diabetes is greater than if body stores fat elsewhere, such as hips and thighs. Women with polycystic ovary syndrome have increased risk of diabetes. 2. Incorrect: Being overweight is a primary risk factor for type 2 diabetes. The more fatty tissue, the more resistant cells become to insulin. 3. Incorrect: A type 1 diabetic will remain a type 1 diabetic. 4. Incorrect: African Americans, Hispanics, American Indians, and Asian Americans are more likely to develop type 2 diabetes than Caucasians are.

A nurse who has never had varicella has been exposed to a client diagnosed with herpes zoster. What actions should the nurse take? You answered this question Incorrectly 1. Notify the infection control nurse. 2. Continue to care for client as varicella and herpes zoster are not related. 3. Go to the lab to have a Tzanck smear performed. 4. Obtain herpes zoster vaccine for protection from this exposure. 5. Receive the varicella-zoster immune globulin within 96 hours of exposure.

RationaleStrategies 1., & 5. Correct: Notify the person responsible for infection control to get post-exposure treatment initiated within a timely manner. For persons who are susceptible, the varicella-zoster immune globulin should be given within 96 hours of exposure. The infection of herpes zoster is contagious until the crusts have dried and fallen off the skin. 2. Incorrect: Varicella is chickenpox and herpes zoster is shingles. Both are closely related. Exposure to herpes zoster by someone who has not had varicella places the person at risk for developing herpes zoster. 3. Incorrect: A Tzanck test consists of examining tissue from the lower surface of a lesion in a vesicular condition to determine cell type. The Tzanck test is not associated with immunity from the varicella-zoster virus. 4. Incorrect: The vaccine will not prevent the nurse from developing shingles from this exposure. The nurse needs immune globulin for immediate protection.

The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client? You answered this question Correctly 1. Document the client's statement in the client's own words. 2. Provide information on advance directives to the client. 3. Inform the client that personnel are available to assist with completing an advance directive. 4. Avoid inquiring about a client's advance directive as this could cause the client anxiety and concern. 5. Ask the daughter if she agrees with her mother's decision.

RationaleStrategies 1., 2. & 3. Correct: The nurse should document the client's statement in the client's own words. The nurse should provide the client with information on advance directives and assurance that there are hospital personnel to assist with completing the advance directive. 4. Incorrect: The nurse who avoids inquiry about a client's advance directive is not serving the client's best interests. The nurse should explain to the client that the law requires all clients be asked about the existence of an advance directive at the time of hospital admission. Preparing an advance directive ensures that the client's wishes will be followed in the event that the client is unable to make healthcare decisions. 5. Incorrect: Providing information is the appropriate nursing action, not questioning the daughter.

What should a community health nurse include when planning a presentation on prevention and early detection of colon cancer? You answered this question Incorrectly 1. Maintain a diet high in fruits, vegetables, and whole grains. 2. Exercise regularly. 3. Regular screening should begin at age 30. 4. Yearly guaiac-based fecal occult blood test. 5. Flexible esophagogastroduodenoscopy every 5 years.

RationaleStrategies 1., 2., & 4. Correct: A diet high in vegetables, fruits, and whole grains has been linked with a decreased risk of colorectal cancer; whereas, a diet high in red meats, processed meats, and cooking meats at very high temperature (frying, broiling or grilling) creates chemicals that may increase the risk for colorectal cancer. There is a greater risk of developing colorectal cancer in individuals who live a sedentary life style. The guaiac-based fecal occult blood test detects blood in the stool through a chemical reaction. This test is done yearly. 3. Incorrect: If there are no identified risk factors (other than age), regular screening should begin at age 50. 5. Incorrect: Flexible sigmoidoscopy looks at the rectum and colon to detect polyps and colon cancer. For people who have none of the risks described earlier, digital rectal examination and testing of the stool for hidden blood are recommended annually beginning at age 40. Flexible sigmoidoscopy is recommended every 5 years at age 50 or older. A double contrast barium enema every 5 to 10 years and colonoscopy every 10 years are acceptable alternatives.

Which symptoms would the nurse be likely to observe in the client who overdosed on diazepam? You answered this question Incorrectly 1. Bradypnea 2. Bradycardia 3. Hyperthermia 4. Somnolence 5. Hyperreflexia 6. Psychosis

RationaleStrategies 1., 2., & 4. Correct: Benzodiazepines are central nervous system (CNS) depressants. Diazepam is a benzodiazepine. They will slow respirations (bradypnea) and the heart rate (bradycardia). Somnolence (extreme, prolonged drowsiness) would be seen. 3. Incorrect: Benzodiazepines would not cause hyperthermia. 5. Incorrect: Benzodiazepines would diminish reflexes since it is a CNS depressant. 6. Incorrect: Psychosis is not a common symptom with CNS depression.

What discharge instructions should the nurse provide to the client post abdominal hysterectomy? You answered this question Incorrectly 1. Ambulate at least 3-4 times per day. 2. Notify the primary healthcare provider if there is a yellow discharge from the surgical wound. 3. Swimming is allowed if staples were used to close the skin. 4. Press a pillow over incision when coughing to ease discomfort. 5. Apply moist heat to surgical site the first couple of days for pain relief.

RationaleStrategies 1., 2., & 4. Correct: The client should get up and move to prevent complications such as deep vein thrombosis (DVT), pneumonia, constipation, etc. The healthcare provider should be notified if the surgical wound is bleeding, red and warm to touch or has a thick, yellow, or green drainage. Pressing a pillow over incision when coughing or sneezing will ease discomfort and protect the incision. 3. Incorrect: Do not go swimming or soak in a bathtub or hot tub until the primary healthcare provider says it is ok. You worry about infection. 5. Incorrect: In the first couple of days, an ice pack may help relieve some pain at the site of surgery. Remember NCLEX wants you to think safety first when it comes to the use of heat.

The home health nurse is assessing the home environment for possible irritants that could increase/precipitate symptoms of respiratory problems. Which assessment questions would be important to determine level of risk? You answered this question Incorrectly 1. What type of heat do you use in the home? 2. Does anyone in the home have hobbies that involve sanding of wood or use of chemicals? 3. Is there anyone in the home who smokes? 4. Do you routinely use aerosol sprays for personal care or cleaning? 5. Is your water supply treated by a municipal agency?

RationaleStrategies 1., 2., 3. & 4. Correct: Presence of wood smoke could increase respiratory problems. Poorly vented gas heaters could increase carbon monoxide in the environment. Use of solvents or other agents that produce irritating fumes could increase risk. The particles from the sanding could irritate the respiratory tract as well. Second-hand smoke is irritating to the respiratory tract. Aerosols could trigger respiratory problems. 5. Incorrect: Water safety would not necessarily increase respiratory risk.

The nurse educator is teaching a group of nursing students about client advocacy. What should the educator tell the students are the consequences of failure to act as a client advocate? You answered this question Incorrectly 1. Life-threatening complications for the client. 2. Legal action against the nurse and/or healthcare facility. 3. Suspension or loss of license to practice nursing. 4. Suspension or loss of license to practice medicine. 5. Loss of client autonomy and right to make decisions.

RationaleStrategies 1., 2., 3. & 5. Correct: The role of client advocate is a nurse's responsibility. Failure to act as a client advocate could result in a range of complications for the client, including life-threatening or life-ending complications. Failure to act as client advocate exposes the nurse to liability, potential legal action against the nurse and/or healthcare facility, and potential suspension or loss of license to practice nursing. The client advocate protects client autonomy and right to make decisions. 4. Incorrect: The nurse does not have a license to practice medicine. The nurse cannot work outside of their scope of practice. This action may result in the possible suspension or loss of license to practice nursing.

Which prescriptions are appropriate for the nursery nurse to initiate on a newborn prior to discharge home? You answered this question Correctly 1. Hepatitis B vaccine 2. Erythromycin Ointment 3. Vitamin K 4. Lanolin 5. PKU Screening

RationaleStrategies 1., 2., 3. & 5. Correct: This vaccine is recommended at birth to decrease the incidence of hepatits B virus. Mandatory prophylactic agent is applied in newborn's eyes as precaution against ophthalmia neonatorium. Vitamin K (Aquamephyton) routine injection to prevent hemorrhagic disease of newborn. PKU-Screening for phenylketonuria is not reliable until the newborn has ingested an ample amount of the amino acid, phenylalanine, a constituent of both human and cow's milk. Nurse must document initial ingestion of milk and perform test at least 24 hours after that time. This test is thus done just prior to discharge. 4. Incorrect: Lanolin is not something that is applied on newborns when admitted to the nursery.​ Lanolin is an emollient for the skin. The normal newborn does not need an emollient applied to the skin.

A client diagnosed with mania and hypertension is hospitalized due to confusion and polyuria. Based on current data, what interventions should the nurse implement? Exhibit You answered this question Incorrectly 1. Hold the lithium carbonate dose. 2. Notify primary healthcare provider of lithium level. 3. Connect client to heart monitor. 4. Administer sodium polystyrene for hyperkalemia. 5. Pad the siderails of the client's bed. exhibit: Ataxia and mild hand tremors noted. BP 120/74, Respirations 18, Heart rate 92.

RationaleStrategies 1., 2., 3., & 5. Correct: Symptoms of lithium toxicity begin to appear at blood levels greater than 1.5 mEq/L. Additionally, concurrent administration of lithium and diuretics such as furosemide increase the chance of toxicity. At serum levels of 1.5-2.0 mEq/L: blurred vision, ataxia, tinnitus, persistent nausea and vomiting, severe diarrhea. At serum levels of 2.0-3.5: excessive output of dilute urine, increasing tremors, muscular irritability, psychomotor retardation, mental confusion, giddiness. At serum levels above 3.5: impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmias, myocardial infarction, cardiovascular collapse. Arrhythmias and seizures can occur with toxicity. So the lithium dose should be held, and the healthcare provider notified. The client is at risk for arrhythmias, so connect to a heart monitor. The client is also at risk for seizures, so pad the side rails. 4. Incorrect: The potassium level is normal, so there is no need to treat hyperkalemia.

A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who will need assistive devices upon discharge. Which devices should the case manager include for this client? You answered this question Correctly 1. Dinner plate food guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip eating utensils 6. Button closures on clothes

RationaleStrategies 1., 2., 3., 4., & 5. Correct: The goal is to promote self-care by the client as much as possible. The case manager should evaluate the need for assistive devices to help with eating, bathing, dressing, and ambulating. The dinner plate food guard will prevent food from being pushed off the plate. The transfer belt will provide safety for the client to get into a chair or back in bed. A raised toilet seat makes it easier for the client to sit on the toilet without falling. The long-handled shoe horn allows the client to put on shoes without assistance. Wide grip utensils accommodate a weak grip. 6. Incorrect: It is hard for someone with hemiplegia to use buttons. Velcro fasteners are best.

What should the nurse document after a client has died? You answered this question Incorrectly 1. Time of death 2. Who pronounced the death 3. Disposition of personal articles 4. Destination of body 5. Primary healthcare provider's prescriptions 6. Time body left facility

RationaleStrategies 1., 2., 3., 4., & 6. Correct: All of these should be documented. Also document consideration of and preparation for organ donation; family notified and decisions made; location of identification tags. 5. Incorrect: The primary healthcare provider's prescriptions do not need to be documented after a client dies.

Which assessment findings would be of concern to the nurse who is caring for a client who has an arterial line to the radial artery? You answered this question Incorrectly 1. Capillary refill: Left hand-2 seconds; Right hand- 4 seconds. 2. Blue tinged color to finger tips of right hand. 3. Warm skin to right and left hand. 4. Left radial pulse-88/min; Right radial pulse-82/min 5. Blanching to right hand.

RationaleStrategies 1., 2., 4., & 5. Correct: These are all signs of poor circulation to the right hand. The arterial line could be occluding circulation and needs to be removed. 3. Incorrect: This is a good sign. We would worry with cool skin/extremity.

A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis. What interventions should the nurse initiate? You answered this question Correctly 1. Wear an N95 respirator when caring for client. 2. Restrict fluid intake to 500 mL per day. 3. Position client in semi-Fowler's position. 4. Place client in a negative pressure airflow room. 5. Do not allow visitors for 48 hours.

RationaleStrategies 1., 3. & 4. Correct: The nurse should suspect that the client is suffering from tuberculosis. Early pulmonary TB is asymptomatic. When the bacterial load increases, nonspecific symptoms of fatigue, weight loss, afternoon fevers, and night sweats may set in. As disease advances, cough, sputum production, and hemoptysis may appear. This client has the classic symptoms of TB and should be placed on airborne precautions. N95 respirator ensures that the nurse does not inhale the TB organism. Placing in a semi-Fowler's position reduces the work of breathing. 2. Incorrect: Unless contraindicated, 3-4 liters of fluid is needed per day to liquefy secretions. 5. Incorrect: Visitors are allowed if standard and airborne precautions are followed.

A nurse is teaching a group of small farm owners how to prevent pesticide exposure for field workers. What points should the nurse include? You answered this question Incorrectly 1. Importance of hand washing before eating. 2. Wearing protective clothing while working in the field and at home. 3. Removing clothing and shoes worn in the field before entering the home. 4. Washing fruit and vegetables prior to eating. 5. Boiling all vegetables for a minimum of 5 minutes prior to eating.

RationaleStrategies 1., 3. & 4. Correct: The standard precautions of hand hygiene is recommended prior to eating. This will reduce the transmission of pathogens and possible pesticides. The pesticides may be present on their clothing, so the clothing and shoes should be removed. Fruits and vegetables should be washed to remove pathogens and pesticides. All points are important to include when teaching prevention of pesticide exposure. 2. Incorrect: Yes, wear protective clothing while working in the field, but it is not necessary to wear protective clothing at home. 5. Incorrect: No, it is not necessary to boil or cook vegetables to remove chemicals from fresh produce. Washing thoroughly with water is adequate.

The nurse notes that a client has impaired swallowing as a result of a cerebrovascular accident (CVA). Which interventions are appropriate for the nurse to include in the plan of care? You answered this question Correctly 1. Sit the client up at a 90° angle during meals. 2. Assist the client to hyperextend the head when preparing to swallow. 3. Encourage the client to sit up for 30 minutes after eating. 4. Educate a family member on the Heimlich maneuver. 5. Start the client on a thin liquid diet.

RationaleStrategies 1., 3. & 4. Correct: This is the optimal position for chewing and swallowing without aspirating. Sitting up 30 minutes after completing a meal will prevent regurgitation of food. In case of choking, family members should know how to perform emergency measures such as the Heimlich maneuver. 2. Incorrect: The client should position the head in forward flexion in preparation for swallowing, called the "chin tuck". Hyperextension would cause aspiration. 5. Incorrect: The client should be started on thick liquid or pureed diet. Thickened or pureed foods are easier to swallow than thin liquids and prevent aspiration

Following a total hip replacement, the nurse provides discharge teaching to the client. The nurse knows that teaching was effective when the client states which activities are safe to perform? You answered this question Correctly 1. Using an abduction pillow while sleeping 2. Crossing the legs 3. Using a toilet extender 4. Showering rather than taking a bath 5. Tying shoes

RationaleStrategies 1., 3., & 4. Correct: The client should use an abduction pillow to keep hip in proper alignment and prevent hip dislocation. A toilet extender keeps the hip in proper alignment and prevents hip dislocation. Showering rather than sitting in a tub will prevent flexion of the hip. 2. Incorrect: Crossing the leg can pop the hip out of place and prevent total healing and success with the replacement. 5. Incorrect: To tie shoes, the client has to bend over which can pop the hip out of place. The client would need to have shoes that do not require tying or have someone do it for them.

Which instructions should the nurse give the unlicensed assistive personnel (UAP) about care needed to reduce the risk of infection when a client has an indwelling catheter? You answered this question Incorrectly 1. Check catheter for kinks in the tubing when the client is in the bed or chair. 2. Instruct the UAP to disconnect the catheter from the bag when measuring output. 3. Wash hands before providing personal care to the client. 4. Ensure that catheter remains secured to the thigh. 5. Make sure that the drainage bag is always below the level of the bladder.

RationaleStrategies 1., 3., 4. & 5. Correct: Tubing that becomes obstructed cannot allow adequate urine flow. The urine flow occurs by gravity. Adequate handwashing before providing care is one defense against infection. Tension on the tubing may cause irritation and subsequent infection. The bag should be below the level of the bladder so that urine flows appropriately. 2. Incorrect: A closed drainage system should be maintained to prevent entry of microorganisms. This would be incorrect and potentially cause harm to the client.

A long-term care nurse is planning care for a newly admitted client diagnosed with Alzheimer's disease. What should the nurse include in the plan of care? You answered this question Correctly 1. Assess client's ability to perform activities of daily living. 2. Perform activities of daily living for the client. 3. Place a clock and calendar in client's room. 4. Encourage family to visit client often. 5. Have nursing staff spend time talking and listening to client.

