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NCLEX Hurst Adult/Maternity/Psy/Priority/Child/Fundamental Questions

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The community health nurse is planning to teach nutritional education to a group of adults attending a health fair. What tips about health eating should the nurse include? Select all that apply 1. Pay attention to fullness cues during meals. 2. Make one fourth of the plate fruits and vegetables. 3. Drink sweet tea rather than soft drinks with meals. 4. Eat foods low in dietary fiber. 5. Consume less than 30% of calories from saturated fatty acids. 6. Use a smaller plate for meals

.1., & 6. Correct: Pay attention to hunger and fullness cues before, during, and after meals. Use them to recognize when to eat and when you have had enough. Portion out foods before eating. A smaller plate will make the amount of food look larger. 2. Incorrect: Make half the plate fruits and vegetables. 3. Incorrect: Cut calories by drinking water or unsweetened beverages rather than drinks with sugar, such as soft drinks and sweet tea. 4. Incorrect: Diets should be high in fiber coming from fruits, vegetables, and whole grains. 5. Incorrect: Individuals should consume less than 10% of calories from saturated fatty acids (approximately 20 grams of saturated fat per day in a 2000 calorie diet).

A client comes into the emergency department (ED) with intense abdominal pain. The nurse completes a physical assessment and evaluates the vital signs and lab work. Based on the information gathered, the nurse expects which diagnostic test will be priority? Nursing Note: 16 year old female admitted to treatment room 3, reporting "intense abdominal pain" at 10/10. States, "pain started 3 days ago, but got worse this morning". Confirms no injury to abdominal area. Rigid, board-like abdomen noted. Last menstrual cycle "6 weeks ago." Vital Signs: Temperature - 100 degrees F (37.77 degrees C) Heart rate - 110/min Respirations - 28/min Blood Pressure - 90/62 LAb Work Hemoglobin - 10 grams/dL (100 grams/L) Hematocrit - 32% (0.32) serum hcg - 27 mIU/mL 1. Transvaginal ultrasound 2. Esophagogastroduodenoscopy (EGD) 3. CAT Scan of the abdomen 4. KUB (Kidney, Ureter, and Bladder)

Which client would be appropriate for the charge nurse to assign to a room with a client who has undergone debulking of a tumor? 1. Client who is one day post laminectomy. 2. Client scheduled for a bone marrow transplant. 3. Client admitted with neutropenia. 4. Client being treated with intracavity radiation therapy.

Which discharge referral would be a priority for the nurse to make in order to promote continuity of care for a client following a colectomy and colostomy formation due to colon cancer? 1. Home health 2. Meals on Wheels 3. Hospice care 4. Registered dietitian

The homecare nurse is visiting a client to assess the response to new medications ordered for benign prostatic hyperplasia (BPH). What symptoms reported by the client would indicate to the nurse the medications are not working? Select all that apply 1. Bladder pain 2. Fever with chills 3. Urinary frequency 4. Terminal dribbling 5. Nighttime sweats

1, 3 and 4. CORRECT: Symptoms of benign prostatic hyperplasia are very similar to those of a urinary tract infection. As the prostate enlarges and presses against the bladder wall, it becomes more difficult for a client to start and maintain a stream of urine, or even to completely empty the bladder. Medications prescribed for this disorder are meant to shrink the prostate, allowing urine to flow easily when voiding. When the medications are ineffective, the client again experiences the original symptoms such as bladder pain, urinary frequency and a tendency to continue 'dribbling' urine after the bladder is emptied. The client may then need a different medication or a change in the dose currently prescribed. 2. INCORRECT: The symptoms of fever with chills are related to infection rather than benign prostatic hyperplasia. Although untreated BPH may lead to a urinary infection because of retained urine, these two symptoms do not relate directly to this prostate disorder.

The nurse is teaching a client who is at risk for developing a stroke. What primary prevention strategies should the nurse include? Select all that apply 1. Promote a diet rich in fruits and vegetables. 2. Provide instruction on benefits of carotid endarterectomy. 3. Limit sodium intake to 2 grams/day. 4. Engage in low intensity exercise once a week. 5. Avoid tobacco products. 6. Decrease alcohol consumption to two drinks per day.

1 & 5. CORRECT: An IUD is a surgically placed method of birth control in which a small, t-shaped piece of plastic, or even copper, is inserted into the uterus to decrease the chance of pregnancy. The client must be very healthy, emotionally amenable to a foreign body to prevent pregnancy, and aware that an IUD is not 100% fail-proof. The mother of a toddler who would like to have another child in a few years is an excellent candidate for the use of an IUD. Also, a client who had a double mastectomy over seven years ago is a good candidate, since treatment that long ago means the client would no longer be receiving any type of immunosuppressant therapy. 2. INCORRECT: A client who has had a recent exacerbation of sickle cell anemia is at high risk for several complications, including infection and clots. This is a foreign body in an already compromised client, leading to many potential complications. 3. INCORRECT: The client being actively treated for cancer is also immunosuppressed and would not be a good choice for an IUD. The risk of infection is much too high. 4. INCORRECT: An adolescent who has recently become sexually active presents a challenge. Remember that an adolescent does not have regular menstrual cycles yet, and can experience intermittent bleeding. Many primary healthcare providers argue that the use of an IUD may be safer since the client would not have to remember a pill, a ring, or a patch. But an even greater concern is the fact that an IUD is NOT 100% effective, still presenting the risk of an unwanted pregnancy. Also, an IUD does not protect against sexually transmitted disease (STDs), which is often a concern in those who have become sexually active.

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

1 & 5. Correct: Both the client with a postoperative appendectomy and the client with nephrolithiasis will need frequent pain assessments. Also neither client has an infection that could be transmitted to the other client.These 2 clients can be assigned to the same room. The clients with asthma and COPD are noninfectious respiratory diseases, so they also can be assigned to the same room. 2. Incorrect: The client with neutropenia has a low number of neutrophils which are a common type of white blood cell important to fighting off infections. The client should be assigned to a single-client room. In addition the other client could be contagious depending on the causative factor of the nausea,vomiting and diarrhea. The client with neutropenia should not be assign with this client since their diagnosis has not been identified. 3. Incorrect: MRSA and C difficile require contact isolation due to different causative organisms. Both of these clients should be assigned to a single-client room. In the healthcare setting it is recommended that clients requiring Contact Precautions should be assigned a single-client room. 4. Incorrect: Think about it an adolescent and an older adult in the same room. The 14 year old client is in the early adolescent stage. Since an admission to the hospital is a stressful situation, the client may exhibit "immature" behaviors and be embarrassed about the healthcare team seeing their bodies. There is a wide gap between a 14 year old and a 80 year old developmental stage. The 80 year old is experiencing developmental changes for older adult client. In addition, this client is exhibiting symptoms of Parkinson's disease.

The charge nurse in the pediatric unit is making assignments for the day shift. What clients would be appropriate for an LPN floated from the medical-surgical unit? Select all that apply 1. A 12-year-old with diabetes mellitus. 2. A 6-year-old one day post tonsillectomy. 3. A 3-year-old admitted in sickle cell crisis. 4. A 9-year-old with Hirschsprung's disease. 5. A 2-year-old in a mist tent with epiglottitis.