RationaleStrategies 1., 3., 4., & 5. Correct: All of these should be included in this client's plan of care. Assess the client's ability to perform activities of daily living and allow client to perform alone if capable. Maintain stimuli such as a clock, newspaper, calendar, and/or weather status. Encourage family to visit to maintain socialization. Plan for staff to spend some time talking and listening to the client. 2. Incorrect: Teach staff to facilitate client's independence in all activities for as long as they are able. Encouraging self-care and allowing the client to be involved in activity of daily living (ADL) is a basic right and core principle of planning client-centered care.

What should the nurse include when providing education to a client receiving tetracycline? You answered this question Correctly 1. Wear long sleeves when going outside. 2. Take tetracycline on a full stomach. 3. Wait at least two hours after taking tetracycline prior to taking iron supplements. 4. Tetracycline can decrease the effectiveness of birth control pills. 5. Do not take this medicine after the expiration date on the label has passed.

RationaleStrategies 1., 3., 4., & 5. Correct: Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Tetracycline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun. Take tetracycline on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective. Tetracycline can make birth control pills less effective. Use a second method of birth control while you are taking this medicine to keep from getting pregnant. Throw away any unused tetracycline when it expires or when it is no longer needed. Do not take this medicine after the expiration date on the label has passed. Expired tetracycline can cause a dangerous syndrome resulting in damage to the kidneys. 2. Incorrect: Take tetracycline on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective.

Which signs and symptoms, if noted by the nurse, would indicate that the client with hyperthyroidism is experiencing thyroid crisis? You answered this question Correctly 1. Hyperkinesis 2. Bradycardia 3. Hypertension 4. Restlessness 5. Confusion

RationaleStrategies 1., 3., 4., & 5. Correct: These are symptoms of thyroid crisis and should be reported immediately. 2. Incorrect: Tachycardia would occur, not bradycardia. Bradycardia is a symptom of hypothyroidism.

A home health nurse is assessing the home environment for safety issues concerning ambulation. Which finding would require the nurse to counsel the client and family? You answered this question Correctly 1. Dim hall lighting 2. Grab bar in bath tub 3. Nonskid strips on outside steps 4. Throw rug at front entrance to home 5. Waxed linoleum kitchen floor

RationaleStrategies 1., 4., & 5. Correct: Rooms and hallways should have adequate lighting so client can see while ambulating and see any objects which may be in the way. Throw rugs (rugs that are not secured) can slide and cause a fall. Slippery floors will contribute to falls. 2. Incorrect: Adequate supports such as railings and grab bars can help prevent falls. 3. Incorrect: Having nonskid strips on outside steps and inside stairs help prevent falls.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? You answered this question Incorrectly 1. Check client for signs of skin breakdown. 2. Check client's vital signs after ambulating. 3. Administer 8 ounces of polyethylene glycol electrolyte solution every 10 minutes. 4. Obtain a stool specimen. 5. Determine what activities the client can do independently.

RationaleStrategies 2. & 4. Correct. These tasks are within the scope of practice for the UAP. 1. Incorrect. The UAP cannot assess the client for signs of skin breakdown. 3. Incorrect. The UAP cannot administer medication. 5. Incorrect. The UAP cannot assess which activities that the client can perform.

A 68 year old client was admitted two days ago to a long-term care facility. The client has chronic kidney disease, coronary artery disease and chronic obstructive pulmonary disease. Oxygen 2 L/per nasal cannula is being administered. Assistance is needed with activities of daily living. The primary healthcare provider visits today and writes new prescriptions. Who is the best person for the charge nurse to delegate carrying out these prescriptions? Exhibit You answered this question Correctly 1. Unlicensed assistive personnel (UAP) 2. LPN/LVN 3. RN 4. Charge Nurse

RationaleStrategies 2. Correct. All the nursing responsibilities associated with the healthcare provider's prescriptions are within the scope of practice of the LPN/LVN. 1. Incorrect. Giving medications is out of the scope of practice of the Unlicensed assistive personnel (UAP). 3. Incorrect. All the nursing responsibilities associated with the healthcare provider's prescriptions are within the scope of practice of the LPN/LVN. The RN would need to be assigned to more unstable clients than this one. 4. Incorrect. The charge nurse is responsible for assuring that all client care is provided during the shift, so carrying out these prescriptions is not the best use of time and resources available to the charge nurse.

What precautions should be taken with computer monitors that display client health information to ensure client's confidentiality? You answered this question Incorrectly 1. Orient the screen facing the client rooms so that healthcare personnel can access the information easily. 2. Have the screen placed facing away from any visitor or client care area where information could be viewed by unauthorized persons. 3. Turn the computer monitors off when the computer is not in use. 4. The computer should be kept in a secured, locked area.

RationaleStrategies 2. Correct: Computer monitors that display client health information should be positioned away from the view of any visitors or unauthorized persons. Even a well-guarded computer monitor, with an authorized employee sitting in front of it, could be a potential breach of confidentiality, depending on the angle of the monitor screen and who was attempting to view the information on it. The responsibility for keeping health information safe is on every member of the healthcare team. 1. Incorrect: No, this would be easily viewed by unauthorized individuals. 3. Incorrect: Not necessary to turn off if proper precautions are taken. 4. Incorrect: Not necessary to keep in secured area if proper precautions are taken.

A primary healthcare provider informs the nurse to prepare for an amniotomy on a client who's labor has not progressed. What should the nurse assess for prior to the primary healthcare provider performing this procedure? You answered this question Incorrectly 1. Fetal attitude 2. Fetal engagement 3. Fetal lie 4. Fetal position

RationaleStrategies 2. Correct: Fetal engagement is important prior to rupturing the membranes so that the umbilical cord cannot prolapse. Fetal engagement is when the fetus is at station 0 (level of mom's ischial spines). 1. Incorrect: Fetal attitude is where the extremities and chin of the fetus are in relation to the fetal body. 3. Incorrect: Fetal lie refers to the maternal spine in relation to the fetal spine. 4. Incorrect: Fetal position tells us the presenting part of the fetus to mom's pelvis.

A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client? You answered this question Correctly 1. "Do you take metronidazole on an empty stomach?" 2. "Are you using any products that contain alcohol?" 3. "How long have you had these symptoms?" 4. "What other medications are you currently taking?"

RationaleStrategies 2. Correct: Flushing, nausea and vomiting, palpitations, tachycardia, psychosis are signs of disulfiram-type reaction seen when using products containing alcohol (cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking metronidazole. 1. Incorrect: Although it is preferable to take metronidazole on an empty stomach, this is not the most important question to ask at this time. 3. Incorrect: How long the client has had these symptoms is not as important as whether the client is using any alcohol containing products. 4. Incorrect: Although the nurse needs to know what other medications the client is taking, it is not as important as knowing if the client is using any alcohol containing products.

Which electrolyte imbalance would be the nurse's priority concern in the burn client? You answered this question Incorrectly 1. Hypernatremia 2. Hyperkalemia 3. Hypoalbuminemia 4. Hypermagnesemia

RationaleStrategies 2. Correct: Good job. When the cells lyse they release potassium, and then the serum potassium goes up. And if the kidneys stop, we are in real trouble. 1. Incorrect: Well this one does occur when the client becomes very dehydrated, but it's not as dangerous as the potassium one. 3. Incorrect: Low albumin can cause problems keeping fluid in the vascular space, but albumin is not an electrolyte. 4. Incorrect: No, the magnesium doesn't go up unless the kidneys shut down.

A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What should the nurse suggest to reduce this side effect? You answered this question Correctly 1. Stop taking the medication and call the primary healthcare provider. 2. Drink plenty of water with the medication. 3. Take the medication before bedtime. 4. Take antacids when taking the medication.

RationaleStrategies 2. Correct: Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet. 1. Incorrect: Slight heartburn does not warrant primary healthcare provider report. Extreme pain or difficulty swallowing should be reported, as should heartburn that increases despite suggestions listed above. 3. Incorrect: The client should take in the morning, thus preventing prolonged contact with the esophagus. 4. Incorrect: The absorption of the medication is decreased when it is taken with calcium, iron, and magnesium, or antacids containing calcium, aluminum, or magnesium. Thirty minutes should elapse before taking the antacid following administration of the alendronate.

The oncoming nurse has just received report and is preparing to make initial rounds. Which postpartum client should the nurse see first? You answered this question Correctly 1. A primipara 6 hours postpartum saturating one peripad every two hours 2. A multigravida 1 hour postpartum and reporting intense perineal pain 3. A primigravida 12 hours postpartum with the uterine fundus at the umbilicus 4. A multigravida 72 hours postpartum with a brownish pink lochia discharge.

RationaleStrategies 2. Correct: Intense perineal pain is a symptom of a perineal hematoma which is a medical emergency. 1. Incorrect: Expected findings for the postpartum period are described here. This is a normal peripad saturation and does not indicate a problem. 3. Incorrect: Expected findings for the postpartum period are described here. This is the proper position of the fundus 12 hours postpartum. 4. Incorrect: Expected findings for the postpartum period are described here also. A client postpartal 72 hours should have a brownish pink lochia discharge.

Which nursing intervention should receive priority after a client has returned from having had eye surgery? You answered this question Correctly 1. Administer pain medication around the clock. 2. Maintain head of bed at 35°. 3. Apply warm compresses. 4. Instruct on importance of turning, coughing, and deep breathing.

RationaleStrategies 2. Correct: Maintaining head of bed in an elevated position will help to decrease intraocular pressure. Do not lie the client supine as this will increase intraocular pressure. If the intraocular pressure increases too much, damage to the eye structures, including the retina and optic nerve, with resulting loss of vision, may result. 1. Incorrect: Although pain management is important, it is not the priority here. The priority intervention of maintaining the bed at 35° is to reduce the risk of increased intraocular pressure. Unless the pain becomes out of proportion or suddenly worsens, it is an expected finding and would not be cause for alarm or require "priority" attention. 3. Incorrect: Warm and hot compresses could possibly increase intraocular pressure and cause damage to the eye structures. 4. Incorrect: Coughing will increase intraocular pressure and could result in damage to the surgical site and/or the structure within the eye. Loss of vision could result if pressure becomes too great. Coughing is a type of valsalva movement which results in an increase in the intraocular pressure.

Which action by a nurse indicates to the charge nurse that the sterile field has been contaminated? You answered this question Correctly 1. The sterile field is above the level of the waist. 2. Sterile gauze dressing within the one inch border of sterile field. 3. Remains facing the sterile field throughout procedure. 4. Inspects sterile wrapped instruments for tears.

RationaleStrategies 2. Correct: No sterile object should be within the one inch border of the sterile field as the object is no longer considered sterile. 1. Incorrect: This is a correct action. Bacteria tend to settle below the level of the waist, so there is less contamination when the field is above the waist and away from the nurse. 3. Incorrect: This is a correct action. The nurse should never turn their back to the sterile field. The fronts of sterile gowns are considered sterile from the chest to the level of the sterile field. 4. Incorrect: This is a correct action. The sterile wrapped instruments and trays should be purposely inspected for small tears that would compromise sterility before opening and placing the instruments on the field.

A client is scheduled for plateletpheresis. When taking the client's history, which information is most significant? You answered this question Incorrectly 1. Allergies to shellfish 2. Date last donated 3. Time of last oral intake 4. Blood type

RationaleStrategies 2. Correct: Platelet donors can have plateletpheresis as often as every 14 days. 1. Incorrect: Allergies to shellfish have nothing to do with withdrawing platelets from the client. 3. Incorrect: Time of last oral intake has no bearing on whether or not a client can donate platelets. 4. Incorrect: Blood type has no bearing on whether or not a client can donate platelets.

A primary healthcare provider prescribed KCL 40 mEq in 100 mL NS to infuse over 30 minutes. What action should the nurse take? You answered this question Correctly 1. Administer the KCL through the lowest IV line port. 2. Clarify the prescription with the primary healthcare provider. 3. Mix KCL 40 mEq into the present infusing bag of NS when it reaches 100 mL. 4. Set the infusion pump to 100 mL / hour.

RationaleStrategies 2. Correct: Potassium chloride should be diluted and administered to infuse no faster than 40 mEq per hour. So this prescription would infuse too quickly and may lead to life threatening arrhythmias. 1. Incorrect: This prescription should not be administered as written. The rate of infusion over 30 minutes is too fast. 3. Incorrect: This is dangerous. Nurses should not add KCL to an existing bag of infusing fluid. This prescription should not be administered as written. 4. Incorrect: The nurse should verify the rate prior to initiating the infusion. The rate of administration should be clarified with the primary healthcare provider.

A client, who is having difficulty falling asleep, asks the nurse for a sleeping aid. What is the first action the nurse should provide to the client? You answered this question Incorrectly 1. Assist client to take a cool bath. 2. Provide a back massage. 3. Administer prescribed triazolam. 4. Give client a crossword puzzle to work.

RationaleStrategies 2. Correct: Research indicates that back massage can enhance client comfort, relaxation, and sleep. This is the least invasive option and should be done first. 1. Incorrect: A cool bath would wake a client, whereas, a warm bath would increase relaxation. 3. Incorrect: Triazolam is a short acting benzodiazepine. Do not go to the sleeping pill first. 4. Incorrect: Distraction is a good strategy for drawing a client's attention away from pain but may increase thinking, thus keeping the client awake.

A nurse is educating the parents of a child with celiac disease. The nurse knows the teaching is successful if the parents choose which food for their child's dinner? You answered this question Correctly 1. Turkey and lettuce sandwich on rye bread 2. Sirloin steak and diced baked potatoes 3. Chicken, vegetables and a whole wheat roll 4. Hotdog and baked beans

RationaleStrategies 2. Correct: Steak and potatoes are gluten free. 1. Incorrect: Client's with celiac disease should maintain a gluten free diet. Rye bread contains gluten. 3. Incorrect: Client's with celiac disease should maintain a gluten free diet. Wheat contains gluten. 4. Incorrect: Client's with celiac disease should maintain a gluten free diet. Processed meats such as hotdogs and most sausages contain gluten.

The nurse is caring for a client who is to receive an IV infusion of heparin. The client's dose is based on a sliding scale prescription. What is the priority lab value to check before initiating the heparin infusion? You answered this question Incorrectly 1. PT and/or INR 2. aPTT 3. Platelet count 4. WBC count

RationaleStrategies 2. Correct: The activated partial thromboplastin time (aPTT) is a lab value used to assess pathways in the clotting cascade and is used to monitor Heparin therapy in clients. To maintain a therapeutic level of Heparin, the aPTT should be maintained at 1.5-2.5 times the normal range. 1. Incorrect: The PT and INR are lab values used to monitor warfarin therapy in clients 3. Incorrect: The platelet count measures an individual's total platelet count. Thrombocytopenia is a platelet count of < 100,000. Thrombocytopenia increases the risk of bleeding; however, since the aPTT directly measures heparin therapy, it is the priority value to monitor. 4. Incorrect: The White Blood Cells (WBC) are not involved in the body's mechanism for clotting.

The six bed Labor and Delivery area is full when the Emergency Department nurse calls for a bed for a woman reporting low back pain, pelvic pressure and increased vaginal discharge at 36 weeks gestation. Which would be the most appropriate action for the charge nurse? You answered this question Correctly 1. Transfer a G4P4 who delivered full-term twins one hour ago to the antepartum/postpartum floor. 2. Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the antepartum/postpartum floor. 3. Transfer an 8 hour postpartum G1P1 on Magnesium Sulfate for eclampsia from the LDR unit to the ante/postpartum unit. 4. Request that the new client be admitted to the antepartum/postpartum floor.

RationaleStrategies 2. Correct: The client and newborn are not in any present distress. Also the delivery occurred 3 hours ago. This client would not be a risk and could be cared for on the antepartum/postpartum floor. 1. Incorrect: This client is at high risk for hemorrhage due to still being in the fourth stage of labor and over distention of her uterus with a term multiple gestation. This client needs to stay in current location for close monitoring. 3. Incorrect: Close monitoring and frequent vital signs are required since central nervous system alterations and respiratory depression are common side effects of Magnesium Sulfate. 4. Incorrect: This client has subtle signs and symptoms of preterm labor and needs close monitoring. Ante and postpartum unit is for stable clients.

The client in the manic phase of bipolar disorder begins climbing onto a table in the dayroom and shouts, "I can fly! I can fly! Watch me fly!" What should be the initial intervention by the nurse? You answered this question Correctly 1. Leave the client alone and remove clients from the dayroom. 2. Call for personnel to escort the client out of the day room. 3. Restrain the client, and notify the primary healthcare provider. 4. Tell the client that there is no way that a person can fly.

RationaleStrategies 2. Correct: The first priority is the safety of the client. If the client jumps off the table, this action may cause an injury to the client. The nurse may need extra help in case the client becomes violent. 1. Incorrect: The client may cause self injury by jumping from a table. The other clients are not in danger. 3. Incorrect: The primary healthcare provider does not need to be notified at this time. Restraints should be used as a last resort. 4. Incorrect: Presenting a client with reality is a therapeutic communication technique. The safety of the client at this time is the priority intervention.

A school nurse educates a group of teachers how to extinguish a fire involving a child whose clothes are on fire. Which statement by the teachers would indicate to the school nurse that the teachers understand what should be done first? You answered this question Incorrectly 1. "Someone should be assigned to call 911." 2. "Lay child flat and roll in a blanket." 3. "A blanket should be thrown over the child's head and body." 4. "Use a fire extinguisher to put out the flames."