1 and 4. CORRECT. The LPN scope of practice is task oriented. An LPN floated to a specialty floor, such as pediatrics, should be assigned the most stable, uncomplicated clients, and ideally those that may have a disease process which also occurs on a medical-surgical floor. The 12-year old with diabetes mellitus is a good choice. This client will require accu-checks and SubQ insulin, both of which are within the scope of practice for the LPN. A client with Hirschsprung's disease experiences bowel dysfunction, usually with constipation, pain or anorexia. This client could also be assigned to an LPN who would have experience with bowel issues. 2. INCORRECT. Even though this child is one day post-op, throat surgery would require frequent assessments of the airway and the client's ability to swallow. Additionally, pain medication is usually given I.V. since the child still has difficulty swallowing. LPN's may not give I.V. meds. 3. INCORRECT. Children in sickle cell crisis require on-going assessments of the vascular system as well as the need for supplemental oxygen and pain medication. In addition to the young age of the client, the disease process requires advanced assessments. This client is not appropriate for the LPN. 5. INCORRECT. A two year old with epiglottitis in a mist tent will need airway and respiratory assessments frequently, along with teaching the parents about this illness. This client is not appropriate for the LPN.

The client with a new diagnosis of hypertension has been instructed to maintain a low sodium diet. Which foods does the nurse plan to teach the client to include on a low sodium diet? 1. Lemonade 2. Broccoli 3. Apple 4. Smoked sausage 5. Boiled shrimp 6. Tomato soup

1, 2, & 3. Correct: Lemonade has about 5 mg of sodium. Broccoli and apples have 0 mg of sodium per serving. 4. Incorrect: Sausage is made from ground meat such as pork, beef, or veal with salt and other spices added. A serving of sausage can have 644 mg of sodium. 5. Incorrect: Shellfish or shrimp are high in sodium. A serving of boiled shrimp can have 111 mg of sodium. Also, the seasoning for the shrimp has sodium added. 6. Incorrect: Processed foods are high in sodium unless the food label states "low sodium". Even though the food may read "low sodium", the client should read the food label to evaluate the sodium content.

A school nurse is planning a lesson on inhalant abuse for a high school health class. Which information does the nurse need to include? Select all that apply 1. Substances used for inhaling include lighter fluid, spray paint, and airplane glue. 2. Inhalants are absorbed through the lungs and cause central nervous system depression rapidly. 3. Although inhaling can make a person very ill, death is highly unlikely. 4. Inhaling substances can cause abdominal pain, lethargy, and renal failure. 5. Inhalants cause the heart to beat slowly.

1, 2, & 4 Correct: Products such as glues, nail polish remover, lighter fluid, spray paints, airplane glue, deodorant and hair sprays, whipped cream canisters, and cleaning fluids are widely available. Many young people inhale the vapors from these sources in search of quick intoxication without being aware that using inhalants, even once, can have serious health consequences. Inhaled chemicals are absorbed rapidly into the bloodstream through the lungs and are quickly distributed to the brain and other organs. Within seconds of inhalation, the user experiences intoxication along with other effects similar to those produced by alcohol. Alcohol-like effects may include slurred speech; the inability to coordinate movements; euphoria; and dizziness. Inhalants also are highly toxic to other organs. It causes abdominal pain, and vomiting. Chronic exposure can produce significant damage to the heart, lungs, liver, and kidneyIn addition, users may experience lightheadedness, hallucinations, and delusions. This information needs to be included in a teaching plan on inhalant abuse. All of these statements are correct and need to be included in a teaching plan on inhalant abuse. 3. Incorrect: With inhalant use, death can occur from respiratory depression or cardiac arrest. 5. Incorrect: Inhalants force the heart to beat rapidly and erratically, leading to cardiac arrest.

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

1, 2, 3, & 5. Correct: The nurse is aware that multiple factors can contribute to acute confusion in clients. The sudden relocation to a new environment, along with pain from injury, could definitely contribute to an acute onset of confusion. The client's ordered bedrest and response to new pain medications are additional factors that could produce an acute change in mental status. 4. Incorrect: Age alone is not a factor for confusion. New onset of confusion may be successfully resolved once any contributing factors are addressed.

What clients could safely be delegated to the LPN/VN? Select all that apply 1. A client two days post appendectomy needing to ambulate. 2. A client with bronchitis receiving nebulizer treatments. 3. A newly diagnosed diabetic client awaiting discharge home. 4. A client newly admitted with exacerbation of myasthenia gravis. 5. A client admitted yesterday for observation following a fall. 6. A client with a nasogastric tube (NG) hooked to low suction.

1, 2, 5 & 6. Correct: Thes clients are appropriate and stable enough for the LPN/VN's scope of practice. While an LPN/VN cannot be assigned a fresh post-op, the first client had an appendectomy two days ago. The LPN/VN could even delegate ambulating this client to unlicensed assistive personnel (UAP). A client with bronchitis will need a respiratory assessment by the RN at some point, but the LPN/VN is definitely qualified to administer aerosol treatments. The third client was admitted for observation following a fall a day ago, indicating no injuries serious enough for a full admission. PNs can insert and monitor NG tubes. 3. Incorrect: This client is a newly diagnosed diabetic who will require extensive teaching about selfcare at home. Additionally, discharging a client always involves teaching, which cannot be initiated by an LPN/VN. This option does not indicate that any teaching had been presented, so the client is not an appropriate assignment for the LPN/VN. 4. Incorrect: Myasthenia Gravis is a progressive weakening of the neuromuscular system placing the greatest risk on the respiratory system. Although this client is on a medical-surgical floor, there is a need for close monitoring and frequent assessment of the respiratory system, requiring an RN.

The nursing supervisor is notified by staff in the sterilization room that a foul odor has been noted. Upon inspecting the room, the nurse notes a small amount of sewage seeping up thru the floor drain. What priority actions should the supervisor initiate? Select all that apply 1. Evacuate staff from the room and lock the door. 2. Tell staff to remove any equipment already sterilized. 3. Report the incident to the administrative Chief Executive Officer (CEO). 4. Call maintenance to thoroughly clean the room. 5. Initiate 'internal disaster protocols' immediately.

1, 3 & 5. Correct: Raw sewage could expose staff to potential hepatitis A as well as other severe health problems. Leaking sewage presents the danger of methane gas formation. The nurse's initial action must be to evacuate all personnel from the room and lock, or seal off, the door until the proper authorized personnel are available. Because this situation could impact the functioning of the facility as well as staff/client health, the administrative CEO needs to be notified immediately. Sewage represents the potential for deadly complications, and therefore the situation is classified as an "internal disaster". Appropriate protocols should be initiated. 2. Incorrect: Any equipment in that room, even if sealed in bags, is no longer considered sterile. Nothing should be removed from that room unless ordered so by the hospital CEO. 4. Incorrect: This situation can be hazardous to both staff and clients, depending on the location of sterilization room. Dealing with leaking sewage requires professional cleanup, along with evaluation by governmental or local authorities to locate and repair the source of the leak.

A cardiac step down unit has requested float staff because of multiple impending admissions. The supervisor can only send one LPN/VN to the floor. Which clients would be appropriate assignments for the LPN/VN? Select all that apply 1. A client with COPD complaining of shortness of breath on exertion. 2. A post-cardiac catherization needing assistance with bedpan. 3. A client receiving heparin injections for deep vein thrombosis. 4. A client with atrial fibrillation currently on a diltiazem drip. 5. A client receiving a blood transfusion that requires monitoring. 6. A client post pacemaker insertion, awaiting discharge instructions.

1, 3 & 5. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. Client #5 -It is considered within the scope of practice for an LPN/VN to monitor a transfusion of a blood product. 2. Incorrect: This client is post cardiac catherization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. Because positioning on a bedpan requires rolling of the client, an RN should be assigned to assess the insertion site and monitor for the presence of bleeding. 4. Incorrect: Atrial fibrillation places the client at risk for blood clots. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. Assessing this client and titrating the diltiazem requires the skills of an RN. 6. Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. These areas require the expertise of an RN and would not be appropriate for an LPN/VN.

An oncology client with a Hickman catheter is being discharged to receive chemotherapy via cassette pump at home. The nurse is aware that discharge instructions should include what information? Select all that apply 1. Always use two pairs of gloves when preparing chemotherapy medications. 2. Discarded chemotherapy cassettes and tubings can be placed in regular trash. 3. Used needles or syringes must be placed into plastic chemotherapy receptacle. 4. Linens soiled with chemotherapy drugs can be washed with regular laundry. 5. Waste is placed into chemotherapy bags and picked up by medical supplier. 6. Regular home cleaning products are appropriate for spilled chemotherapy medications.

1, 3 and 5. CORRECT: Administering chemotherapy medications at home would require the same diligence and precautions that are used in the hospital setting. In order to prevent contamination, the individual preparing the chemotherapy should wear two pairs of gloves and should not prepare the drugs in an area where food is prepared. Used needles or syringes must be discarded in a hard, yellow plastic receptacle marked "chemotherapy". Any "soft" waste products, such as dressings or towels used to clean up spills, must be double-bagged and then placed into the designated "chemotherapy bag". These wastes are then picked up by the medical supplier for disposal. 2. INCORRECT: No equipment used to prepare or administer chemotherapy medications can ever be placed in regular trash. Specially designated chemotherapy disposal receptacles must be used for all types of chemotherapy waste. 4. INCORRECT: Several days after receiving chemotherapy, the human body eliminates unused or excess product through body waste such as stool, urine, or even emesis. Linens that become soiled with such waste products must be washed separately from normal linens for the first washing. A second washing is necessary, although the linens may be thrown in with other clothing for the second washing. 6. INCORRECT: It is never appropriate to use regular home cleaning products when cleaning up spilled chemotherapy drugs. The medical supplier who delivers the equipment will also deliver the specific "chemotherapy spill kit" needed for the medication in use. In the home setting, it is advised to clean up the area of the spill at least three times.

When shopping at the mall, a nurse witnesses an individual collapse in cardiac arrest. A bystander begins CPR while the nurse opens an automatic external defibrillator (AED) brought by security. What critical actions should the nurse perform before delivering a shock? Select all that apply 1. Apply defibrillator pads to bare skin. 2. Verify that synchronizer button is on. 3. Continue CPR until advised to deliver shock. 4. Stop CPR while machine analyzes the rhythm. 5. Shout "clear" prior to activating shock button. 6. Apply cream under de-fib pads to prevent burns.

1, 3, 4 and 5. CORRECT. Even in a public setting, the defibrillator pads must be applied directly to bare skin for a solid connection, with one pad in the left axillary area and the other pad just below the right clavicle. CPR should be initiated immediately while the machine is set up and the pads are positioned. CPR should stop momentarily while the AED analyzes the rhythm. Then, if a shock is advised, the nurse shouts "clear" to any individual near the client prior to administering a shock. If no shock is advised, CPR should continue. 2. INCORRECT. The synchronized cardioversion mode is used only when converting erratic rhythms back into sinus rhythm, such as atrial fibrillation or atrial flutter. Cardioversion administers a low-voltage shock at a specific point during a heartbeat and can only be used on beating heart. When utilizing the AED for a client in cardiac arrest, the machine must be set to the defibrillate mode only. 6. INCORRECT. Defibrillator pads are applied directly to dry, bare skin in order to maintain an optimal connection to deliver a shock. In the hospital setting, clients with excessive chest hair may need to be shaved, but not in the public setting. Substances such as cream or oils would actually increase the severity of a burn while diminishing the effectiveness of the shock.

A primary healthcare provider prescribes contact precautions for a newly admitted client. What equipment does the nurse need to place outside of the client's room for use when entering the room? 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. N95 respirator

1. & 2. Correct: Healthcare personnel caring for clients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the client or potentially contaminated areas in the client's environment. 3. Incorrect: Goggles are not required with contact precautions.It is used when splashing is anticipated. 4. Incorrect: A surgical mask is not required with contact precautions. It would be used for droplet precautions. 5. Incorrect: A N95 respirator is not required with contact precautions. It is used for airborne precautions.

The nurse is assessing a newborn to determine gestational age. What findings by the nurse would indicate the infant is premature? Select all that apply 1. Folded ear pinna springs back slowly. 2. Peripheral cyanosis on feet and hands. 3. Shoulders and chest have moderate lanugo. 4. Vernix covering axilla, back and buttocks. 5. Feet soles entirely covered with crease

1, 3. & 4. Correct: The nurse is assessing a neonate for indications of premature gestational age. In a full term infant, the ear pinna would spring back firmly and quickly, so a slow response indicates probable prematurity. Lanugo is also an indicator of gestational age. Lanugo that covers all the shoulders and chest indicate prematurity. Vernix is the waxy, cheesy coating that is noted on the neonate after birth. A large amount of vernix, in this case covering axilla, back and the buttocks, denotes prematurity. 2. Incorrect: Peripheral cyanosis on an infant's hands and feet is common in full term infants due to immature circulation the first few hours after birth. If the cyanosis continues after that point in time, the nurse would check the infant's body temperature or blood glucose. 5. Incorrect: Creases on the soles of an infant's foot are an indication of gestational age. Soles that are covered entirely with creases indicate full term maturity.

An elderly, bed-bound client receiving G-tube feedings at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway?

1. Seizure precautions 2. Monitor for signs of increased intracranial pressure 3. Orient to time, place, and person 4. Obtain vital signs q 15 minutes 1

A medical secretary is transcribing hand written medical orders for several clients. When the charge nurse reviews the orders, several seem to have transcription errors. What orders should the nurse verify immediately with the primary healthcare provider? Select all that apply 1. "Adm. Diagnosis: Anterior MI cardiac enzymes x 3 & 12-lead ECT." 2. "S/P cataract removal to OD Continue eye gtts twice daily to OU" 3. "H & P: Client indicates hx of cirrhosis with HDV, HTN and IDDM." 4. "Dx: renal insufficiency. Fluid restriction 1000mL/24 hr with I & D q shift." 5. "Reports hx of COPD x 20 years, with occasional wet cough and SBO."