RationaleStrategies 2. Correct: The flames should be extinguished first. The best way to accomplish this it to lay the child flat and roll in a blanket. This is referred to as the drop and roll method, when a blanket is available. 1. Incorrect: 911 should be called but the most important thing to do is to extinguish the flames first. 3. Incorrect: Throwing a blanket over the child's head can trap smoke. This may lead to smoke inhalation and does not extinguish the fire. 4. Incorrect: The fastest and most effective way to extinguish the flames is by using the drop and roll method.

A nurse drops a bottle of IV fluid, which shatters on the floor in the hallway. What action should the nurse take? You answered this question Correctly 1. Notify housekeeping to clean up the spill. 2. Pick up glass with a broom and dustpan and dispose into a puncture resistant sharps container. 3. Pick up the glass with gloved hands and dispose into a puncture resistant sharps container. 4. Use a wet mop to collect the glass and dispose of it in the garbage can.

RationaleStrategies 2. Correct: The nurse must not be cut by the broken glass. Proper removal of glass includes using a dustpan and broom to collect the glass and disposing of it into a puncture resistant sharps container. 1. Incorrect: While waiting for housekeeping someone could fall or get cut. The nurse should initiate cleanup. 3. Incorrect: Hands are never used to pick up glass even if they are gloved because of the increased risk of getting cut. 4. Incorrect: A wet mop will not pick up the glass, and glass pieces will stick to a wet mop.

An emergency department (ED) nurse working triage has assessed four clients. Which client should receive the highest priority? You answered this question Correctly 1. Alert client who fell on the side walk. Skin warm and dry to the touch, with a three inch laceration on the right knee continuously oozing dark red liquid. 2. Elderly client who moans when the nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds. 3. A client who "passed out" but regained consciousness when feet were elevated. Awake and confused, with warm and dry skin. 4. An alert, responsive client who reports severe abdominal and shoulder pain that began two hours after eating at a local fast food restaurant. Skin is warm and dry.

RationaleStrategies 2. Correct: This client is responding to verbal stimuli by moaning and has an open airway; but any client with an altered level of consciousness is at risk for airway obstruction. The skin assessment indicates a circulation problem. 1. Incorrect: This client demonstrates no signs of life threatening problems. The client is stable. 3. Incorrect: This client has an open airway and the skin findings do not suggest a circulation problem. This client is confused but alert, so lower priority. 4. Incorrect: The client is alert and talking so the airway is open. The client's skin findings do not suggest a circulation problem. This client has no immediate life-threatening problems.

When assessing a client, the nurse finds that in response to painful stimuli the upper extremities exhibit flexion of the arm, wrist, and fingers with adduction of the limb, while the lower extremity exhibits extension, internal rotation, and plantar flexion. How would the nurse accurately document this finding? You answered this question Correctly 1. Decerebrate posturing 2. Decorticate posturing 3. Reflex posturing 4. Superficial posturing

RationaleStrategies 2. Correct: This describes decorticate posturing because they are moving towards the core of the body. 1. Incorrect: Decerebrate posturing occurs when the client is stimulated, and teeth clench and the arms are stiffly extended, adducted, and hyperpronated. The legs are stiffly extended with plantar flexion of the feet. Abnormal extension occurs with lesions in the area of the brain stem. 3. Incorrect: There is no such condition as reflex posturing. This is a distractor and can be ruled out by focusing on the meaning of the terms and similarities in verbiage. 4. Incorrect: There is no such condition as superficial posturing. This is a distractor and can be ruled out by focusing on the meaning of the terms and similarities in verbiage.

A client received 2nd and 3rd degree burns on both arms and the anterior trunk when pouring gas on a burning trash pile. With the percentage of burns indicated, what should the nurse anticipate? You answered this question Correctly 1. Movement of fluid out of the cells into the vascular space. 2. Increased capillary permeability and 3rd spacing of fluids. 3. Rapid fluid shift out of the vascular bed 48 hours after the burn. 4. Severe fluid volume excess in the first 24 hours after the burn.

RationaleStrategies 2. Correct: Using the Rule of Nines, the client would have burned approximately 36% of the body. For burns greater than 20-25% of the total body surface area, the nurse should recognize that significant vascular damage occurs which causes increased permeability. The fluid leaks out of the vascular space and out into the tissues (3rd spacing). The client can go into a severe fluid volume deficit and shock. 1. Incorrect: The movement of fluid is out of the vascular space into the tissues, not out of the cells into the vascular space. 3. Incorrect: The majority of fluid shifts out of the vascular bed occur in the first 24 hours. The diuresis phase begins about 48 hours after the burn injury when fluid is returning to the vascular bed. 4. Incorrect: The client is at risk for fluid volume deficit (not fluid volume excess) in the first 24 hours as the fluid leaks out into the tissue.

A nurse is caring for a client in an outpatient clinic. The client lost her husband of 51 years three months ago. Which findings support that the client is experiencing normal grief reactions rather than clinical depression? You answered this question Correctly 1. The client is experiencing anhedonia. 2. The client states, "I have good and bad days." 3. The client smiles at the nurse while talking about her grandchild. 4. The client has a persistent state of dysphoria. 5. The client states, "I am having fewer crying spells." x

RationaleStrategies 2., 3. & 5. Correct: A client going through a normal grieving process will experience a mixture of good and bad days. The client experiences moments of pleasure and cries less. 1. Incorrect: Anhedonia is the inability to experience pleasure seen in clinical depression. This would not be a positive sign of normal grieving in a client. 4. Incorrect: Dysphoria is a mood of general dissatisfaction, restlessness, depression, and anxiety. This is often seen in clinical depression.

The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. Which signs/symptoms are an indication to the nurse that treatment goals have not been met? You answered this question Correctly 1. Diuresis 2. Dyspnea on exertion 3. Persistent cough 4. Warm, dry skin 5. Heart rate irregular at 118/min 6. Alert and oriented

RationaleStrategies 2., 3. & 5. Correct: When the cardiac output decreases, renal perfusion decreases, which leads to decreased urine output and fluid retention. This leads to difficulty breathing. Tachycardiac and rhythm irregularity are signs of fluid volume excess (FVE) and decreased output. Persistent cough, wheezing, and pink blood tinged sputum are all signs that the client is still sick. 1. Incorrect: No, that is what we want, but there is not enough blood to the kidneys, and the renin angiotensin (aldosterone) mechanism has activated. 4. Incorrect: Indication of improved cardiac output. 6. Incorrect: Indication of improved cardiac output.

What should the nurse include when providing teaching to a female client prescribed doxycycline for the treatment of acne? You answered this question Correctly 1. Take this medication with food to maximize absorption. 2. Use a non-hormone method of birth control while taking this medication. 3. Wear protective clothing when outside. 4. Drink plenty of fluids while taking this medication. 5. Iron and calcium supplements can be taken with this medication.

RationaleStrategies 2., 3., & 4. Correct: Doxycycline is a tetracycline antibiotic. Doxycycline can make birth control pills less effective. A non-hormone method of birth control (such as a condom, diaphragm, spermicide) should be used to prevent pregnancy while using doxycycline. Avoid exposure to sunlight or tanning beds. Doxycycline can make you sunburn more easily. Wear protective clothing and use sunscreen (SPF 30 or higher) when outdoors. Take doxycycline with a full glass of water. Drink plenty of liquids while taking this medicine. 1. Incorrect: Take on an empty stomach to maximize absorption, although may not be tolerated unless administered with food. 5. Incorrect: Do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking doxycycline. Absorption will be altered. For instance, iron can bind to doxycycline in the gastrointestinal tract, which may prevent their absorption into the bloodstream and possibly reduce their effectiveness. To avoid or minimize the interaction, iron containing medications and doxycycline should preferably be taken at least three hours apart in most cases.

The charge nurse on the pediatric unit is reviewing the protocol for blood administration with a staff nurse. Which actions by the staff nurse indicate understanding of blood administration? You answered this question Correctly 1. The blood infusion time was within 6 hours. 2. A filter was used when administering the blood. 3. A second nurse checked the blood compatibility. 4. A set of vital signs was taken 5 minutes after the blood infusion started. 5. One form of client identification were obtained prior to infusion.

RationaleStrategies 2., 3., & 4. Correct: Filters are used when infusing blood. Two nurses must check the blood product label and blood group. Vital signs are checked frequently during a blood transfusion. For example: A baseline set of vital signs are taken, then again 5 minutes after the initiation of the transfusion, then 15 minutes after transfusion started and every 15 minutes for one hour, then every 30 minutes for one hour, then hourly until infusion is complete. 1. Incorrect: Blood should hang for no longer than 4 hours because it increases the chances of a reaction. 5. Incorrect: At least two methods of proper identification should be obtained, such as asking client his/her name and checking ID band.

A client is diagnosed with new onset grand mal seizures. Which nursing interventions should the nurse implement for this client? You answered this question Incorrectly 1. Have an unlicensed assisitve personnel stay with the client. 2. Pad the side rails with blankets. 3. Place the bed in low position. 4. Keep a padded tongue blade at the bedside. 5. Instruct client to call for help when ambulating.

RationaleStrategies 2., 3., & 5. Correct: During a seizure these interventions will help to protect the client from injury. The client may strike the side rails. The bed should be placed in the low position in case the client falls out of the bed. The client would need assistance to the floor if a seizure starts while ambulating. 1. Incorrect: It is not necessary to have someone stay with this client at all times. Place a call light within reach, put the client close to the nurses' station, and pad the side rails. Have the client call for assistance to bathroom. Maintain bed rest until seizures are controlled or ambulate the client with assistance to protect from injury. 4. Incorrect: Do not place a padded tongue blade in a client's mouth during a seizure. The padded tongue blade could cause injury.

The nurse's goal is to reduce the risk of flu and its complications by offering a class at the local high school. Which groups of people should be included in the nurse's teaching plan as needing the flu shot? You answered this question Incorrectly 1. Babies less than 6 months old 2. Any child older than 6 months 3. Pregnant women 4. Parents of young children 5. People with a chronic illness

RationaleStrategies 2., 3., 4. & 5. Correct: All people greater than 6 months of age should get a flu shot, unless allergic to eggs, or if there has been an adverse reaction in the past. Pregnant women should receive the flu shot. Parents of young children may be exposed to the flu and should get the vaccine. People with a chronic illness are more susceptible to flu and its complications. 1. Incorrect: Flu vaccine has not been approved for babies less than 6 months old.

The nurse is planning health promotion strategies for an older client on a limited, fixed income who is trying to increase activity. The client has been cleared for moderate physical activity by the primary healthcare provider. Which strategies would be appropriate for this client? You answered this question Correctly 1. Suggest that the client join a local gym for access to equipment and support. 2. Suggest contacting a neighbor so that they can walk each day in the neighborhood. 3. Encourage client to get up and walk around the house during each TV commercial break. 4. Suggest the client go to the community senior center for daily strengthening exercises. 5. Encourage client to use one-pound soup cans for muscle toning.

RationaleStrategies 2., 3., 4. & 5. Correct: The neighborhood buddy is accessible and can be a source of emotional support too, which increases the likelihood of continuing the plan. This activity is easily accessible and burns calories during the day or evening. Senior centers usually do not cost any money for the client, and other seniors may help motivate the client to increase activity level. The use of ordinary items does not further strain a fixed income. 1. Incorrect: Joining a gym will require monthly fees, thus impacting financial resources in a negative way. Additionally, transportation to and from the gym could impact finances in a negative way.

The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider? You answered this question Incorrectly 1. BP 150/108 decreases to 138/86 2. Weight gain of 5 pounds (2.27 kg) in one week 3. Serum sodium level of 139 mmol/L 4. Angioedema 5. Serum potassium of 5.8 mEq

RationaleStrategies 2., 4., & 5. Correct: Weight gain of 5 pounds in one week is a s/s of an adverse effect of ACE inhibitor use. Weight gain is a sign of fluid retention. Angioedema is an adverse effect of ACE inhibitors and can be life threatening. This should be reported immediately to the healthcare provider. The potassium level is too high. Hyperkalemia is an adverse effect of an ACE inhibitor and needs to be reported. 1. Incorrect: This is an expected response of an ACE inhibitor. ACE inhibitors block the normal effects of renin-angiotensin-aldosterone system, thereby decreasing the blood pressure. 3. Incorrect: The serum sodium level here is within normal limits. There is no need to report normal lab values.

What symptoms would the nurse anticipate in a client being admitted to the hospital with a calcium level of 3.2 mg/dL (0.80 mmol/L)? You answered this question Incorrectly 1. Slowed deep tendon reflexes. 2. Muscle rigidity and cramping. 3. Hypoactive bowel sounds. 4. Positive Chvostek's sign. 5. Seizures 6. Laryngospasms

RationaleStrategies 2., 4., 5., & 6. Correct: Normal serum calcium is 8.7 - 10.3 mg/dL (2.18 - 2.58 mmol/L). The client with a calcium level of 3.2 mg/dL (0.80 mmol/L) is hypocalcemic. With hypocalcemia, the muscle tone is rigid and tight. Therefore, the client may report muscle cramping. A hallmark sign of hypocalcemia is a positive Chvostek's sign, which is a twitching of facial muscles following tapping in the area of the cheekbone, indicative of hyperirritability. The client may be at risk of having seizures due to the neuromuscular irritability. Prolonged contraction of the respiratory and laryngeal muscles causes laryngospasm and stridor and may result in cyanosis. 1. Incorrect: With hypocalcemia, the deep tendon reflexes are increased, not decreased. 3. Incorrect: The client with hypocalcemia tends to have increased gastric motility, resulting in hyperactive (not hypoactive) bowel sounds. In addition, abdominal cramping and diarrhea are common with hypocalcemia.

A client is hospitalized for chronic renal failure. The nurse will need to notify the primary healthcare provider concerning which findings? You answered this question Correctly 1. Sodium 135 mEq/L 2. Potassium 5.8 mEq/L 3. BP 100/70 4. No weight loss 5. Ionized Calcium 4.0 mg/dL

RationaleStrategies 2., 5. Correct: Normal K 3.5-5.0 mEq/L; Normal ionized serum Ca 4.5-5.5 mg/dL. The abnormal lab results need to be reported. 1. Incorrect: Normal sodium 135-145 mEq/L. 3. Incorrect: Hypertension is a potential complication of chronic renal failure. 4. Incorrect: Desired outcome: client exhibits no rapid increases or decreases in weight.

Which assignments would be most appropriate for the RN to delegate to an LPN/VN? You answered this question Correctly 1. Six year old with new onset diabetes. 2. Ten year old with pneumonia admitted two days ago. 3. Three month old admitted with severe dehydration. 4. Four year old admitted for developmental studies. 5. Twelve year old with post op wound infection taking oral antibiotics.

RationaleStrategies 2.,4. & 5. Correct: The best assignments for the LPN/VN would be the child with pneumonia admitted two days ago and the child admitted for developmental studies. The twelve year old with post op wound infection taking oral antibiotics is also stable. 1. Incorrect: The diabetic requires much teaching and supervision. This is an unstable client that should not be assigned to an LPN/VN. 3. Incorrect: The child with dehydration will require close intravenous fluid (IVF) monitoring, assessment and evaluation of condition. This client is unstable and should not be assigned to an LPN/VN.

The nurse is caring for a 5-year old child brought to the Emergency Department by the parents for pain and swelling in the left arm. An x-ray of the arm confirmed a fracture. The parents give conflicting stories about the accident. What action by the nurse is most appropriate? You answered this question Correctly 1. Prepare the child for casting of the arm. 2. Ask the primary healthcare provider to order bone series film. 3. Consult social services. 4. Obtain a history as to how the accident happened.

RationaleStrategies 3. Correct: All states have laws that mandate reporting of child maltreatment. Usually the social service department handles these types of referrals. 1. Incorrect: Casting may be needed, but the most appropriate action is identifying safety issues and possible child abuse. 2. Incorrect: X-rays would be the primary healthcare provider's decision. 4. Incorrect: There is nothing wrong with this answer, but you only have one chance to tell the NCLEX people you know the most important thing to do is to consult social services. This is a safety issue.

What should the nurse do first when caring for a client who is being admitted with a diagnosis of meningococcal meningitis? You answered this question Correctly 1. Assess neuro status. 2. Obtain health history. 3. Institute droplet precautions. 4. Orient client to the room and procedures.

RationaleStrategies 3. Correct: Although all the options are appropriate, the priority is to place the client on droplet precaution to prevent the spread of meningococcal meningitis. 1. Incorrect: Placing client in isolation should be done first (actually prior to arriving to room) since the client has a diagnosis of meningococcal meningitis. Assessment of the neuro status can be done next. 2. Incorrect: The health history can be obtained after placing the client on droplet precautions. 4. Incorrect: Orientation can occur after the initiation of droplet precautions.

A home health nurse has taught a client about home dressing changes using a clean technique. Which statement made by a client indicates to the nurse that the client understands this technique? You answered this question Correctly 1. "The wound should be cleaned using a washcloth, soap, and water." 2. "Povidone-iodine should be applied to the wound with each dressing change." 3. "It is important that I wash my hands using soap and water before removing my dressing." 4. "I will use sterile gloves to clean my wound and change the dressings."

RationaleStrategies 3. Correct: Clean technique requires washing hands with soap and water prior to removing the dressing. 1. Incorrect: The wound should be cleaned with 4x4's and sterile water. Soap can be very drying to the wound. A washcloth may not be clean as it has been sitting in a cabinet. 2. Incorrect: Povidone-iodine is harsh and damages healthy tissue, so should not be applied to the wound. 4. Incorrect: Sterile gloves are not needed when using clean technique. Clean gloves may be used.

The nurse is caring for a client diagnosed with type 2 diabetes who was brought to the emergency department in an unresponsive state. A diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is made. The nurse prepares for the administration of which initial therapy? You answered this question Correctly 1. Oxygen by nasal cannula 2. Long-acting IV insulin 3. Normal saline 4. IV dextran

RationaleStrategies 3. Correct: Clients in HHNS diurese due to a high glucose load in the vascular space. The client becomes severely volume depleted and is at risk for developing shock. Therapy is focused on combating shock. 1. Incorrect: Oxygen by nasal cannula is not the priority for this client. Don't pick oxygen as a priority every time. Oxygen does not fix the problem. The problem is shock. 2. Incorrect: The client will be given short-acting insulin. 4. Incorrect: Dextran is contraindicated as this will increase blood sugar even more.

The nurse is caring for a depressed client. The client has a flat affect, apathy, and slowed physical movement. The client has not bathed in several days and there is a malodorous odor noted. Which intervention would be most appropriate at this time? You answered this question Incorrectly 1. Explain the rules about daily showers. 2. Leave the client alone since there is slowed movement. 3. Tell the client it is time to take a shower. 4. Ask when he or she would like to take a shower.

RationaleStrategies 3. Correct: Depressed clients often have little energy to do or think. Give short, simple commands during this time. 1. Incorrect: Not very therapeutic. This is difficult to comprehend at this time. Give short, clear, simple commands. 2. Incorrect: Do not ignore the problem. You must do what is best for the client and this would not be the best decision. 4. Incorrect: The client will not want to do anything at this time. It will be put off and depressed client's often have difficulty making decisions.

Two days after a myocardial infarction, a client begins reporting orthopnea and dyspnea. Further assessment reveals bi-basilar crackles, jugular venous distension, an S3 heart sound, a BP of 100/60 mm Hg, and apical pulse of 90 beats per minute. The urine output has steadily declined over the past 12 hours. What should the nurse do first? You answered this question Incorrectly 1. Notify the primary healthcare provider. 2. Increase the IV rate. 3. Elevate the head of the bed. 4. Observe for cardiac arrhythmias.

RationaleStrategies 3. Correct: Elevate the head of the bed first. The client is reporting inability to breathe. (Orthopnea means the client needs to sit up to breathe better.) With ANY client having difficulty breathing, the first intervention for the nurse is to sit the client up. This client is showing s/s of heart failure. 1. Incorrect: Your next step is to call the primary healthcare provider after you do something to try to fix the problem. 2. Incorrect: Increasing the IV rate is contraindicated and would make the problem worse. 4. Incorrect: After an MI, all clients are observed for cardiac arrhythmias. This, however, does not fix the problem.

A clinic nurse is educating a client diagnosed with Bell's Palsy. What is the most important educational point the nurse must emphasize to the client? You answered this question Incorrectly 1. Physical therapy will be needed to maintain muscle tone of the face. 2. Massaging the face several times daily using a gentle upward motion. 3. Proper methods of closing eyelids and eye patching. 4. Non-steroidal anti-inflammatory medications are used to alleviate painful muscles.

RationaleStrategies 3. Correct: Even though all are educational points that need to be provided to the client, this is the most important educational point to make. Keratitis, or the inflammation of the cornea, is one of the most dangerous complications for a client with Bell's palsy. As a precautionary measure, the nurse must ensure that the cornea is protected even if the eyelids will not close. 1. Incorrect: Physical therapy will be needed, however care to prevent eye injury takes priority. 2. Incorrect: This can be done once the client's facial sensitivity to touch decreases and the client can tolerate touching the face. Preventing eye injury takes priority. 4. Incorrect: This is true, but again, protecting the eye is the most important point to convey to the client.

The clinical specialist is teaching a group of new staff nurses about therapeutic communication. Which statement by one of the staff nurses indicates to the clinical specialist that further teaching is needed? You answered this question Correctly 1. Effective communication involves feedback to let the sender know that the message was understood by the receiver. 2. An effective message should be clear and complete. 3. Therapeutic communication does not include the use of gestures. 4. I must listen with a "third ear" to be aware of what the client is not saying.

RationaleStrategies 3. Correct: Gestures are a type of nonverbal communication which can provide assistance in communicating therapeutically with a client. Other forms of nonverbal communication include facial expression, touch, mannerisms, posture, position, and personal space. 1. Incorrect: This is a correct statement regarding therapeutic communication. 2. Incorrect: This is a correct statement regarding therapeutic communication. 4. Incorrect: This is a correct statement regarding therapeutic communication. The third ear listens for what the client is not saying or picks up on hints as to the real message.

When caring for a client with hepatitis A, the nurse should take what special precaution? You answered this question Correctly 1. Wear gloves when handling blood and body fluids. 2. Wear a mask and gown before entering the room. 3. Use gloves when removing the client's bedpan. 4. Use caution when bringing food to the client.

RationaleStrategies 3. Correct: Hepatitis A is transmitted by the fecal/oral route. 1. Incorrect: Hepatitis B is transmitted by contact with blood and body fluids. 2. Incorrect: Masks are not necessary when a client is placed on contact isolation. Hepatitis A is NOT transmitted by airborne or droplet transmission. 4. Incorrect: Use caution in bringing fresh produce to clients placed on reverse isolation.

The home health nurse is caring for a client with a neurological urinary tract dysfunction. What information should be included when teaching the client how to perform intermittent self catheterization? You answered this question Correctly 1. Performed in an emergency department (ED). 2. Prevents urinary catheter infections. 3. Perform as a clean procedure. 4. Requires using sterile gloves.

RationaleStrategies 3. Correct: Home intermittent catheterization is a clean, not sterile technique when performed in the home environment. Home intermittent catheterization is preferred over continuous use of an indwelling catheter, as an indwelling catheter increases client risk of urinary tract infection (UTI). 1. Incorrect: The client can be taught to do self-catheterization at home. The client does not need to go to the emergency department (ED) to perform the self-catheterization procedure. 2. Incorrect: Performing intermittent self-catheterization at home is recommended for urinary retention. It does not prevent urinary tract infections. 4. Incorrect: Intermittent self-catheterization is a clean procedure, not sterile technique.

The nurse is performing CPR on an adult client with facial and neck trauma. Following the administration of rescue breaths, where is the best location for the nurse to assess for a pulse in this client? You answered this question Incorrectly 1. Apical area 2. Carotid artery 3. Femoral artery 4. Radial artery

RationaleStrategies 3. Correct: Pulses that are best palpated are large and close to the trunk of the body. The femoral artery is large and at the trunk (proximal) of the body. 1. Incorrect: It would take too long to use a stethoscope and listen for an apical pulse on the client. A quicker area of checking the pulse would need to be used. 2. Incorrect: The client has bilateral neck trauma. The carotid artery would not be the best site to assess for a pulse. 4. Incorrect: The radial artery is not as large as the femoral artery and is distal to the femoral artery.

A nurse invites a friend home one evening. On arrival, the friend sees the nurse's large, white, long-haired cat sitting on the couch and begins to experience palpitations, trembling, nausea, shortness of breath, and a feeling of losing control. What should the nurse do first? You answered this question Correctly 1. Stay with the friend until the friend feels better. 2. Have the friend breathe into a paper bag. 3. Remove the cat from the room. 4. Dim the lights in the room.

RationaleStrategies 3. Correct: Remove the source of the panic attack first, then continue to assess the person for symptoms. Removing the cat "fixes" the problem. 1. Incorrect: This is a correct answer, but remove the cat first. 2. Incorrect: This will help hyperventilation if it occurs, but the stem of the question said the client was having "shortness of breath" related to seeing the cat. Remove the cat first as this will fix the problem and alleviate the symptoms. 4. Incorrect: This is a correct answer, but remove the cat first.

Which statement by a student nurse indicates to the nurse educator that teaching regarding witnessing consent signatures has been successful? You answered this question Correctly 1. "Two people must witness a consent signature." 2. "A RN must witness a consent signature." 3. "Signing as a witness implies that the client willingly signed the consent." 4. "A witness must be over the age of 21."

RationaleStrategies 3. Correct: Signing as a witness implies that the witness has observed the client personally signing the consent form with no coercion. 1. Incorrect: Only one signature is required as a witness. 2. Incorrect: The witness does not have to be an RN. 4. Incorrect: A witness is required to be over the age of 18.

The nurse is caring for a client taking spironolactone. Which dietary change should the nurse teach the client to make when starting treatment with this medication? You answered this question Correctly 1. Eat extra helpings of bananas. 2. Increase intake of water. 3. Avoid salt substitutes. 4. Increase intake of green leafy vegetables.

RationaleStrategies 3. Correct: Spironolactone is a potassium sparing diuretic. Salt substitutes have potassium instead of sodium and should be avoided. 1. Incorrect: Bananas have potassium and should be avoided to prevent hyperkalemia and life-threatening arrhythmias. 2. Incorrect: Water intake does not affect the use of spironolactone and is not the best answer to the question. 4. Incorrect: Green leafy vegetables contain vitamin K and are not contraindicated. This is a distractor to the answer that could cause the most harm to the client if not chosen.

The nurse is assessing pain after surgery in a 3 year old client with a known developmental delay. Which pain scale should the nurse use to assess this client's pain level? You answered this question Incorrectly 1. CRIES scale 2. Numeric scale 3. FLACC scale 4. FACES scale

RationaleStrategies 3. Correct: The FLACC scale can be used for pediatric clients from age 2 months to 7 years and is appropriate when clients cannot communicate their pain. 1. Incorrect: The CRIES scale is used with neonates and infants. 2. Incorrect: Not age-appropriate; used for children ages 5 and up. 4. Incorrect: Not age-appropriate. The FACES scale is indicated for children ages 3 years and up. When using the FACES scale, the child must be able to understand the difference between pain and being sad. Because this child is only 3 years old (the bottom age for use of the FACES scale), and because the client has a developmental delay, the FLACC scale is a better choice as it is based on nursing observations.

A new admit arrives to the nursing unit with one thousand dollars in cash. What would be the best action by the nurse to safeguard the client's money? You answered this question Correctly 1. Insist the money go home with the client's visitor. 2. Place the money in the client's bedside table drawer. 3. Put itemized cash in envelope and place in hospital safe. 4. Lock money up in narcotic cabinet with client's identity and room number.

RationaleStrategies 3. Correct: The best action by the nurse would be to itemize the valuables, place in an envelope, and put in the hospital safe. 1. Incorrect: This is not the best option. The visitor may not be the best person to take the money. The client also has the right to refuse. 2. Incorrect: This is not a safe option. Anyone could retrieve the money. 4. Incorrect: This is not a safe option. Anyone with access could retrieve the money.

Following surgery, a client refuses to ambulate as prescribed. What action should the nurse take? You answered this question Correctly 1. Notify the primary health care provider of client's refusal to ambulate. 2. Offer the client pain medication. 3. Explain complications associated with bed rest. 4. Perform passive range of motion exercises.

RationaleStrategies 3. Correct: The nurse should educate the client about complications that can be prevented with ambulation, such as constipation, pneumonia, or deep vein thrombosis (DVT). 1. Incorrect: The first action should be for the nurse to educate the client so an informed decision can be made. This would put the nurse in an advocacy role and would more likely persuade the client to comply with ambulation. 2. Incorrect: The first action should be for the nurse to educate the client so that he/she can make an informed decision. Offering pain medication would be appropriate if pain is impeding the client's ability to move; however, pain medications may make the client at risk for falls so safety precautions would be priority. 4. Incorrect: The first action should be for the nurse to educate the client so that an informed decision can be made. Passive range of motion would not be the best option at this time.

A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops slurred speech, shuffling gait and drooling. Which prescribed PRN medication would the nurse administer? You answered this question Incorrectly 1. Lorazepam 2. Atropine 3. Benztropine 4. Chlorpromazine

RationaleStrategies 3. Correct: These signs and symptoms are reflective of pseudoparkinsonism, a form of extrapyramidal side effects which are side effects of the haloperidol. An anticholinergic agent maybe used for treatment. This is an anticholinergic agent that may be used for extrapyramidal side effects. 1. Incorrect: This is a sedative/hypnotic or antianxiety agent. It is not used for treatment of extrapyramidal side effects. 2. Incorrect: This is an anticholinergic agent, but not one commonly used to treat pseudoparkinsonism, a form of extrapyramidal side effects. It is commonly used to treat arrhythmias and preoperatively to decrease secretions. 4. Incorrect: This is another antipsychotic medication.

A client has been prescribed vancomycin 1 gram IV every 12 hours for the treatment of methicillin-resistant staphylococcus aureus (MRSA). Which action by a new nurse when administering this medication would require intervention by the charge nurse? You answered this question Correctly 1. Dilutes medication in NS 100 mL. 2. Delivers medication via an IV pump. 3. Calculates infusion rate at 30 minutes. 4. Monitors IV site every 30 minutes during infusion.

RationaleStrategies 3. Correct: This dose of medication should be delivered over at least 60 minutes to prevent hypotension and ototoxicity. 1. Incorrect: The minimum dilution for 1 gram is 100 mL, so this action does not need intervention. 2. Incorrect: This is a correct action by the new nurse. A pump is required to ensure that medication is not delivered too rapidly. 4. Incorrect: A peripheral IV site should be monitored for pain, redness or swelling prior to initiating the infusion and every 30 minutes until the completion of the infusion.

The nurse is caring for a client who has taken an acetaminophen overdose. Which symptom is the client most likely to exhibit? You answered this question Correctly 1. Expectorating pink frothy sputum 2. Sudden onset of mid-sternal chest pain 3. Jaundiced conjunctiva 4. Diaphoresis and fever

RationaleStrategies 3. Correct: This is a sign of liver damage, which is caused by an overdose of acetaminophen. 1. Incorrect: This is a symptom of pulmonary edema, not liver damage. 2. Incorrect: This is a symptom of myocardial ischemia, not liver damage. 4. Incorrect: Acetaminophen would decrease fever, and fever could cause diaphoresis so neither of these are expected with acetaminophen overdose.

The nurse is evaluating dietary education provided to a client diagnosed with cholecystitis. The nurse determines that further teaching is necessary when the client chooses which meal to consume? You answered this question Incorrectly 1. Cup of oatmeal, blueberries, soymilk 2. Whole grain pasta, marinara sauce, baked fish, coffee 3. Spaghetti with meat sauce, peas, garlic French bread, tea 4. Lentil soup, vegetable medley, fruit salad, water

RationaleStrategies 3. Correct: This is not a good choose for this client. Meat is high fat. French bread with butter is low fiber and high fat. 1. Incorrect: This is a good meal choose when on a low fat, high fiber diet. Blueberries are high in fiber and all are low fat. 2. Incorrect: This is a good low fat, high fiber meal choose. Whole grain pasta is high in fiber and low in fat. Fish and marinara sauce are low in fat. 4. Incorrect: These are low fat, high fiber items to consume.

The nurse is providing post-operative care to the craniotomy client. Hourly urinary output increases from 100 mL last hour to 500 mL this hour. What action by the nurse takes priority? You answered this question Correctly 1. Elevate HOB 90 degrees 2. Auscultate apical pulse 3. Obtain a blood pressure 4. Assess Glasgow Coma Score

RationaleStrategies 3. Correct: This is the best answer because we are "worried" this client is going into SHOCK due to diabetes insipidus. So, you better be checking a BP. This is a time where checking the BP is appropriate. If we "assume the worst" I better check a blood pressure. It could have dropped out the bottom. 1. Incorrect: This client is losing too much fluid. We worry about shock. Lower the HOB. 2. Incorrect: Checking the pulse is a good thing, but not as important as checking the BP. 4. Incorrect: If my client is going into shock, the highest priority is to assess the BP.

A client is hospitalized because of severe malnutrition related to anorexia nervosa. What is the most important goal for this client? You answered this question Incorrectly 1. Verbalize understanding that eating behaviors are maladaptive. 2. Verbalize the importance of adequate nutrition. 3. Achieve at least 80% of expected body weight. 4. Acknowledge misperception of body image as fat.

RationaleStrategies 3. Correct: Until appropriate weight is gained, the client continues to be at risk for major health complications including hypotension, cardiac arrhythmias, poor muscle tone, increased risk for infection, abnormal liver function, and damaged kidneys. 1., 2. & 4. Incorrect: These are all appropriate goals; however, the most important one is that the client gain adequate weight.