1, 4 & 5. Correct: Hand-written orders can be challenging to read and interpret. The simple misplacement of a decimal point or one incorrect letter can change the entire meaning of the order. In the first option, the secretary wrote "12-lead ECT", instead of ECG. ECT is electroshock therapy, which is definitely not appropriate for a client following a heart attack. In the 4th option the client has renal insufficiency and is placed on fluid restrictions; however, it should have been transcribed as "I & O q. shift". The secretary transcribed "I & D", which means incision and drainage. The last option mentions COPD with occasional cough and SOB (shortness of breath). Instead the information was transcribed as "SBO", which is a small bowel obstruction. Though the client may have had that issue in the past, the data is dealing with respiratory issues, not gastric problems. 2. Incorrect: The transcription of this order is accurate. This client has had a cataract removed from the right eye (OD) and should continue eye drops two times a day to both eyes (OU). 3. Incorrect: The past medical history has been correctly interpreted. The healthcare provider has noted the client indicated treatment for cirrhosis with hepatitis D virus, hypertension and insulin- dependent diabetes mellitus.

The charge nurse is delegating assignments on the Alzheimer's unit of a long-term care facility. What task could be assigned to the unlicensed assistive personnel (UAP)? Select all that apply 1. Replace soiled heel protectors on bedfast client. 2. Provide TUMS to client reporting heartburn. 3. Trim fingernails on confused diabetic client. 4. Escort dementia client on an outdoor walk. 5. Assist client to complete the daily menu list.

1, 4 & 5.Correct: The tasks appropriate for the unlicensed assistive personnel (UAP) focus on activities of daily living. Replacing any item of clothing, including heel protectors, is appropriate for the UAP. Ambulating a client outside is an excellent activity to delegate to the UAP, in addition to helping a client complete the diet menu. The UAP can read the selections to the client and mark the choice. 2. Incorrect: When a client reports heartburn, there are potential issues requiring assessment by the RN. The client may actually be experiencing a cardiac event which would require intervention and contacting the primary healthcare provider. Though TUMS is an over the counter product, it is still considered a medication and should be administered nursing staff. 3. Incorrect: Although trimming nails is usually an acceptable task to delegate, diabetics need close assessment as well as specific shaping techniques for nails. This responsibility involves assessing and must be delegated to nursing staff.

The emergency room nurse is assessing a client with an eye injury that occurred while chopping wood. The client states the chain saw caused a log to splinter, sending slivers of wood into the right eye. While waiting for the eye specialist, the nurse discusses future safety precautions for such an activity. What safety precautions are most important for the nurse to include in client teaching? Select all that apply 1. Wear heavy gloves. 2. Stand with feet together. 3. Use steel-toed boots. 4. Wear unbreakable googles. 5. Use ear covers and plugs. 6. Wear loose-fitting clothing.

1, 4 and 5. CORRECT. When engaging in a potentially risky activity, precautions should be taken even if the activity has been completed multiple times before. Functional body parts, such as hands, fingers and toes, are particularly vulnerable to injury. Heavy duty work gloves made of leather or suede along with protective eye googles should be worn even before turning on any machines. Ears should also be protected with regulation ear phones or ear plugs because of equipment noise levels. 2. INCORRECT. Any activity involving equipment poses a safety risk, no matter how often an individual completes that action. A client should have both feet firmly planted on a flat surface, approximately shoulder-width apart, with weight distributed evenly over the hips. Standing with feet together distributes body weight unevenly, increasing the risk for injury. 3. INCORRECT. While sturdy leather boots provide protection for the feet, it is not necessary to have steel-toed boots. However, the client should never wear sneakers, sandals or other light-weight, non-protective foot wear when using any type of machinery or equipment. 6. INCORRECT. Loose fitting clothing could easily become caught in equipment, yanking the body in towards sharp blades and other moving parts. A client needs snug fitting clothing to cover exposed extremities to prevent even minor injuries.

A client has been admitted with a diagnosis of pneumocystis carinii pneumonia (PCP). What initial assessment findings would the nurse expect? (Select All That Apply). 1. Fever 2. Night sweats 3. Hemoptysis 4. Dry cough 5. Dyspnea

1, 4 and 5. CORRECT: Pneumocystis carinii pneumonia, now known as pneumocystis jirovecii, is caused by a fungus and occurs in clients with weakened immune systems. Expected assessment findings include fever, dry non-productive cough and dyspnea. Any additional symptoms are related to other co-morbidities and not the pneumonia itself. 2. INCORRECT: Night sweats are an early symptom of active tuberculosis and are often the definitive symptom, along with a productive cough, that indicates the need for immediate testing and isolation. 3. INCORRECT: Hemoptysis is among the late signs of lung cancer, in addition to weight loss. Lung cancer is asymptomatic in its early stages

When inspecting the equipment in a client's room, what would the nurse recognize as electrical safety hazard(s)? Select all that apply 1. Flickering overhead light 2. Ground-fault circuit interrupter electrical sockets 3. Hospital labeled UL power strip 4. Bent electrical bed cord 5. Cracked electrical socket

1, 4, & 5. CORRECT. Dim or flickering lights are indications that there is a possible electrical wiring problem. Use of a damaged electrical cord or socket increases the risk of an electrical fire, shock, or burn. 2. INCORRECT. Ground-fault circuit interrupter (GFCI) electrical sockets should be in place in hospital and healthcare facilities. A GFCI socket will immediately cut off power if it detects someone receives a shock, helping prevent serious injury. 3. INCORRECT. While power strips are not ideal in the hospital setting, power strips that have been inspected and tagged with a hospital label may be used when multiple electrical outlets are required. Additionally, only power strips with the Underwriters Laboratories (UL) seal should be used.

A licensed practical nurse (LPN) on the Labor and Delivery unit is assisting the nurse with multiple admissions. What tasks could the LPN complete until the nurse is available? Select all that apply 1. Take initial vital signs. 2. Measure cervical dilation. 3. Check fundal height and fetal heart rate (FHR). 4. Obtain urine for protein and glucose. 5. Collect vaginal swab to test for chlamydia.

1, 4, & 5. Correct: The LPN scope of practice varies from state to state, although basic tasks are consistent. Taking vital signs, even initially, is among the tasks that can be delegated to the LPN. Other appropriate duties include collecting urine for ordered tests and even obtaining a vaginal swab. These can definitely be delegated to a licensed practical nurse. 2. Incorrect: Measuring cervical dilation is an invasive assessment not within the LPN scope of practice. An experienced registered nurse or primary healthcare provider must be specifically trained to perform this procedure. 3. Incorrect: Fundal height is a determination of uterine size to assess fetal growth and development which cannot be delegated to an LPN. Additionally, determining fetal heart rate involves assessment of fetal well being and not within the LPN scope of practice.

A client with Hepatitis C has returned from surgery with a total laryngectomy. The nurse knows that what personal protective equipment is necessary when providing trach care? (Select All That Apply). Select all that apply 1. Face mask 2. Shoe covers 3. N-95 mask 4. Goggles 5. Gloves 6. Gown

1, 4, 5 and 6. CORRECT: The client has had a total laryngectomy which will initially produce large amounts of thick, bloody mucus. Hepatitis C is transmitted through blood and body fluids. During trach care, the nurse needs to be protected by specific personal protective equipment (PPE's). For this procedure, the nurse should utilize gown, gloves, goggles and face mask. 2. INCORRECT: Tracheostomy care is completed in close proximity to the client. Splattering of blood and body fluids on the floor is unlikely, so shoe covers are unnecessary. 3. INCORRECT: The N-95 face mask is a specially fitted mask used by nurses when providing care for clients with active tuberculosis. It is not necessary for a client with Hepatitis C.