The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice for the nurse to place the client in until full consciousness is regained? You answered this question Incorrectly 1. Supine 2. Fowler's 3. Lateral 4. High Fowler's

RationaleStrategies 3. Correct: When someone is very sedated and not fully conscious, we want them on their side so the airway remains open and the secretions can drain. 1. Incorrect: No, the jaw will fall back, the tongue will block the airway, and the client will have airway obstruction, either partial or maybe even life-threatening. 2. Incorrect: No, if you sit a client up who is not fully conscious, the client's head tips forward and blocks the airway. 4. Incorrect: Again, head may fall forward and block airway.

A small community has experienced a severe tornado that hit a shopping mall and caused extreme damage and suspected mass casualties and injuries. Which intervention takes priority? You answered this question Incorrectly 1. Triage victims and tag according to injury. 2. Assess the immediate area for electrical wires on the ground and in vicinity of victims. 3. Activate the community emergency response team. 4. Begin attending to injuries as they are encountered.

RationaleStrategies 3. Correct: With mass casualties, community response teams are needed. 1. Incorrect: This would be the third step. 2. Incorrect: This would be the second step so that further injuries are not encountered. 4. Incorrect: Triage must occur before treatment of anyone so that an accurate assessment of level of injuries can be made. With mass casualties, a color tag system is usually implemented.

A client with a history of congestive heart failure has an implantable cardioverter defibrillator (ICD) surgically implanted. What teaching points should the nurse provide the client prior to discharge? You answered this question Incorrectly 1. Avoid hot baths and showers. 2. Increase intake of leafy green vegetable products. 3. Avoid magnets directly over the site. 4. Notify primary healthcare provider whenever a shock is delivered by the ICD. 5. Driving is not recommended for 1 year after placement of an ICD.

RationaleStrategies 3., & 4. Correct: Magnets can deactivate the defibrillator. Other transmitter devices should also be avoided. Most arrhythmias need only one shock, but the healthcare provider should be notified when a shock is delivered so that monitoring can increase. 1. Incorrect: Hot baths or showers are not contraindicated with ICDs. 2. Incorrect: Increase of leafy green vegetable products would have no relation to the ICD but should be avoided if the client is on warfarin. 5. Incorrect: The client cannot drive for 6 months after implantation of an ICD and cannot drive for 6 months after any shock therapy from the ICD.

Which assignment would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? You answered this question Incorrectly 1. Obtaining a sterile urine specimen from an indwelling catheter. 2. Inserting an in-and-out catheter on a client postpartum. 3. Taking vital signs on a client 12 hours postpartum. 4. Removing an indwelling catheter on a client postpartum. 5. Perform perineal care on a client with an episiotomy.

RationaleStrategies 3., & 5. Correct: Taking vital signs is within the scope of practice for the UAP, but the nurse is responsible for evaluating the vital signs. Performing perineal care is within the scope of practice for the UAP. The nurse is responsible for assessing the episiotomy and confirming that perineal care is done properly. 1. Incorrect: Invasive procedures are not appropriate tasks for UAP (obtaining sterile specimen from indwelling catheter). 2. Incorrect: Invasive procedures are not appropriate tasks for UAP (inserting catheter). 4. Incorrect: Invasive procedures are not appropriate tasks for UAP (removing indwelling catheter).

Family members have been asking triage nurses if loved ones were admitted to the hospital during a national emergency situation with massive casualties. What response should be made by the nurses? You answered this question Incorrectly 1. Tell the family members that information about clients cannot be provided. 2. Ask for the victims' permission before talking with the family members. 3. Instruct the family to wait for public announcements about victims. 4. Inform them if their family members have been admitted.

RationaleStrategies 4. Correct. The national emergency situation allows waivers for the Health Insurance Portability and Accountability Act (HIPAA) provisions. Due to the emergency situation, the nurse may inform the family members about the status of their loved ones. 1. Incorrect. During a national disaster declared by the President, information may be given to families without client consent. 2. Incorrect. There is no need to make the family more worried if information is known. Waivers for certain elements of HIPAA are allowed during the emergency period. 3. Incorrect. The nurse may legally give information to the family. The triage nurse may provide information concerning their family members.

The nurse makes selections from the hospital menu for a client who is confused and suspicious of others. Which menu choice is best? You answered this question Correctly 1. Ham and vegetable casserole 2. Cheese and crackers 3. Caffeine free tea 4. Packaged sugar free Jell-O

RationaleStrategies 4. Correct: A client who is suspicious of others needs foods that are packaged and can see them opened. 1. Incorrect: A client who is suspicious of others needs to be able to identify the ingredients in the food that is being eaten. A casserole contains many ingredients and the client may fear that something has been added to the food. 2. Incorrect: Finger foods are best for clients that are manic. 3. Incorrect: Drinks and foods with no caffeine are okay for the confused and suspicious client but this menu choice is not the best choice from the list here.

A hysterical college student arrives in the emergency department in bloody soiled clothing. The nursing assessment reveals facial bruising and multiple contusions consistent with the client's report of being raped. Which initial nursing intervention takes priority at this time? You answered this question Correctly 1. Notify police of the alleged rape. 2. Allow the client privacy to wash self. 3. Remove clothing and bag for evidence. 4. Encourage client to express fears and anxiety.

RationaleStrategies 4. Correct: Although there are specific protocols that must be followed when dealing with rape clients, it is important to remember that this client had all control taken away during the attack. The emotional effects of rape are as traumatizing as the physical injuries. Allowing the client to first express emotions, such as fear or anxiety, returns a small amount of control to a situation in which the client has little or none. 1. Incorrect: The police will indeed be notified of the situation by the hospital personnel, but the nurse's initial priority is to focus on the client's needs, both physical and emotional. 2. Incorrect: The client will not be permitted to clean self until all evidence has been collected per protocol. However, initial contact between nurse and client should focus on more than just the physical aspects of the situation. 3. Incorrect: Collection of all evidence for the police is a crucial part of treating rape clients and will be completed according to protocols. But it is more important to remember that this client has already been violated during the attack. Removing clothing before addressing emotional needs may further exacerbate that sense of violation.

The nurse is teaching a client who has been prescribed daily glucocorticoids for the treatment of Addison's disease. What teaching points should the nurse emphasize? You answered this question Correctly 1. Be aware of the development of hypoglycemia. 2. Test the urine for albumin or other proteins. 3. Take the medication 30 minutes prior to bedtime. 4. Maintain the prescribed dose without interruption in therapy.

RationaleStrategies 4. Correct: Glucocorticoids should not be abruptly discontinued due to the risk of adrenal suppression with prolonged use. Doses should be tapered before being discontinued. 1. Incorrect: Increased blood sugar is an adverse effect associated with glucocorticoid therapy, not hypoglycemia. 2. Incorrect: Protein in the urine is not associated with glucocorticoid therapy. 3. Incorrect: Insomnia is an adverse effect associated with glucocorticoid therapy. Daily dosing of glucocorticoids should be done in the morning to decrease this effect.

The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given? You answered this question Incorrectly 1. "The action of the medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you do not break a bone." 4. "Glycopyrrolate will decrease stomach secretions."

RationaleStrategies 4. Correct: Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease the risk of aspiration. 1. Incorrect: The client has a right to be told the reason the drug is given. This is a nontherapeutic communication response. The nurse should not refuse the client's desire to understand their medications. 2. Incorrect: Glycopyrrolate blocks the secretions in the mouth, throat, airway and stomach. The medication does not prevent the client having a seizure. The ECT will induce a seizure, which is the desire. 3. Incorrect: This is not the drug's purpose so this would be incorrect information to give to the client.

A nurse attaches a client to continuous cardiac monitoring due to a potassium level of 2.8 mEq (2.8 mmol). The nurse should monitor for which dysrhythmia? You answered this question Correctly 1. Third degree heart block 2. Atrial fibrillation 3. Premature atrial contractions 4. Premature ventricular contractions

RationaleStrategies 4. Correct: Hypokalemia is reflected by the EKG. The earliest EKG change is often premature ventricular contractions (PVCs) which can deteriorate into ventricular tachycardia or fibrillation (VT/VF) without appropriate potassium replacement. 1. Incorrect: Atrial-ventricular blocks are not often seen initially with hypokalemia. 2. Incorrect: Atrial fibrillation is not often seen with hypokalemia. 3. Incorrect: PACs are not often seen initially with hypokalemia.

The nurse is caring for a client who has been diagnosed with dissociative identity disorder. What is the most appropriate short term goal? You answered this question Incorrectly 1. Recovery of memory deficits. 2. Demonstration of the ability to perceive stimuli correctly. 3. Elimination of causative phobia. 4. Verbal recognition of the existence of multiple personalities.

RationaleStrategies 4. Correct: In order for therapy to be successful, the client must first acknowledge that there are multiple personalities within the client's personality. 1. Incorrect: This is related to a client with dissociative amnesia. 2. Incorrect: This is related to a client with disturbed sensory perception. 3. Incorrect: This outcome would not be related to this client.

A client with gestational diabetes delivers an infant with macrosomia. What is the most vital component of the infant's assessment for the nurse to perform? You answered this question Incorrectly 1. Evaluation of the infant for cephalhematoma. 2. Determining if the infant sustained a clavicle fracture. 3. Observing for arm movement to evaluate for facial palsy. 4. Frequent blood glucose monitoring to ensure stable values.

RationaleStrategies 4. Correct: Infants of diabetic mothers are at risk for hypoglycemia following birth. Hypoglycemia can trigger seizures and cognitive deficits. 1. Incorrect: Assessing for cephalhematoma is important in macrosomia infants, but not as vital as ensuring stable glucose levels. 2. Incorrect: Assessing for clavicle fracture is important in macrosomia infants, but not as vital as ensuring stable glucose levels. 3. Incorrect: Assessing for facial palsy is important in macrosomia infants, but not as vital as ensuring stable glucose levels.

The charge nurse was notified that a client with 2nd degree burns is being admitted to the floor. Which nurse should be assigned this client? You answered this question Correctly 1. A nurse caring for clients with spina bifida and acute gastroenteritis. 2. The new nurse, out of orientation for 2 months, caring for clients diagnosed with tonsillitis and anorexia nervosa. 3. The pregnant nurse caring for clients with cystic fibrosis and staph infection. 4. A nurse caring for clients with irritable bowel syndrome and post op appendectomy.

RationaleStrategies 4. Correct: It would be best to assign the client to this nurse because the clients this nurse is caring for do not have anything contagious, which will decrease the risk of the burn client becoming infected. 1. Incorrect: This nurse is caring for a client with infection: acute gastroenteritis. 2. Incorrect: This nurse is caring for a client with infection: tonsillitis. 3. Incorrect: This nurse caring for a client with infection: staph infection.

The nurse is teaching a diabetic client who has been prescribed Lispro insulin about avoiding hypoglycemia. What administration teaching is priority? You answered this question Correctly 1. Take insulin 30 minutes before bedtime 2. Take insulin twice daily in AM and PM 3. Take insulin one hour before meals 4. Take insulin with meals

RationaleStrategies 4. Correct: Lispro is a rapid-acting insulin that should only be taken with food or within 15 minutes of a meal. 1. Incorrect: Lispro is a rapid-acting insulin and should not be taken without food. 2. Incorrect: Lispro is a rapid-acting insulin and should not be taken without food. 3. Incorrect: Lispro is a rapid-acting insulin and should not be taken without food. Giving an hour before eating is too early and would put the client at risk for hypoglycemia.

The nurse is assigned to care for a client who has developed intestinal obstruction and has had an NG tube inserted to low suction. Blood gases are pH 7.54, pCO2 52, HCO3 35. Assessment of the client by the nurse reveals that the client is weak, shaky, and reporting tingling of the fingers. The nurse determines that this client is in which acid/base imbalance? You answered this question Correctly 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

RationaleStrategies 4. Correct: Metabolic alkalosis occurs from gastric losses via vomiting, NG tubes to suction, or lavage, and potent diuretics. Signs and symptoms include n/v, sensorium changes, tremors, convulsions. pH > 7.45, pCO2 > 45, HCO3 > 27. 1. Incorrect: Not a respiratory related acid/base imbalance. 2. Incorrect: Not a respiratory related acid/base imbalance. 3. Incorrect: Not acidosis. There is loss of gastric acid.

Post cataract removal a client reports nausea and severe pain in the operative eye. Which nursing intervention takes priority? You answered this question Correctly 1. Administer morphine and ondansetron. 2. Reposition client to non-operative side. 3. Massage the canthus to unblock the lacrimal duct. 4. Notify the primary healthcare provider.

RationaleStrategies 4. Correct: Severe pain with nausea indicates an increase in intraocular pressure and needs to be reported at once. Eye damage can result if not resolved quickly. The primary healthcare provider may prescribe medications or take the client back to surgery. 1. Incorrect: This is not the priority as severe pain and nausea indicates an increase in intraocular pressure and needs to be reported at once. 2. Incorrect: Repositioning will not fix the problem. Severe pain with nausea indicates an increase in intraocular pressure and needs to be reported at once. 3. Incorrect: The problem is an increase in intraocular pressure which needs to be reported to the primary healthcare provider.

Which nursing action is likely to improve client satisfaction and demonstrate acts of beneficence? You answered this question Correctly 1. Allowing clients to make their own decisions about care 2. Answering all questions posed by client in an honest manner 3. Reporting faulty equipment to the proper departments 4. Sitting at the bedside and listening to an elderly client

RationaleStrategies 4. Correct: Sitting and listening demonstrates kindness and compassion that are consistent with the ethical term "beneficence." Beneficence is taking positive action to help others and a desire to do good which is the core principle of client advocacy. 1. Incorrect: Autonomy is the ethical principle illustrated here by supporting independent decision making with clients. 2. Incorrect: Fidelity is the ethical principle illustrated here and refers to the concept of keeping a commitment. It is based upon the virtue of caring. 3. Incorrect: Reporting faulty equipment is an act to promote nonmaleficence or to do no harm. This is the core of nursing ethics.

A client diagnosed with arachnophobia is prescribed alprazolam 0.5 mg orally three times daily. The nurse knows that teaching about this medication is successful when the client makes what statement? You answered this question Correctly 1. Alprazolam will take up to two weeks to start working. 2. The drug does not cause drowsiness, so my daily activities will not suffer. 3. This medication cannot be taken with food. 4. I should not stop taking alprazolam suddenly.

RationaleStrategies 4. Correct: Suddenly stopping could produce serious withdrawal symptoms, such as depression, insomnia, anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, and delirium. 1. Incorrect: Alprazolam works relatively quickly. 2. Incorrect: Drowsiness, confusion, and lethargy are the most common side effects. The client should not drive or operate dangerous machinery while taking the medication. 3. Incorrect: If the client experiences nausea and vomiting, take with food or milk.

A client, admitted to the medical unit with persistent vomiting, reports weakness and leg cramps. The spouse states that the client is irritable. The primary healthcare provider has prescribed lab work and blood gases. Based on this assessment, the nurse anticipates which acid/base imbalance? You answered this question Correctly 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

RationaleStrategies 4. Correct: Symptoms of 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 acid base imbalance. 2. Incorrect: Not respiratory related acid base imbalance. 3. Incorrect: Not acidosis. There is loss of gastric acid and K with persistent vomiting.

The nurse is caring for a Native American client who has returned to the surgical floor following abdominal surgery. The nurse is concerned about the level of discomfort that the client is experiencing. Which comment is the nurse likely to hear upon assessment? You answered this question Correctly 1. "The pain is getting worse. I can't stand it." 2. "I need something for pain as soon as possible." 3. "I hope that the pain will go away soon." 4. "I am doing okay. The pain is not bad."

RationaleStrategies 4. Correct: The Native American client is likely to be quiet and less expressive of pain. Native Americans tend to tolerate high levels of pain. 1. Incorrect: This comment is likely to come from the dominant American culture where pain is considered something to be treated. 2. Incorrect: Native Americans tend to tolerate high levels of pain. Abdominal surgery usually results in sensations of pain for most people. 3. Incorrect: The Native American client is likely to be very quiet about the pain being experienced.

A client with heart failure and pulmonary edema is given furosemide intravenously. Which assessment indicates that the furosemide has achieved the desired effect? You answered this question Incorrectly 1. Weight has decreased 2 pounds. 2. Systolic blood pressure has decreased. 3. Urinary output has increased. 4. Lungs have fewer rales on auscultation.

RationaleStrategies 4. Correct: The goal for diuretic therapy in this client is to prevent/relieve fluid accumulation in the lungs. This answer addresses the most life-threatening sequelae with HF. The number one thing to worry about in clients with HF is pulmonary edema, because this is what can kill the client. 1. Incorrect: Weight loss is a good assessment of fluid loss or gain, especially acute weight changes. The stem of the question, however, asks which is the desired effect? The desired effect is to decrease fluid in the lungs and weight loss alone does not ensure that the lungs are clearing. 2. Incorrect: Lowered blood pressure is an expected finding, but treatment of pulmonary edema is the primary goal. 3. Incorrect: Increased urinary output is an expected finding, but treatment of pulmonary edema is the primary goal.

Upon receiving a diagnosis of Stage 4 lung cancer, an elderly client expresses regret for having chosen to smoke. Which response by the nurse would best help the client cope at this time? You answered this question Correctly 1. "You are lucky to have lived a very long life." 2. "We have younger clients in worse shape than you." 3. "The doctor will make sure to treat any pain." 4. "You are regretting your decision to smoke."

RationaleStrategies 4. Correct: The nurse responds with an open-ended statement that reflects back what the client has stated. This allows the client to continue expressing concerns and feelings about the diagnosis or past choices. At this time, encouraging the client to verbalize is the best choice to help with coping. 1. Incorrect: This is a closed-ended statement that diminishes the client's feelings about the diagnosis or possible personal choices that may have led to this situation. The response infers that the client should be grateful for the life lived and belittles the client's response. 2. Incorrect: Such a non-therapeutic statement does not address the client's feelings and in fact devalues the client by comparing this situation to that of other clients. The nurse should focus on helping the client to cope at this time by encouraging the expression of feelings. 3. Incorrect: Rather than allowing the client to verbalize concerns or emotions, the nurse has responded with a close-ended statement that addresses a topic not initiated by the client's comments. This option does nothing to help the client cope, but rather may instill fear by referring to pain that may or may not occur.

The nurse assesses a multigravida who is four hours postpartum. Findings include that fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The lochia is moderately heavy and bright red. Which nursing intervention has priority? You answered this question Correctly 1. Massage the fundus. 2. Administer intravenous oxytocin. 3. Document these normal findings. 4. Assist the client up to void.

RationaleStrategies 4. Correct: These findings are caused by a full bladder, which prevents the uterus from contracting down and achieving homeostasis. Once the bladder is empty, the fundus will contract adequately and return to its normal location at level of umbilicus or 1 finger breadth below the umbilicus and in the midline. A distended bladder will displace the uterus, usually to the right. 1. Incorrect: The nurse may check fundus after client voids to ensure that this fixes the problem. 2. Incorrect: Administering oxytocin is not the first intervention for this issue. 3. Incorrect: These are not normal findings so this would be incorrect information for the nurse to document.

The nurse is caring for a client with possible hepatic failure. The nurse asks the client to sign a permit for a procedure. The nurse recalls the client's admission signature as legible, but, now observes a jerky, illegible signature. What should the nurse suspect is the cause of this handwriting change? You answered this question Correctly 1. Fetor 2. Ataxia 3. Apraxia 4. Asterixis

RationaleStrategies 4. Correct: Yes, the liver flap, which is an abnormal muscle tremor, is usually found in clients with diseases of the liver. This is an indication that the hepatic failure is worsening and needs to be documented. 1. Incorrect: This is an offensive odor of the client's breath often associated with liver failure. 2. Incorrect: This is uncoordinated movement that is associated with many different neuromuscular disorders. 3. Incorrect: This is a term to describe not using items for their intended purpose and is associated with neurological disorders and damage to the brain.

Which foods should the nurse teach a client to avoid when prescribed a diet limiting purine rich foods? You answered this question Correctly 1. Peanut butter 2. Potatoes 3. Apples 4. Venison 5. Scallops

RationaleStrategies 4., & 5. Correct: Meats such as liver, bacon, veal, and venison are high in purine and should be avoided. Seafood such as sardines, mussels, codfish, scallops, trout, and haddock are high in purine and should be avoided. 1., 2., & 3. Incorrect: The client can enjoy peanut butter, potatoes, fruits and fruit juices, vegetables.

Exhibit: Azithromycin 500 mg in 250 ml D5W over one hour IVPB daily Cefriaxone 500 mg in 50 ml of D5W IVPB over 30 minutes BID. D51/2 NS at 125 ml/hr Saline Loc for IVPBs The nurse is caring for a client who has pneumonia and is dehydrated. The primary healthcare provider has prescribed IV fluids and IV antibiotics. Based on the primary healthcare provider's prescription and oral intake, what would be the 24 hour intake for this client? Exhibit You answered this question CorrectlyEnter the answer for the question below.

RationaleStrategies Answer: ___3670_ mls Rationale: The intake would be calculated by adding the following: Azithromycin: 250 mls Ceftriaxone: 50 ml X 2 = 100 mls IV of D51/2 NS at 125 ml/hr: 125mls X 24 hours = 3000 mls Total oral intake is 270 +50 = 320 mls TOTAL INTAKE = 3670 mls

In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last. You answered this question CorrectlyThe Correct Order Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. Clean around Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's over surgical wound and Penrose drain. Apply abdominal dressing pad. Your Selected Order Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. Clean around Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's over surgical wound and Penrose drain. Apply abdominal dressing pad.

RationaleStrategies First, apply clean gloves. Second, remove soiled dressings. Third, discard soiled dressings and clean gloves in red bag. Fourth, don sterile gloves. Fifth, clean surgical wound with moistened sterile 4x4's. Sixth, clean around Penrose drain using circular pattern inside to outside. Seventh, place dry, sterile 4x4's over surgical wound and Penrose drain. Eighth, apply abdominal dressing pad.

A client who has been on bed rest for several days is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last. You answered this question CorrectlyThe Correct Order Assess the client's orientation. Assist the client to sit on the side of the bed for 1-2 minutes. Apply a gait belt to the client's waist. Have the client stand by the side of the bed for a few seconds. Ambulate in the room. Your Selected Order Assess the client's orientation. Assist the client to sit on the side of the bed for 1-2 minutes. Apply a gait belt to the client's waist. Have the client stand by the side of the bed for a few seconds. Ambulate in the room.

RationaleStrategies In order to keep a client safe, the nurse should first assess the client's orientation to determine the client's ability to follow instructions. Second, to avoid orthostatic hypotension, the nurse should assist the client to sit on the side of the bed. Third, apply the gait belt to ensure safety while ambulating. Fourth, assist the client to stand for a few seconds. The fifth action is to ambulate in the room.

The primary healthcare provider prescribed tolbutamide 250 mg orally twice a day. The pharmacy dispensed tolbutamide 0.5 g scored tablets. How many tablets will the nurse administer? Round your answer using one decimal point. You answered this question CorrectlyEnter the answer for the question below.

RationaleStrategies Step 1: 1000 mg : 1 g = x mg: 0.5 g x = 500 mg Step 2: 500 mg: 1 tab = 250 mg : x tab 500 x = 250 X = 0.5

The nurse is working with the parents of a preschooler to help promote healthy sleep patterns of approximately 8-12 hours per night. Which intervention should assist the parents to achieve adequate sleep for their preschooler? You answered this question Correctly 1. Offer a time of exercise prior to bedtime. 2. Follow a bedtime routine at least three or four nights per week. 3. Spend about 30 minutes with the preschooler prior to bedtime for stories, prayers, etc. 4. Do not encourage your preschooler to take a toy to bed.

RationaleStrategiesLet's Talk 3. Correct: Rituals help the preschooler to feel secure. Quiet time to read, tell stories, and say prayers prepares the child for sleep. 1. Incorrect: Stimulation of activity before bedtime impedes sleep. 2. Incorrect: The routine should be maintained each night if at all possible. Only through routine does the child feel secure in preparation for bedtime. 4. Incorrect: A special toy helps the child to feel secure and adds to the nighttime routine.

Rifampin

Red orange tears and urine, also contraceptives don't work as well

632. Following routine diagnostic test, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client? A. Maintain adequate cardiac output B. Promote adequate tissue perfusion C. Promote rest and sleep D. Reduce the risk for injury

Reduce the risk for injury.

676. When checking a third grader's height and weight the school nurse notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder (ADHD). Which intervention should the nurse implement?

Refer child to the family healthcare provider.

644. Which instruction is most important for the nurse to provide a client who receives a new plan of care to treat osteoporosis? a. Begin a weight-bearing exercise plan b. Increase intake of foods rich in calcium c. Schedule a bone density tests every year. d. Remain upright after taking the medication.

Remain upright after taking the medication.

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.

618. The nurse is preparing to discharge an older adult female client who is at risk for hy...nurse include with this client's discharge teaching? A. Report any muscle twitching or seizures B. Take vitamin D with calcium daily C. Low fat yogurt is a good source of calcium D. Keep a diet record to monitor calcium intake E. Avoid seafood, particularly selfish

Report any muscle twitching or seizures. Take vitamin D with calcium daily. Low fat yogurt is a good source of calcium. Keep a diet record to monitor calcium intake. Rationale: Twitching and seizure are signs of low calcium. (A) Vit D supplement with calcium to enhance calcium absorption, especially in older adults. Dairy product should be included in the diet. Keeping a food record is a good healthcare practice. Foods high in calcium are recommended to maintain normal calcium level and it is important to verify if the client has allergy to shellfish.

663. The nurse is reinforcing home care instructions with a client who is being discharged following...prostate (TURP). Which intervention is most important for the nurse to include in the client... a. Avoid strenuous activity for 6 weeks b. Report fresh blood in the urine. c. Take acetaminophen for fever 101 d. Consume 6 to 8 glasses of water daily.

Report fresh blood in the urine. Rational: Blood in the urine may be evidence of bleeding that needs immediate intervention

693. A gravida 2 para 1, at 38-weeks gestation, scheduled for a repeat cesarean section in one week, is brought to the labor and delivery unit complaining of contractions every 10 minutes. While assessing the client, the client's mothers enter the labor suite and says in a loud voice, "I've had 8 children and I know she's in labor. I want her to have her cesarean section right now!" what action should the nurse take? A. Request the mother to leave the room B. Tell the mother to stop speaking for the client C. Request security to remove her from the room D. Notify the charge nurse of the situation

Request the mother to leave the room.

709. To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement? a- Confirm that all the staff nurses are being assigned to equal number of clients. b- Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. c- Assign each staff nurse a turn unit charge nurse on a regular, rotating basis. d- Analyze the amount of overtime needed by the nursing staff to complete assignments.

Review the staff nurse job description to ensure that it is clear, accurate, and current. Rationale: Role ambiguity occurs when there is inadequate explanation of job descriptions and assigned tasks, as well as the rapid technological changes that produce uncertainty and frustration. A and D may be implemented if the nurse manager is concerned about role overload, which is the inability to accomplish the tasks related to one's role. C is not related to ambiguity.

Air/Pulmonary Embolism

S/S: Chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom, bloody sputum Turn patient to left side and lower the head of the bed

Transmission Based Precautions - Droplet Think of SPIDERMAN

SPIDERMAN S = sepsis, scarlett fever, streptococcal pharyngitis P = parvovirus B19, pneumonia, pertussis (whooping cough) I = Influezna D = diptheria (pharyngeal) E = epiglottitis R = rubella M =meningitis, mumps, mycoplasma or meningeal pneumonia AN = Adenovirus (private room or cohort mark)

641. A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being...18 months-old child and lives in a rural area. Her husband takes the family car to work daily...transportation during the day. What intervention is most important for the nurse to implement? a. Teach a client amount the use of a home pregnancy test. b. Schedule a weekly home visit to draw hCG values. c. Make a 5 week follow- up with healthcare provider d. Begin chemotherapy administration during the first home visit

Schedule a weekly home visit to draw hCG values. Rationale: To monitor for development of choriocarcinoma, a complication TD, level of hCG should be monitor for negative results.

609. A male client recently released from a correctional facility arrives at the clinic with a cough, fever, and chills. His history reveals active tuberculosis (TB) 10 years ago. What action should the nurse implement? (Select all that apply) a- Administer a PPD test b- Schedule the client for the chest radiograph c- Obtain sputum for acid fast bacillus (AFB) testing d- Place a mask on the client until he is moved to isolation. e- Send the client home with instructions for a prescribe antibiotic.

Schedule the client for the chest radiograph. Obtain sputum for acid fast bacillus (AFB) testing. Place a mask on the client until he is moved to isolation.

A client diagnosed with arachnophobia is prescribed alprazolam 0.5 mg orally three times daily. The nurse knows that teaching about this medication is successful when the client makes what statement?

Sedative It can treat anxiety and panic disorder Suddenly stopping could produce serious withdrawal symptoms, such as depression, insomnia, anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, and delirium. Alprazolam works relatively quickly. Drowsiness, confusion, and lethargy are the most common side effects. The client should not drive or operate dangerous machinery while taking the medication. If the client experiences nausea and vomiting, take with food or milk.

Which needle should the nurse use to administer intravenous fluids (IV) via a client's implanted port?

See Picture

614. In caring for a client receiving the amino glycoside antibiotic gentamicin, it is most important for the nurse to monitor which diagnostic test? a- Urinalysis b- Serum creatinine c- Serum osmolarity d- Liver enzymes.

Serum creatinine. Rationale: Aminoglycosides can cause nephrotoxicity, so it is important for the nurse to monitor the serum creatinine level can monitor the renal function.

Which statement by a student nurse indicates to the nurse educator that teaching regarding witnessing consent signatures has been successful?

Signing as a witness implies that the witness has observed the client personally signing the consent form with no coercion. Only one signature is required as a witness. The witness does not have to be an RN. A witness is required to be over the age of 18.

Which nursing action is likely to improve client satisfaction and demonstrate acts of beneficence?

Sitting and listening demonstrates kindness and compassion that are consistent with the ethical term "beneficence." Beneficence is taking positive action to help others and a desire to do good which is the core principle of client advocacy.

A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child?

Sitting up and leaning forward

Hyperthyroidism think of Michael Jackson in THRILLER

Skinny, Nervous, Buldging Eyes, Up all Night, Heart Beating Fast

791. An infant is receiving gavage feedings via nasogastric tube. At the beginning of the feeding, the infant's heart rate drops to 80 beats / minute. What action should the nurse take?

Slow the feeding and monitor the infant's response.

754. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client's discharge plan? (Select all that apply). A. Practice relaxation exercises B. Limit fluids to avoid bladder distention C. Space activities to allow for rest periods D. Avoid persons with infections E. Take warm baths before starting exercise

Space activities to allow for rest periods. Take warm baths before starting exercise .

The nurse is caring for a client taking spironolactone. Which dietary change should the nurse teach the client to make when starting treatment with this medication?

Spironolactone is a potassium sparing diuretic. Salt substitutes have potassium instead of sodium and should be avoided.

The primary healthcare provider prescribed tolbutamide 250 mg orally twice a day. The pharmacy dispensed tolbutamide 0.5 g scored tablets. How many tablets will the nurse administer? Round your answer using one decimal point.

Step 1: 1000 mg : 1 g = x mg: 0.5 g x = 500 mg Step 2: 500 mg: 1 tab = 250 mg : x tab 500 x = 250 X = 0.5

The primary healthcare provider prescribed tolbutamide 250 mg orally twice a day. The pharmacy dispensed tolbutamide 0.5 g scored tablets. How many tablets will the nurse administer? Round your answer using one decimal point. Enter the answer for the question below.

Step 1: 1000 mg : 1 g = x mg: 0.5 g x = 500 mg Step 2: 500 mg: 1 tab = 250 mg : x tab 500 x = 250 X = 0.5

696. During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 f. which intervention should the nurse implement? A. Stop the transfusion start a saline B. Observe for a maculopapular rash C. Report the fever to the blood bank D. Give a PRN dose of acetaminophen

Stop the transfusion start a saline.

628. When administering ceftriaxone sodium (Rocephin) intravenously to a client before...most immediate intervention by the nurse? A. Stridor B. Nausea C. Headache D. Pruritis

Stridor.

725. A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now they taste "bitter". He complains that he simply has no appetite. What action should the nurse implement? a- Instruct the client to add ground beef and chicken in small amount to casseroles. b- Encourage the client to try to eat these foods in moderation despite the taste c- Advise the client to replace the bitter-tasting foods with fruits and vegetables. d- Suggest the use of alternative sources of protein such as dairy products and nuts.

Suggest the use of alternative sources of protein such as dairy products and nuts. Rationale: Beef, chicken, and eggs are good source of protein. To promote weight gain and adequate protein intake, the nurse should teach the client about another source of protein. Attempting to eat food that cause a bitter taste A and B is likely to increase the client's anorexia. C does not provide a sufficient source of protein.

648. A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10), two hours ago, he received hydrocodone / acetaminophen 7.5/7.50 mg his vital signs are elevated from reading of a previous hour: temperature 97.8 F, heart rate 102 beats / minute, respiration 20 breaths/minutes. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but left is greater than right. Preoperatively, clopidrogel was prescribed for a history of previous peripheral stents. Another nurse is holding manual pressure on the femoral arterial access site which may be leaking into the abdomen. What data is needed to make this report complete? a. Client's lungs are clear bilaterally and oxygen saturation is 97% b. Surgeon needs to see client immediately to evaluate the situation c. Left peripheral pulses were present only by Doppler pre-procedure d. Client' history includes multiple back surgeries and chronic pain.

Surgeon needs to see client immediately to evaluate the situation.

706. A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnose osteoporosis. What instruction should the nurse include in the client's teaching plan? a- Consume a light snack with the medication b- Take on an empty stomach with a full glass of water c- Ingest an antacid 30 minutes of taking the medication. d- Eat within 30 minutes of taking the medication.

Take on an empty stomach with a full glass of water.

The nurse is caring for a depressed client. The client has a flat affect, apathy, and slowed physical movement. The client has not bathed in several days and there is a malodorous odor noted. Which intervention would be most appropriate at this time?