A client arrives at the emergency room with severe right foot pain and is admitted with a diagnosis of hyperuricemia (gout). The nurse is reviewing diet habits and life style with the client to develop a teaching care plan. The nurse has identified what habits that may contribute to an exacerbation of gout? Select all that apply 1. A daily glass of white wine 2. Bacon and eggs on weekends 3. Smoking two cigars every day 4. One half liter of soda daily 5. Baked cod twice a week 6. A BMI of 31.5 kg/m2

1, 4, 5 &6. Correct: Hyperuricemia is the presence of excessive uric acid crystals which lodge in or around joint spaces. Large amounts of purine in the body contribute to the development of the crystals. Alcohol, including wines and beer, increases these crystals as do sugary drinks such as soda pop. Red meats like liver, kidneys and even raw steak should be avoided along with specific fish such as cod, tuna, sardines and even anchovies. Another contributing factor is obesity. With an average BMI range of 24-25 kg/m2, depending on height, an adult client with a BMI of 30.5 kg/m2 is considered obese. 2. Incorrect: Though bacon is a meat product, pork is not as bad as red or organ meats. Eggs are beneficial and are not known to exacerbate gout. 3. Incorrect: Although smoking may affect many of the body functions, by itself smoking does not contribute to the development of uric acid crystals.

A client arrives at the emergency room with severe right foot pain and is admitted with a diagnosis of hyperuricemia (gout). The nurse is reviewing diet habits and life style with the client to develop a teaching care plan. The nurse has identified what habits that may contribute to an exacerbation of gout? Select all that apply 1. A daily glass of white wine. 2. Bacon and eggs on weekends. 3. Smoking two cigars every day. 4. One half liter of soda daily. 5. Baked cod twice a week. 6. A BMI of 31.5 kg/m2.

A client with Hepatitis C has returned from surgery with a total laryngectomy. The nurse knows that what personal protective equipment is necessary when providing trach care? (Select All That Apply). 1. Face mask 2. Shoe covers 3. N-95 mask 4. Goggles 5. Gloves 6. Gown

The nurse is instructing the mother of a toddler diagnosed with cystic fibrosis (CF) about specific dietary modifications the child will need. The nurse knows the teaching is successful when the mother selects what foods? (Select All That Apply). Select all that apply 1. Potato chips 2. Low-fat yogurt 3. Salt-free bacon 4. Hot dog on a bun 5. Fresh avocados 6. Macaroni and cheese

1, 4, 5, and 6. CORRECT: Individuals with cystic fibrosis have many nutrient deficiencies along with insufficiencies of fat, protein and salt. The diet needs to include extra dairy, fat and protein, and salt in order to provide nourishment for growth and development. Prepared foods high in salt, such as potato chips and hot dogs, should be included in meals and snacks on a daily basis. Extra protein such as bacon, and whole dairy products, like milkshakes, butter and cheese, contribute to the required high calorie, salt-enhanced diet needed for proper growth and development in children with CF. 2. INCORRECT: Yogurt would be a good source of nutrients for this child; however, low-fat yogurt removes most of the needed nutritional value. 3. INCORRECT: Individuals with CF need extra fat, protein and salt in the diet because of the inability to properly metabolize these nutrients. Low-salt bacon removes a great source of added sodium necessary to their diet.

In what order should the nurse assess assigned clients following shift report? What would be the priority order? 1. Client reporting shortness of breath after receiving a bronchodilator respiratory treatment. 2. Newly admitted client diagnosed with esophageal cancer. 3. Client on ventilator needing a nasogastric tube feeding. 4. Client two hour post lobectomy. 5. Client with emphysema who has a pulse oximetry reading of 89%.

1, 4. 2.,3, 5 The first client the nurse needs to assess is the one reporting shortness of breath after having bronchodilator respiratory treatment. Remember the ABCs. Airway comes first. The second client that should be assessed by the nurse is the client who is two hour post lobectomy. Do you recognize that this client needs to be monitored for breathing difficulty and bleeding? Newly admitted clients should be considered unstable until determined otherwise, so the client diagnosed with esophageal cancer should be assessed third, only after the clients with potential airway, breathing, and bleeding problems. Following Maslow's Hierarchy of Needs would require that the nurse to assess and care for the client on a ventilator needing a nasogastric tube feeding next. Food is a physiologic need. Lastly, the nurse should assess the client with emphysema who has a pulse oximetry reading of 89%. A normal ABG oxygen level for healthy lungs falls between 80 and 100 millimeters of mercury (mm Hg). A normal pulse ox reading is typically between 95 and 100%. However, in COPD or other lung diseases, these ranges may not apply. For example, it isn't uncommon for people with severe COPD to maintain their pulse ox levels between 88-92%.

What should be the priority nursing actions when caring for a child following a tonsillectomy and adenoidectomy? Select All 1. Encourage oral intake of fluids. 2. Suction the mouth and throat as needed. 3. Administer pain medication around the clock. 4. Apply ice collar to the front of the neck as needed. 5. Encourage coughing and deep breathing every two hours.

1,3,4

The triage nurse in the emergency department is prioritizing the client care for new clients. What is the correct order in which the clients should be evaluated? 1. Infant having a tonic-clonic seizure. 2. Adult reporting right lower quadrant abdominal pain. 3. Child who has a laceration to the hand with bleeding controlled by pressure. 4. Teenager with a blood glucose of 108 mg/dL (6 mmol/L). 5. Elderly client rating intermittent substernal chest pain a 4 on a 10-point pain scale.

1, 5,2,3,4 First the nurse needs to evaluate the infant having a seizure. This client is in acute distress. The infant should be treated first to assess the infant's airway and neurological status. Second would be the elderly client presenting with chest pain who has a pain intensity of 4 on a scale of 10. Chest pain is possible symptom of a lethal cardiac event. At the time of the triage the infant's seizure activity and potential airway obstruction should be attended to first. Third would be the adult client with abdominal pain. The abdomen is painful, but clients with potential life-threatening complications should be evaluated first. Next, the child presenting with a laceration to the hand, should be seen. The bleeding is under control with pressure so can be seen after the other three clients. The teenage client's blood glucose level is with normal limits. The other clients should be attended to first, so this client would be last.

A nurse is attempting to help a client who has self-care difficulty due to left sided paralysis. Which interventions should the nurse plan to include? Select All 1. Provide the client with a button hook for dressing 2. Have the client wear slip-on shoes 3. Have client comb own hair 4. Offer to take the client to the toilet every 1-2 hours 5. Identify preferences for personal care items and food 6. Have client pivot on left foot to sit in chair placed on right side parallel to the bed.