Tell the client it is time to take a shower. Depressed clients often have little energy to do or think. Give short, simple commands during this time.

678. An unlicensed assistive personnel (UAP) informs the nurse who is giving medications that a female client is crying. The client was just informed that she has a malignant tumor. What action should the nurse implement first?

Tell the client that the nurse will be back to talk to her after medications are given.

For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action? a- Loss of appetite b- Serum K 4.0 mEq/or mmol/dl (SI) c- Loose, runny stool d- Tented skin turgor.

Tented skin turgor Rationale: D indicate dehydration, a serious complication following prolonged diarrhea that requires further interventions by the nurse.

A healthy newborn has just been delivered and placed in the care of the nurse. What nursing actions should the nurse initiate? Place in the correct priority order. Assess newborn's airway and breathing. Bulb suction excessive mucus. Assess newborn's heart rate. Place identification bands on newborn and mom. Administer sterile ophthalmic ointment containing 0.5% erythromycin.

That is the correct order

In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last. Clean around Penrose drain using a circular pattern inside to outside. Clean surgical wound with moistened sterile 4x4's. Apply clean gloves. Discard soiled dressings and clean gloves in red bag Apply abdominal dressing pad. Place dry, sterile 4x4's over surgical wound and Penrose drain. Don sterile gloves. Remove soiled dressings.

The Correct Order Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. Clean around Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's over surgical wound and Penrose drain. Apply abdominal dressing pad.

A client who has been on bed rest for several days is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last. Ambulate in the room. Assist the client to sit on the side of the bed for 1-2 minutes. Have the client stand by the side of the bed for a few seconds. Assess the client's orientation. Apply a gait belt to the client's waist.

The Correct Order Assess the client's orientation. Assist the client to sit on the side of the bed for 1-2 minutes. Apply a gait belt to the client's waist. Have the client stand by the side of the bed for a few seconds. Ambulate in the room. In order to keep a client safe, the nurse should first assess the client's orientation to determine the client's ability to follow instructions. Second, to avoid orthostatic hypotension, the nurse should assist the client to sit on the side of the bed. Third, apply the gait belt to ensure safety while ambulating. Fourth, assist the client to stand for a few seconds. The fifth action is to ambulate in the room.

The nurse is searching for information about the nursing care of a client receiving an experimental drug for the treatment of obesity. Which database is most likely to address this issue?

The Cumulative Index for Nursing and Allied Health Literature (CINAHL) is a source for reviewing nursing and allied health information.

The nurse is assessing pain after surgery in a 3 year old client with a known developmental delay. Which pain scale should the nurse use to assess this client's pain level?

The FLACC scale can be used for pediatric clients from age 2 months to 7 years and is appropriate when clients cannot communicate their pain.

Tetralogy of Fallot, remember HOPS

Think DROP (child drops to floor or squats) or POSH Defect, septal Right Ventricular Hypertrophy Overriding Aorta Pulmonary Stenosis

FHR patterns for OB

Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill

A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure? Place actions in the correct order. Elevate head of bed to fowler's position. Measure distal NG tube from nose tip to earlobe to xiphoid process. Lubricate 2-3 inches of distal NG tube. Insert NG tube into unobstructed naris. Advance NG tube upward and backward until resistance is met. Rotate catheter and advance into nasopharynx. Have client swallow ice as NG tube advances into stomach. Secure NG tube.

This is the correct order

The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat through a non-tunneled central venous catheter lumen with no other medication or fluid infusing. In what order should the nurse administer this prescription? Cleanse access port Connect 10 mL normal saline to access port Gently aspirate for blood Flush saline using push-pause method Administer phenytoin Flush with normal saline, then with heparin

This is the correct order

The six bed Labor and Delivery area is full when the Emergency Department nurse calls for a bed for a woman reporting low back pain, pelvic pressure and increased vaginal discharge at 36 weeks gestation. Which would be the most appropriate action for the charge nurse? 1. Transfer a G4P4 who delivered full-term twins one hour ago to the antepartum/postpartum floor. 2. Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the antepartum/postpartum floor. 3. Transfer an 8 hour postpartum G1P1 on Magnesium Sulfate for eclampsia from the LDR unit to the ante/postpartum unit. 4. Request that the new client be admitted to the antepartum/postpartum floor.

Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the antepartum/postpartum floor. The client and newborn are not in any present distress. Also the delivery occurred 3 hours ago. This client would not be a risk and could be cared for on the antepartum/postpartum floor.

635. Following a gun shot wound to the abdomen, a young adult male had an emergency bowel...Multiple blood products while in the operating room. His current blood pressure is 78/52...He is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values...Grams / dl (70 mmol / L SI), platelets 20,000 / mm 3 (20 x 10 9 / L (SI units), and white blood cells. Based on these assessments findings, which intervention, should the nurse implements first? a. Transfuse packed red blood cells b. Obtain blood and sputum cultures. c. Infuse 1000 ml normal saline d. Titrate oxygen to keep o2 saturation 90%

Transfuse packed red blood cells. Rational: The client is exhibiting signs of multiple organ dysfunction syndrome. Transfusion is the first intervention which provide hemoglobin to carry the oxygen to the tissues, is critical.

Dopamine (Intropin)

Treatment for hypotension, shock, low cardiac output, poor perfusion to vital organs; monitor EKG for arrhythmias and monitor BP

Apresoline (hydralazine)

Treatment of HTN or CHF; report flu-like symptoms; rise slowly from a sitting/lying position; take with meals

Bentyl (dicyclomine)

Treatment of IBS; assess for anticholinergic side effects

Cogentin (benztropine)

Treatment of Parkinson's and EPS effects of other drugs

Artane (trihexyphenidyl)

Treatment of Parkinson's; may cause a sedative effect

Sinemet (carbidopa/levodopa)

Treatment of Parkinson's; the client's sweat, saliva, and urine may turn reddish brown occasionally; may cause drowsiness

Indocin (NSAID)

Treatment of arthritis (osteo, RA, gouty), bursitis, and tendonitis

Synthroid (levothyroxine)

Treatment of hypothyroidism; may take several weeks to take effect; notify doctor of CP; take in the AM on an empty stomach; could cause hyperthyroidism

Tigan (trimethobenzamide)

Treatment of post-op N/V and for nausea associated with gastroenteritis

Hypomagnesemia

Tremors, tetany, seizures, dysrhythmias, depression, confusion, dysphagia; digoxin toxicity

774. An alert older client with diabetes mellitus type 1 is admitted with a serum glucose of 420 mg/dl (23.31 mmol/L (SI)). As the nurse administers 10 units of regular insulin intravenous (IV), the client immediately begins to vomit. What action should the nurse implement first?

Turn the client to a lateral position.

A positive Western blot in a child <18 months (presence of HIV antibodies) indicates only that the mother is infected.

Two or more positive p24 antigen tests will confirm HIV in kids <18 months. The p24 can be used at any age.

Sengstaken blakemore tube used for

Tx of esophageal varices. Keep scissors at the bedside

A client is hospitalized because of severe malnutrition related to anorexia nervosa. What is the most important goal for this client?

Until appropriate weight is gained, the client continues to be at risk for major health complications including hypotension, cardiac arrhythmias, poor muscle tone, increased risk for infection, abnormal liver function, and damaged kidneys.

Dead tissues cannot have PVC's(premature ventricular contraction), If left untreated pvc's can lead to ?

Ventricular fibrillation (VF)

For toddlers above 18 months

Ventrogluteal

The nurse is preparing to administer iron dextran IM. Which injection site would be best for administration?

Ventrogluteal site This site would be used for Z track IM injections. Iron preparations are administered by the Z track technique, preferably in a large, deep muscle such as the ventrogluteal muscle.

The nurse is caring for a client who has been diagnosed with dissociative identity disorder. What is the most appropriate short term goal?

Verbal recognition of the existence of multiple personalities. This condition is also reffered to as multiple personality disorder. s/s: The existence of two or more distinct identities .The distinct identities are accompanied by changes in behavior, memory and thinking. Ongoing gaps in memory about everyday events, personal information and/or past traumatic events. The symptoms cause significant distress or problems in social, occupational or other areas of functioning.

chicken pox

Vesicular Rash (central to distal) dew drop on rose petal

715. The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN? a- Diabetic ketoacidosis whose Glasgow coma Scale score changed from 10 to 7 b- Myxedema coma whose blood pressure changed from 80/50 to 70/40 c- Viral meningitis whose temperature changed from 101 F to 102 F. d- Subdural hematoma whose blood pressure changed from 150/80 to 170/60.

Viral meningitis whose temperature changed from 101 F to 102 F. Rationale: The most stable patient should be assigned to the PN, changes in the Glasgow coma Scale indicated the client's neurological status is worsening. The client decreasing BP is physiologically unstable. An increasing systolic blood pressure and widening pulse pressure is indicative of increasing intracranial pressure.

747. A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity? A. Tachycarcia B. Dyspnea C. Vomiting D. Muscle cramps

Vomiting.

Give NSAIDS, Corticosteroids, drugs for Bipolar, Cephalosporins, and Sulfanomides

WITH food

707. The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm hg and as soon as the cuff is deflated a korotkoff sound is heard. Which intervention should the nurse implement next? a- Wait 1 minute and palpate the systolic pressure before auscultating again. b- Educate the client about risk factor that predispose one for hypertension c- Obtain a medication history to assess for drugs that affect blood pressure d- Provide a quiet environment and retake the blood pressure in 20 mints.

Wait 1 minute and palpate the systolic pressure before auscultating again. Rationale: To accurately assess blood pressure, the sphygmomanometer cuff should be inflated above the client's usual systolic reading, but a Korotkoff sound heard immediately upon deflating the cuff indicated that the cuff was insufficiently inflated. The systolic pressure should be palpated at the radial pulse, which provides a reference as to how high to inflate the cuff when auscultating the blood pressure. B, there is insufficient date to suggest that the client has hypertension. C A medication history can be obtained after an accurate blood pressure measurement is obtained

643. After removing a left femoral arterial sheath, which assessment finding warrant immediately interventions by the nurse? (Select all that apply.) A. Unrelieved back and flank pain. B. Quarter-size red drainage at site C. Cool and pale left leg and foot. D. Tenderness over insertion site E. Left groin egg-size hematoma.

a-Unrelieved back and flank pain. c-Cool and pale left leg and foot. e-Left groin egg-size hematoma.

A child with a ventriculoperitoneal shunt will have a small upper-_____incision. This is where the shunt is guided into the abdominal cavity, and tunneled under the skin up to the ventricles. You should watch for abdominal _____, since fluid from the ventricles will be redirected to the peritoneum. You should also watch for signs of increasing ____, such as irritability, bulging fontanels, and high-pitched cry in an infant. In a toddler watch lack of appetite and headache. Careful on a bed position question! Bed-position after shunt placement is ___, so fluid doesn't reduce too rapidly. If you see s/s of increasing icp, then raise the hob to ____ degrees.

abdominal incision distention intracranial pressure flat 15-30

Hypospadias

abnormality in which urethral meatus is located on the ventral (back) surface of the penis anywhere from the corona to the perineum (remember hypo, low (for lower side or under side)

Grave's Disease/ hyperthyroidism

accelerated physical and mental function. Sensitivity to heat. Fine/soft hair.

When using a bronchodilator inhaler inconjuction with a glucocorticoid inhaler; __________.

administer the bronchodilator first

Liver biopsy facts

administrate Vit K, NPO morning of exam 6 hr, give sedative, teach pt that he will be asked to hold breath for 5-10 seconds, supine position, lateral with upper arms elevated post - position on right side, frequent V/S, report severe abdominal pain STAT, no heavy lifting 1 week

Ask every new admission if he has an _______

advanced directive. If not, explain it and give him the option to sign or not

The person who hyperventilates is most likely to experience respiratory_________.

alkalosis

KEY WORDS are very important. Avoid answers with absolutes:

always, never, must, etc

Osteomyletitis is

an infectious bone disease. get blood cultures then give antibiotics then if necessary surgery to drain abscess

Always check for allergies before administering

antibiotics (especially PCN). Make sure culture and sensitivity has been done before administration of first dose of antibiotic.

Glucagon increases the effects of oral

anticoagulants

Imipramine HCI

antidepressant which is not routinely given with methylprednisolone

give prophylactic antibiotic therapy before

any invasive procedure.

APE To Man

aortic, pulmonic, erb's point, tricuspid, mitral

position on the right side with legs flexed after

appendectomy

RLQ

appendicitis, watch for peritonitis

the deltoid and gluteus maximus are

appropriate sites for children

Detached Retina

area of detachment should be in the dependent position dependent meaning supported by something

Asthma has intercostal retractions

be concerned

If the patient is not a child, an answer with family option can

be ruled out easily

A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops slurred speech, shuffling gait and drooling. Which prescribed PRN medication would the nurse administer? 1. Lorazepam 2. Atropine 3. Benztropine 4. Chlorpromazine

benzotropine These signs and symptoms are reflective of pseudoparkinsonism, a form of extrapyramidal side effects which are side effects of the haloperidol. An anticholinergic agent maybe used for treatment. This is an anticholinergic agent that may be used for extrapyramidal side effects.

A laxative is given the night before an IVP in order to

better visualize the organs

Hirschsprung's

bile is lower obstruction, no bile is upper obstruction; ribbon like stools.

LVN/LPN cannot handle

blood

Fat Embolism

blood tinged sputum (r/t inflammation) Increase ESR, respiratory alkalosis (not acidosis r/t tachypnea). Hypocalcemia, increased serum lipids. "snow storm" effect on CXR

Cushings ulcers are related to

brain injury

Before going for Pulmonary Function Tests, a patient's

bronchodilators will be withheld and they are not allowed to smoke 4 hours prior

the main hypersensitivity reaction seen with antiplatelet drugs is

bronchospasm (anaphylaxis)

addison's disease

bronze like skin pigmentation

lyme's disease

bull's eye rash

If mixing antipsychotics (ie Haldol, Throazine, Prolixin) with fluids, med is incompatible with

caffeine and apple juice

Hodgkin's disease

cancer of the lymph. very curable in early stages

kawasaki leads to

cardiac problems

rheumatic fever can lead to

cardiac valves malfunctions

SIADH (increased ADH)

changes in level of consciousness, decreased DTR's, tachycardia, n/v/a, HA, ADMINISTER DECLOMYCIN, diuretics

Acid Ash diet

cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread

4 options for cancer management

chemo, radiation, surgery, allow to die with dignity.

guided imagery is great for?

chronic pain

Alzheimer's disease is

chronic, progressive, degenerative cognitive disorder that accounts for more than 60% of all dementias

If the baby is anterior, the sounds are heard

closer to midline, between the umbilicus and where you would listen to a posterior presentation.

Cataract

cloudy, blurry vision. Treated by lens removal surgery

acromegaly

coarse facial feature large, bulging head. prominent scalp veins.

An NG tube can be irrigated with

cola, and should be taught to family when a client is going home with an NG tube.

hepatitis A is

contact precautions

Levodopa for parkinsons

contraindicated in patients with glaucoma, avoid B6

Sinemet for parkinsons

contraindicated with MAOIs

Decorticate is toward the '___' Decerebrite is the other way (__)

cord; out

After pain relief,

cough and deep breathe is important in pancreatitis, because of fluid pushing up in the diaphragm

angina

crushing, stabbing chest pain relieved by nitro

myasthenia gravis

decrease in receptor sites for acetylcholine. Since smallest concentration of ACTH receptors are in cranial nerves, expect fatigue and weakness in eye, mastication, pharyngeal muscles

Atropine used to

decrease secretions

MG

descending muscle weakness

cystic fibrosis give

diet low fat, high sodium, fat soluble vitamins ADEK aerosal bronchodilators, mucolytics, and pancreatic enzymes

After Total Hip Replacement

don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows.

"O" is the universal

donor

Yogurt has live cultures

dont give to immunosuppressed pt

Pull pinna

down and back for kids < 3 years when instilling eardrops

Addison's disease

down, down, down, up, down hyponatremia, hypotension, decreased blood volume, hyperkalemia, hypoglycemia

orthostasis is verified by a

drop in pressure with increasing heart rate

Water intoxication will be evidenced by

drowsiness and altered mental status in a patient with TUR syndrome, or as an adverse reaction to desmopressin (for diabetes insipidus).

Benzodiazepines

drugs that lower anxiety and reduce stress

Anticholinergic effects - assessment

dry mouth==can't spit urinary retention=can't p*ss constipated =can't sh*t blurred vision=can't see

Basophils reliease histamine

during an allergic response

Rifampin, for TB

dyes bodily fluids orange

Head Injury

elevate HOB 30 degrees to decrease intracranial pressure

Lumbar puncture facts

fetal position post - neuro assess q15-30 until stable, flat 2-3 hr, encourage fluid, oral analgesics for headache, observe dressing

with pneumonia,

fever and chills are usually present. For the elderly confusion is often present.

In an emergency, patients with greater chance to live are treated

first

when a pt comes in and is in active labor

first action of nurse is to listen to fetal heart tones/rate

hepatic encephalopathy

flapping tremors

during sickle cell crisis, there are two interventions to prioritize

fluids and pain relief

Push fluids with Allopurinol -

flush the uric acid out of system

Below Knee Amputation

foot of bed elevated for first 24 hours, position prone daily to provide for hip extension.