1,2,3,4,5

A client is admitted with atrial fibrillation and heart failure secondary to chronic hypertension. Current medications include: Digoxin, Captopril, Carvedilol, Furosemide, and Warfarin. Based on this profile, what lab work is essential for the nurse to monitor? Select All 1. Digoxin level 2. Potassium level 3. PT/INR 4. aPTT 5. CPK-MB 6. BNP

1,2,3,6,

A mother brings her 6 week old infant to the ED and reports that the baby isn't gaining weight, and has not wet a diaper in 12 hours. The baby vomits after every feeding. Which nursing interventions would help this infant? Select All 1. Upright position with feedings and at night 2. Small frequent feedings that are thickened 3. Supine position for sleeping 4. Administration of H2 blockers 5. Give Pedialyte only until vomiting stops

1,2,4

Which tasks can the RN safely delegate to an LPN/LVN when caring for a client scheduled for an adrenalectomy? Select All 1. Check fingerstick glucose level. 2. Administer regular insulin SQ based on sliding scale prescription. 3. Assess client's cardiac rhythm. 4. Reinforce teaching regarding postoperative care. 5. Review client's pre-surgical laboratory values.

1,2,4

What activities would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP) caring for a client post-cholecystectomy? Select All 1. Measuring and recording intake and output. 2. Assisting with ambulation in the hallway. 3. Reinforce information about a low fat diet. 4. Assisting with daily hygiene. 5. Measuring and recording vital signs. 6. Inserting a foley catheter.

1,2,4,5

In what order should the nurse assess assigned clients following shift report? Place in priority order. 1. Client diagnosed with pneumonia who has a pulse oximetry reading of 89%. 2. Client who had a feeding tube inserted, due to recurrent aspiration pneumonia, which is now clogged. 3. Client diagnosed with pneumonia who has an arterial oxygenation level of 85%. 4. Client diagnosed with active tuberculosis who has a sputum specimen that needs to go to the lab

1,3,4,2 All these clients have a respiratory problem. So, now you must decide which of these high priority clients should be seen in what order. The first client the nurse needs to assess is the one diagnosed with pneumonia who has a pulse oximetry reading of 90%. A pulse oximeter oxygen saturation level of 94-99% is considered normal for most healthy individuals. A level of 92 percent indicates potential hypoxemia, or deficiency in oxygen reaching tissues in the body. Supplementary oxygen should be used if SpO2 level falls below 90%, which is unacceptable for a prolonged period. The second client that should be assessed by the nurse is the client diagnosed with pneumonia who has an arterial oxygenation level of 85%. Normal arterial oxygen level is 80-100%. Although 89% is within normal range, it is on the low side of normal. The nurse should assess the client for potential respiratory complications. The third client the nurse needs to see is the client diagnosed with active tuberculosis who has a sputum specimen that needs to go to the lab. Sputum specimens need to go to the lab in a timely manner. The nurse could assign the UAP to this task. In any case, the nurse should assess this client third. The fourth client the nurse should assess is the client with the clogged feeding tube. Clogged feeding tubes occur with regularity. Delay in feeding a client will not result in permanent damage.

The nurse is caring for a client with increased intracranial pressure (ICP). Which actions would increase the client's ICP? Select All 1 . Using restraints 2. Elevating head 3. Performing Valsalva 4. Blowing nose 5. Keeping client supine 6. Suctioning

1,3,4,5,6

In what order should the nurse assess assigned clients following shift report? Place in priority order. 1. Elderly client admitted 30 minutes ago with reports of constipation for four days. 2. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. 3. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. 4. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour.

1,5,3,2 All these clients have a GI problem. So, now you must decide which of these high priority clients should be seen in what order. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. This is an elderly client who is a new admit. The client reports constipation for 4 days which may be an indication of worse problems. The client is considered unstable until assessed by the nurse. The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. Did you think dehydration and fluid volume deficit? The third client that should be assessed by the nurse is the client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. This is normal for clients with hemorrhoids. But the client does need to be assessed prior to the client with Crohn's disease who is improving. The fourth client the nurse should assess is the client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Semi-formed stools are great news! The client is getting better. During exacerbation, the client will have many diarrhea stools.

A client was admitted to the unit during the night shift with chronic hypertension. At 0830, the unlicensed assistive personnel (UAP) reports that the client's blood pressure is 198/94 mm Hg. What would be the best action for the charge nurse to delegate at this time?

1. Ask a nursing student 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 staff RN administer the 0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for pain. 3

A client who is being evaluated for a recent head injury requests hydrocodone with acetaminophen for a headache. What response by the nurse is most appropriate?

1. "A hydrocodone and salicylate combination would probably provide better relief." 2. "Due to the impact that your head received, the healtcare provider may want to order a narcotic to be given intravenously for a more rapid relief." 3. "Acetaminophen is not recommended for clients with head injuries, but I can ask for a substitution." 4. "Hydrocodone is an opioid which is usually avoided because it could cause drowsiness and possibly prevent recognition of a worsening condition." 4

A community health nurse is planning to teach a group of caregivers about early warning signs of Alzheimer's Disease (AD). What signs should the nurse include? Select all that apply 1. Mild disorientation 2. Difficulty with words and numbers 3. Poor personal hygiene 4. Agitation 5. Visual agnosia 6. Dysgraphia

1. & 2. Correct: Early warning signs of Alzheimer's Disease include mild disorientation and difficulty with words and numbers. This client may have difficulty recognizing numbers or doing basic calculations. The person may begin to have trouble with words. 3. Incorrect: Poor personal hygiene occurs as Alzheimer's Disease progresses due to ongoing loss of neurons. 4. Incorrect: Behavioral manifestations occur later in the disease process as a result of changes that take place within the brain. They are not intentional or controllable by the person with this disease. 5. Incorrect: With progression of this disease, additional cognitive impairments are noted, including visual agnosia, which is the inability to recognize objects by sight. 6. Incorrect: Dysgraphia is defined as difficulty communicating via writing and occurs during disease progression.

The home health nurse is caring for a client who is identified as high risk for falls. What evaluation would indicate a therapeutic response to home fall prevention education? Select all that apply 1. Installs a grab bar in the tub. 2. Turns night lights on at bedtime. 3. Only uses assistive devices when leaving home. 4. Goes barefoot while in the home. 5. Uses throw rugs in walking areas to prevent slipping.

1. & 2. Correct: Placing a grab bar in a slippery tub can assist the client in getting into and out of the tub. Turning on night lights at night ensures that the client 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 the home. The client should be encouraged to use assistive devices, such as canes or walkers, at all times. 4. Incorrect: The client should always wear properly fitting shoes that have nonskid protection. The client increases their risk for injury when properly fitting shoes are not worn. 5. Incorrect: Throw rugs actually may increase the risk of tripping.

A client diagnosed with confusion and dehydration is admitted to the medical unit. The RN is working with an LPN and an unlicensed assistive personnel (UAP). Which tasks would be best for the RN to assign to the LPN? Select all that apply 1. Insert an indwelling urinary catheter 2. Reinforce the teaching plan with the client's family 3. Maintain fluids at bedside 4. Assess I & O for adequate fluid replacement 5. Obtain daily weights

1. & 2. Correct: The LPN can insert a indwelling urinary catheter since hourly urinary output measurements are needed, this is within the scope of practice. The LPN can reinforce an already prepared teaching plan, but cannot develop one. 3. Incorrect: This can best be accomplished by the UAP, it can be done by LPN but not best use of resources. 4. Incorrect: Assessment is a role of the RN. LPN can observe and data collect but not assess and evaluate on the NCLEX. 5. Incorrect: Weighing a client is a task that may be assigned to the UAP.

Which nursing statements about a client reflect correct documentation in the hospital medical record? 1. 20% of breakfast consumed. 2. 4 inch by 2 inch wound noted on right arm. 3. Enema administered. 4. Appears upset at spouse. 5. Lying in bed.

1. & 2. Correct: The nurse should record findings or observations precisely and accurately. Percent of breakfast eaten is accurate documentation. An arm wound should include its exact size and location. 3. Incorrect: Documentation of enema administered should also include type of solution, amount and results. 4. Incorrect: Documenting observed behaviors or conversations is appropriate; however, drawing conclusions about feelings is not. A better notation would be to describe facial expression and any emotions exhibited,( i.e. crying, laughing, etc.). 5. Incorrect: This documentation does not give body position and does not provide pertinent information about the position of bed and side rails or light placement.

Which nursing statements about a client reflect correct documentation in the hospital medical record? Select all that apply 1. 20% of breakfast consumed. 2. 4 inch by 2 inch wound noted on right arm. 3. Enema administered. 4. Appears upset at spouse. 5. Lying in bed.

A client has been admitted with advanced Cirrhosis. The nurse's assessment reveals an abdominal girth increase of 5 inches (12.7 cm) and a weight increase of 6 lbs.(2.71 kg) since yesterday's measurements. What further assessment findings would the nurse expect? Select all that apply 1. Hypotension 2. Cool extremities 3. Bradycardia 4. CVP readng of 8 mm/Hg 5. Radial pulses 4+/4+

1. & 2. Correct: These are signs and symptoms of FVD due to 3rd spacing and shock is what you are afraid of. 3. Incorrect: We would expect the heart rate to increase in FVD in an effort to move what little volume you have left through the system. 4. Incorrect: This is a high CVP, and with FVD you would expect it to be low. 5. Incorrect: Pulses are evaluated on a 4 point scale, so 4 would be a bounding pulse which would indicate fluid volume excess.

Following a large hurricane, multiple clients arrive at the emergency room for treatment. The charge nurse must triage and assign clients to appropriate staff. Which clients could be assigned to an LPN? Select all that apply 1. Child with superficial burns on both upper arms. 2. Adolescent with bruising to left upper quadrant. 3. Crying toddler missing both upper front teeth. 4. Adult reporting headache and blurred vision. 5. Elderly adult reporting nausea and heartburn.

1. & 3. Correct: An LPN should be assigned clients with predictable outcomes. Even though the client is a child, superficial burns require only dry sterile dressings and possibly oral pain medication, both tasks which are within the scope of practice for an LPN. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. However, providing care for missing teeth would also be within the LPN scope of practice. 2. Incorrect: Bruising of the left upper quadrant is often indicative of a ruptured spleen and internal bleeding. This adolescent will require further tests, such as CT scan, and possibly emergency surgery. Because of the complexity of the situation, an RN should be assigned this client. 4. Incorrect: Since these clients were injured during the hurricane, the charge nurse must assume the worst. This client is reporting headache and diplopia; therefore, a safe nurse would consider the possibility of head trauma with brain swelling accounting for the blurred vision. Such potential makes this client serious to critical, and as such, should be assigned to an RN for on-going neurologic assessment. 5. Incorrect: While the trauma of a hurricane could adversely affect the digestive system, the charge nurse would assume the worst and suspect the likelihood the client is having a myocardial infarction. Only an RN can complete the appropriate assessment, testing, and other needs expected with an M.I. client.

A client is admitted for management of chronic obstructive pulmonary disease (COPD). What finding would be of concern to the nurse?

1. Pursed lip breathing 2. Productive cough with thick white sputum 3. Ankles with 2+ pitting edema 4. Barrel chest 3. Correct: Swelling in the legs or feet is a serious symptom and should be of concern to the nurse. To make up for the damage to the lungs, the heart must pump harder to get enough oxygen to the rest of the body. Further investigation is needed.

The Emergency Department triage nurse encounters a client who says that he has received exposure to a liquid hazardous chemical at work. He reports that he is only 1 of about 20 people. What should the nurse do? Select all that apply 1. Call the supervisor and inform of the possibility of contamination in the surrounding space. 2. Obtain vital signs immediately. 3. Call personnel trained in containment and decontamination immediately. 4. Direct the individual to a bed space immediately. 5. Instruct the client to remove clothing and put on disposable hospital gown.

1. & 3. Correct: The nurse should report this to the supervisor who can determine the next action to take regarding isolation, decontamination, and use of the current space. Those who are trained in hazardous exposures should be informed immediately so that appropriate action is taken. These actions are priority for minimizing the exposure of clients and staff to the hazardous chemical. 2. Incorrect: The nurse should avoid contact with the client until personnel trained for handling hazardous exposures are present. 4. Incorrect: Containment is necessary to prevent further contamination of the space and individuals in the area. Directing the client to a bed space would not be containment. 5. Incorrect. The client may need to be directed to a decontamination area to prevent further contamination of the area, so removing clothing before going to this area would put others at risk for exposure to the hazardous chemical.

The nurse plans to teach a client how to manage the use of a behind the ear hearing aid. What teaching strategies should the nurse include? Select all that apply 1. Hairspray should not be used while wearing the hearing aid. 2. A whistling sound when the hearing aid is inserted indicates proper placement. 3. Submerse hearing aid in cool water daily to clean. 4. Illustrate where damage commonly occurs on a hearing aid. 5. Batteries last 6 months with daily wearing of 10-12 hours.

1. & 4. Correct: The residual from the hair spray causes the hearing aid to become oily and greasy. The client should routinely inspect the hearing aid for damage, especially where damage is more likely: ear mold, earphone, dials, cord, and connection plugs.2. Incorrect: A whistling sound indicates incorrect ear mold insertion, improper fit of aid, and buildup of earwax or fluid.3. Incorrect: Do not submerse hearing aid in water, as it will damage the device.5. Incorrect: Batteries last 1 week with daily wearing of 10-12 hours.

The pediatric nurse is planning an educational seminar for new parents. The seminar will focus on tips for administering medication to children. Which points should the nurse include? Select all that apply 1. Demonstrate proper measuring techniques for liquid medications. 2. Put crushed medications into the child's favorite food. 3. Place liquid medication in an 8-ounce bottle of formula. 4. Call medication "candy" to encourage children to take the medicine. 5. Do not place medications in a container other than the original container.

1. & 5. Correct: Demonstration with return demonstration by the parent is an appropriate teaching strategy. Give clear examples and demonstrations and speak in layman's terms. Never put medications in dishes, cups, bottles, or other household containers that children or other family members may be unaware of. 2. Incorrect: Do not place crushed drugs into the child's favorite food or snack. The medication can change the taste of the food, and the child may refuse, therefore missing part or all of the dose. Additionally, the effectiveness of some medications may be harmed by the crushing of the drugs.3. Incorrect: Do not place liquid drugs in a large bottle of formula. Unless the child drinks the entire amount, he or she will not receive the correct dose.4. Incorrect: Don't refer to drugs as candy. Children may try to take more candy leading to overdose.

A client is admitted to the emergency department following a motor vehicle accident (MVA). The client reports abdominal discomfort, weakness, and nausea. Vital signs: BP 88/52, HR 118/min, RR 24/ min. Which healthcare provider prescription should the nurse implement first?