Demerol is

for pain control

Iron PO

give with Vitamin C or on an empty stomach

Versed (midazolam)

given for conscious sedation watch for resp. depression and hypotension

Protonix (pantoprazole)

given prophylactically to prevent stress ulcers

During the acute stage of Hep A

gown and gloves are required. In the convalescent stage it is no longer contagious.

If your normally lucid patient starts seeing bugs you better check

his respiratory status first. The first sign of hypoxia is restlessness, followed by agitation, and things go downhill from there all the way to delirium, hallucinations, and coma. So check the o2 stat, and get abg's if possible.

EEG

hold meds for 24-48 hours prior, no caffeine or cigarettes for 24 hours prior, pt can eat, pt must stay awake night before exam, pt may be asked to hyperventilate and watch a bright flashing light, after EEG, assess pt for seizures, pt will be at increased risk

Cushings

hyperNa, hypoK, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump

After removal of the pituitary gland what should you watch for?

hypocortisolism and temporary diabetes insipidus

Somnolence is a symptom of

hypothyroidism

Cardinal signs of ARDS

hypoxemia (low oxygen level in tissues).

After a hydrocele repair provide

ice bags and scrotal support

An occlusive dressing is used

if a chest tube is accidentally pulled out of the patient

if a kid has a cold, you can still give

immunizations

Haldol preferred antipsychotic

in elderly, but high risk extrapyramidal side effects (dystonia, tardive dyskinesia, tightening of jaw, stiff neck, swollen tongue, later on swollen airway), monitor for early signs of reaction and give IM Benadryl

While treating DKA, bringing the glucose down too far and too fast can result in

increased intracranial pressure d/t water being pulled into the CSF.

Thyroid storm

increased temp, pulse and HTN

Hypovolemia

increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030

LTB (Latent Tuberculosis)

inspiratory stridor

Appendicitis pain

is in RLQ with rebound tenderness

An answer option that states "reassess in 15 minutes"

is probably wrong

Iatragenic means

it was caused by treatment, procedure, or medication.

Woman in Labor with Unreasuring FHR

late decelerations, decreased variability, fetal bradycardia, etc. Turn on left side (and give O2, stop pitocin, increase IV fluids)

Positioning with pneumonia

lay on the affected side to splint and reduce pain. But if you are trying to reduce congestion the sick lung goes up. (Ever had a stuffy nose, and you lay with the stuffy side up and it clears?)

absence of menstruation

leads to osteoporosis in the anorexic

Patients with GERD should lay on their

left side with the HOB elevated 30 degrees

Infection kills cancer patients most because of the

leukopenia caused by radiation

Med of choice for VTach

lidocaine

Pt with Heat Stroke

lie flat with legs elevated

leprosy

lioning face (lion like face)

Med of choice for bipolar

lithium

Tylenol poisoning

liver failure possible for about 4 days. Close observation required during this time-frame, as well as tx with Mucomyst.

with R side cardiac cath

look for valve problems

With Omphalocele and Gastroschisis (herniation of abdominal contents) dress with ______ ______ dressing covered with plastic wrap, and keep eye on temp. Kid can loose heat quickly.

loose saline dressing

In emphysema the stimulus to breathe is

low PO2 not increased PCO2 like the rest of us, so don't slam them with oxygen. Encourage pursed lip breathing which promotes CO2 elimination, encourage up to 3000 ml/day fluids, high fowlers and leaning foward

PTB (Pulmonary tuberculosis)

low grade afternoon fever

After thyroidectomy

low or semi-Fowler's, support head, neck and shoulders

absent reflexes

lower motor neuron issue

in pH regulation, the two organs of concern are

lungs/kidneys

PDA (patent ductus arteriosus)

machine like murmur

Digoxin and Lasix patient

make sure patient is getting enough potassium

Nephrotic syndrome is characterized by

massive proteinuria (looks dark and frothy) caused by glomerular damage. Corticosteroids are the mainstay. Generalized edema common.

Dexedrine, used for ADHD

may alter insulin needs, avoid taking MAOIs, take in morning insomnia possible side effect

If a TB patient is unable/unwilling to comply with tx they

may need supervision (direct observation). TB is a public health risk.

low residue diet

means low fiber

amniotic fluid yellow with particles

meconium stained

the first sign of pyloric stenosis in a baby is ____________________. Later you may be able to palpate a mass, the baby will seem hungry often, and may spit up after feedings

mild vomiting that progresses to projectile vomiting.

Take iron elixir with juice or water.... never with

milk

alk ash diet

milk, veggies, rhubarb, salmon

TIA (transient ischemic attack)

mini stroke with no dead brain tissue

Glaucoma intraocular pressure is greater than the normal (22 mm Hg), give

miotics to constrict (pilocarpine) NO ATROPINE

Tet spells treated with

morphine

Akathisia

motor restlessness, need to keep going, treatment with antiparkinsons med, can be mistaken for agitation

contact precautions

multidrug resistant organism; respiratory, skin, wound enteric and eye INFECTIONS

Bence Jones protein in urine confirms

multiple myeloma

Mevacor (lovastatin)

must be given with evening meal if it is QD (per day)

Tensilon test given if muscle is tense in ?

myasthenia gravis

Multiple sclerosis

myelin sheath destruction. disruptions in nerve impulse conduction

Addisonian Crisis

n/v, confusion, abdominal pain, extreme weakness, severe hypoglycemia, fever dehydration, decreased BP

Apply eye drops to conjunctival sac and afterwards apply pressure to

nasolacrimal duct/inner canthus

Hyponatremia

nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids

Amynoglycosides (like vancomycin) cause

nephrotoxicity and ototoxicity

No milk (as well as fresh fruit or veggies) on

neutropenic precautions

unstable angina is not relieved by

nitroglycerin

Neutropenic patients

no live vaccines, no fresh fruits, no flowers should be used

Jews

no meat and milk together

EEG prep

no sleep the night before, meals not withheld, no stimulants for 24 hr before, tranquilizer/stimulant meds help 24-48 hr, may be asked to hyperventilate 3-4 min and watch a bright flashing light

if two or three answers are similar or alike,

none is correct

Pancreatic enzymes are taken with each meal

not before, not after, but with each meal

S3 sound is normal in CHF,

not normal in MI

in a disaster you should triage the person who is most likely to

not survive last

meningeal irritation S/S

nuchal rigidity, positive Brudzinski + Kernig signs and PHOTOPHOBIA too!

Always deal with actual problems

or harm before potential problems

Feed upright to avoid

otitis media

McBurney's Point

pain in RLQ indicative of appendicitis

HODGEKIN'S DSE/LYMPHOMA -

painless, progressive enlargement of spleen & lymph tissues, Reedstenberg Cells

Pernicious anemia s/s include

pallor, tachycardia, and sore red tongue

Glaucoma patients lose

peripheral vision. Treated with meds

dengue

petechiae or positive herman's sign (It appears on the upper and lower extremities, purplish or violaceous red with blanched areas about 1 cm or less in size.)

Sign of fat embolism is

petechiae. Treat with heparin.

parkinson's

pill rolling tremors

After Myringotomy

position on side of affected ear after surgery (allows drainage of secretions)

Administration of Enema

position patient in left side lying (sim's) with knees flexed

Infant with Spina Bifida

position prone (on abdomen) so that sac doesn't rupture

After Infratentorial Surgery (incision at nape of neck)

position pt flat and lateral on either side

For a lung biopsy

position pt lying on side of bed or with arms raised up on pillows over bedside table, have pt hold breath in mid-expiration, chest x-ray done immediately afterwards to check for complication of pneumothorax, sterile dressing applied

Tube Feeding with Decreased LOC

position pt on right side (promotes emptying of the stomach) with the HOB elevated (to prevent aspiration)

Pneumovax 23 gets administered

post splenectomy to prevent pneumococcal sepsis

salt substitutes may contain

potassium

DKA is rare in diabetes mellitus type II because there is enough insulin to ?

prevent breakdown of fats

PTU and Tapazole

prevention of thyroid storm

If two answers are the exact opposite, one of them is

probably right (consider one of them)

diptheria

pseudo membrane formation

For a lumbar puncture

pt is positioned in lateral recumbent fetal position, keep pt flat for 2-3 hrs afterwards, sterile dressing, frequent neuro assessments

After lumbar puncture and oil based myelogram

pt lies in flat supine (to prevent headache and leaking of CSF)

Cytovene, used for retinitis caused by cytomegalovirus

pt will need regular eye exams, report dizziness, confusion or seizures immediately

After cataract surgery

pt will sleep on unaffected side with a night shield for 1-4 weeks.

A typical adverse reaction to oral hypoglycemics is

rash, photosensitivity

"AB" is the universal

recipient

ulcerative colitis

recurrent bloody diarrhea

pernicious anemia

red beefy tongue

Koplick's spots are

red spots with blue center characteristic of PRODROMAL stage of Measles. Usually in mouth.

Pernicious Anemia

red, beefy tongue; will take Vitamin B12 for life

If patients have hallucinations ______ them. In delusions________ them.

redirect, distract

Phenergan an antiemetic used to

reduce nausea

BPH

reduced size and force of urine

an ill child

regresses in behavior

Low magnesium and high creatinine signal

renal failure

It is always the correct answer to

report suspected cases of child abuse

Gonorrhea is a

reportable disease

Cephalhematoma (caput succinidanium)?

resolves on its own in a few days. This is the type of edema that crosses the suture lines.

The biggest concern with cold stress and the newborn is

respiratory distress

Signs of hypoxia

restless, anxious, cyanotic tachycardia, increased resps. (also monitor ABG's)

glucose tolerance test for pregnant women

result of 140 or higher needs further evaluation

Group A strep precedes

rheumatic fever. Chorea is part of this sickness (grimacing, sudden body movements, etc.) and it embarrasses kids. They have joint pain. Watch for elevated antistreptolysin O to be elevated. Penicillin!

cholera

rice watery stool

pulmonary sarcoidosis leads to

right sided heart failure

Cor pulmonale

right-sided heart failure caused by left ventricular failure (so pick edema, jvd, if it is a choice)

Parkinson's = RAT

rigidity, akinesia (loss of muscle movement), tremors. Treat with levodopa.

If your laboring mom's water breaks and she is any minus station you better know there is a

risk of prolapsed cord.

tetanus

risus sardonicus (highly characteristic, abnormal, sustained spasm of the facial muscles that appears to produce grinning.)

pneumonia

rusty sputum

cystic fibrosis

salty skin

ARDS (fluids in alveoli) and DIC (disseminated intravascular coagulation) are always:

secondary to something else (another disease process)

eclampsia is

seizure

William's position

semi Fowler's with knees flexed to reduce low back pain

Paracentesis

semi fowler's or upright on edge of bed. Empty bladder. post VS--report elevated temp. watch for hypovolemia

Post-Thyroidectomy

semi-Fowler's, prevent neck flexion/hyperextension, trach at bedside

renal impairment

serum creatinine elevated and urine clearance decreased Norm. Serum creatinine 0.8-1.8 (men), 0.5-1.5 (women) Norm. Urine clearance 85-135

Anectine is used for

short-term neuromuscular blocking agent for procedures like intubation and ECT. Norcuron is for intermediate or long-term.

ICP (intracranial pressure)

should be <2. measure head circumference.

Do not give demerol to patients with

sickle cell crisis

IVP (IV pyelogram) requires bowel prep

so they can visualize the bladder better

thrombocytopenia - bleeding precautions

soft bristled toothbrush no insertion of anything (including suppositories, douche) no IM meds as much as possible

bananas, potatoes, citrus fruits

source of potassium

liver cirrhosis

spider like varices

spinal shock occurs immediately after

spinal injury

Triage green

stable, can wait even longer to be seen, "walking wounded"

Triage yellow

stable, can wait up to an hour for treatment, ie., burns, see second

Tetanus, Hepatitis B, HIV precautions

standard precautions

Level of consciousness is the most important assessment parameter with

status epilepticus

malaria

stepladder like fever with chills

incentive spirometry

steps - sit upright, exhale, insert mouthpiece, inhale for 3 seconds, and then HOLD for 10 seconds

kawasaki syndrome

strawberry tongue

First sign of PE is

sudden chest pain, followed by dyspnea and tachypnea

bethamethasone (celestone)

surfactant. Med for lung expansion

Asthma and Arthritis

swimming best

Dantrium, for spasticity, may

take a week or more to be effective

SSRIs (antidepressants)

take about 3 weeks to work

Amphogel and Renegal:

take with meals

Milieu therapy

taking care of patient/environment

Shilling test

test for pernicious anemia/ how well one absorbs Vitamin B12

HbA1c

test to assess how well blood sugars have been controlled over the past 90-120 days. 4- 6 corresponds to a blood sugar of 70-110; 7 is ideal for a diabetic and corresponds to a blood sugar of 130.

For cord compression, place the mother in

the TRENDELENBERG position because this removes pressure of the presenting part off the cord. (If her head is down, the baby is no longer being pulled out of the body by gravity)

Caclium channel blockers affect

the afterload

When getting down to two answers, choose

the assessment answer (assess, collect, auscultate, monitor, palpate) over the intervention except in an emergency or distress situation. If one answer has an absolute, discard it. Give priority to answers that deal directly to the patient's body, not the machines/equipments.

Polyuria is common with?

the hypercalcemia caused by hyperparathyroidism.

common sites for metastasis include

the liver, brain, lung, bone, and lymph

when on nitroprusside, monitor

thiocynate (cyanide) Normal value should be 1, > 1 is heading toward toxicity

Paget's disease

tinnitus, bone pain, enlargement of bone, thick bones.

the immediate intervention after a sucking stab wound is

to dress the wound and tape it on three sides which allows air to escape. Do not use an occlusive dressing, which could convert the wound from open pneumo to closed one, and a tension pneumothorax is worse situation. After that get your chest tube tray, labs, IV

Rh negative mothers receive rhogam

to protect next baby

Neostigmine/Atropine (anticholinergic)

to reverse effect of pancuronium

babinski sign

toes curl= GREAT Toes fan = BAD

tension pneumothorax

trachea shifts to opposite side

Premarin (conjugated estrogens)

treatment after menopause estrogen replacement

Ritalin (methylphenidate)

treatment of ADHD assess for heart related side effects report immediately child may need a drug holiday because it stunts growth

Librium (chlordiazepoxide)

treatment of alcohol withdrawals don't take alcohol with this very bad nausea and vomiting can occur

Vistaril (hydroxyzine)

treatment of anxiety and also itching watch for dry mouth, given preop commonly

adenosine is the

treatment of choice for paroxysmal atrial tachycardia

Timolol (Timoptic)

treatment of glaucoma

Diamox (Acetazolamide)

treatment of glaucoma, high altitude sickness. don't take if allergic to sulfa drugs

Onconvin (vincristine)

treatment of leukemia GIVEN IV ONLY

Kwell (lindane)

treatment of scabies and lice Scabies - apply lotion once and leave on for 8-12 hours Lice - use the shampoo and leave on for 4 minutes with hair uncovered then rinse with warm water and comb with a fine tooth comb

Navane (thiothixene)

treatment of schizophrenia assess for EPS

Dilantin (phenytoin)

treatment of seizures therapeutic drug level 10-20

Peritoneal Dialysis when Outflow is Inadequate

turn pt from side to side BEFORE checking for kinks in tubing

For late decels

turn the mother to her left side, to allow more blood flow to the placenta

Triage black

unstable clients that will probably not make it, need comfort measures

Triage red

unstable, ie., occluded airway, actively bleeding, see first

Cushing's disease

up, up, up, down, up hypernatremia, hypertension, increased blood volume, hypokalemia, hyperglycemia

Fetal alcohol syndrome

upturned nose flat nasal bridge thin upper lip SGA

phobic disorders

use systematic desensitization

Hemovac

used after mastectomy, empty when full or q8hr, remove plug, empty contents, place on flat surface, cleanse opening and plug with alcohol sponge, compress evacuator completely to remove air, release plug, check system for operation.

Methadone is an opioid analgesic

used to detoxify/treat pain in narcotic addicts

Greenstick fractures

usually seen in kids, bone breaks on one side and bends on the other

Pitocin med used for

uterine stimulation

Vasopressin - "press in"

vasoconstrict

CO2 causes

vasoconstriction

Amiodorone is effective in both

ventricular and atrial complications.

Digitalis increases

ventricular irritability, and could convert a rhythm to v-fib following cardioversion.

meniere's disease

vertigo, tinnitus

a breast cancer patient treated with Tamoxifen should report changes in

visual acuity, because the adverse effect could be irreversible

retinal detatchment

visual floaters, flashes of light, curtain vision

PT/PTT are elevated when client is on:

warfarin

vitamin K is to _________ as Protamine sulfate is to _________ as Calcium Gluconate is to _________ as Mucomyst is to _____________ as Amicar is to _________

warfarin (coumadin) heparin magnesium sulfate acetaminophen TPA

wherever there is sugar (glucose)

water follows