1. Administer ondansetron 2 mg IV. 2. Insert a foley catheter in order to obtain hourly urinary outputs. 3. Infuse lactated ringers (LR) at 200 mL per hour. 4. Type and cross match for four units of packed red blood cells. 3

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

1. & 5. Correct: Droplet precautions are utilized whenever a client has specific microorganisms that are spread by coughing, sneezing or talking. Individuals within three feet of the client can be contaminated by breathing in those respiratory droplets. Mumps require approximately 9 days of isolation with droplet precautions after the swelling becomes visible. Clients with pertussis also require droplet precautions. Pertussis is a very contagious disease only found in humans. It is spread from person to person. People with pertussis usually spread the disease to another person by coughing or sneezing or when spending a lot of time near one another where you share breathing space. 2. Incorrect: MRSA is a bacterial infection that can be spread by either direct contact with the client, or indirect contact with environmental surfaces that have been contaminated by the client. This client will require contact precautions. Depending on the type of care being provided to this client, staff may need gloves, gown, mask or eye protection. 3. Incorrect: Shingles (Herpes Zoster) is transmitted through air and direct contact with respiratory secretions and the lesions. Therefore, airborne and contact precautions should be initiated. This client should be placed in a private room with negative pressure to prevent contaminating others. Staff entering this room must wear a special filter mask (N95), gown and gloves. Additionally, pregnant staff or family should not enter the room at all during this time. 4. Incorrect: HIV is a viral disease transmitted through the blood or body fluids of contaminated individuals, blood transfusions, or needles from IV drug usage. Standard precautions are adequate for most HIV clients unless the client has an open wound.

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

1. & 5. Correct: Pernicious anemia is a type of vitamin B12 anemia. The body needs vitamin B12 to make red blood cells. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. 2. Incorrect: The client does not have to eat meat or dairy products in order to obtain vitamin B-12. Supplements can be taken and the client can eat vegetables that are considered to be high in protein. 3. Incorrect: A strict vegan will not eat dairy products or eggs. 4. Incorrect: For a vegetable to qualify as a low-protein source, it must contain 4g or less of protein. Green vegetables, such as lettuce, cabbage, bell pepper and asparagus provide only 1 to 2g of protein per serving. Orange vegetables, including carrots, sweet potatoes and squash also contain only 1 to 2 g.

A client, scheduled for a total hysterectomy for advanced cervical cancer, is crying and states, "I want to have more children! I do not know if I should have this procedure." Which responses by the nurse are appropriate? Select all that apply 1. Allow the client to discuss her fears. 2. Tell the client that her health is more important than having children. 3. Explain to the client that cryotherapy may be an option for treatment. 4. Advise the client to delay surgery until she is absolutely sure. 5. Encourage client to discuss with surgeon again about the total hysterectomy.

1. & 5. Correct: This may be anticipatory grieving and being scared. Let the client talk and encourage her to talk again to the primary healthcare provider. She may need reassurance that she is making the right decision. 2. Incorrect: This is negating the client's feelings and is not helpful in this situation. 3. Incorrect: Cryotherapy is destruction of tissue by freezing with liquid nitrogen. Cryotherapy may be used with precursor lesions (mild to moderate dysplasia). It is not an appropriate treatment for advanced cervical cancer. 4. Incorrect: The cancer is already in an advanced stage. Will the waiting help her survive?

A client diagnosed Alzheimer's disease has been prescribed memantine. What should the nurse teach the caregiver about this medication? Select all that apply 1. When beginning this medication provide ambulatory assistance. 2. This medication is prescribed to help improve mild dementia. 3. This medication must be taken without food. 4. If a dose is missed, double the next dose. 5. If the client cannot swallow the capsule you sprinkle on applesauce.

1. & 5. Correct: This medication can cause dizziness, so safety precautions should be taught to the caregiver. Extended release caps should not be crushed, chewed, or divided. If the client cannot swallow it whole, it can be opened and sprinkled on a small amount of applesauce. 2. Incorrect: Memantine is used for moderate to severe dementia associated with Alzheimer's disease. 3. Incorrect: Memantine can be taken with or without food. 4. Incorrect: If the client misses a single dose of memantine, that client should not double up on the next dose. The next dose should be taken as scheduled.

Which assessments will provide the nurse with the most information regarding a client's neurologic function? Select all that apply 1. Level of consciousness 2. Doll's eyes reflex 3. Babinski reflex 4. Reaction to painful stimuli 5. Verbal ability

1. & 5. Correct: Yes, the most important and subtle changes are related to the client's level of consciousness, verbal ability, orientation, and ability to move to command. 2. Incorrect: No, only helps with the determination of brain death. 3. Incorrect: Identifies diseases of the brain and spinal cord. 4. Incorrect: This should be last resort.

PEDIATRICS The charge nurse in the pediatric unit is making assignments for the day shift. What clients would be most appropriate for an LPN reassigned from the medical surgical unit? Select all that apply 1. A 12 year old with diabetes mellitus. 2. A 6 year old one day post tonsillectomy. 3. A 3 year old admitted in sickle cell crisis. 4. A 9 year old with Hirschsprung's disease. 5. A 2 year old in a mist tent with epiglottitis.

1. &4. Correct: The LPN scope of practice is task oriented. An LPN reassigned to a specialty floor, such as pediatrics, should be assigned the most stable, uncomplicated clients, and ideally those that may have a disease process which also occurs on a medical surgical unit. The 12 year old with diabetes mellitus is a good choice. This client will require accu checks and subcutaneous insulin, both of which are within the scope of practice for the LPN. A client with Hirschsprung's disease experiences bowel dysfunction, usually with constipation, pain or anorexia. This client could also be assigned to an LPN who has experience with bowel issues. 2. Incorrect: Even though this child is one day post-op, throat surgery would require frequent assessments of the airway and the client's ability to swallow. Additionally, pain medication is usually given IV since the child still has difficulty swallowing. The LPN may not give IV meds. 3. Incorrect: Children in sickle cell crisis require on-going assessments of the vascular system as well as the need for supplemental oxygen and pain medication. In addition to the young age of the client, the disease process requires advanced assessments. This client is not appropriate for the LPN. 5. Incorrect: A two year old with epiglottitis in a mist tent will need airway and respiratory assessments frequently, along with teaching the parents about this illness. This client is not appropriate for the LPN.

The nurse is to administer a fluid bolus to a 25 pound (11.36 kg) child. The primary healthcare provider prescribes a bolus of 20 mL/kg.

1. 500 mL isotonic solution 2. 500 mL hypotonic solution 3. 227 mL isotonic solution 4. 227 mL hypotonic solution 3

Following escharotomy of a circumferential burn to the arm, which assessment is the best indicator when evaluating the effectiveness of this procedure?

1. Absence of pain in the extremity. 2. Prompt capillary refill after blanching. 3. Bleeding at the site of the incision. 4. Ability of the client to wiggle his/her fingers. 2

A client has sustained burns to the upper torso, face, and neck as a result of a steam injury when a pressure cooker exploded at home. Which intervention is the nurse's priority?

1. Administer fentanyl for pain. 2. Prepare for endotracheal intubation. 3. Administer 1000mL of LR. 4. Drench immediately with running water. 2

A client is admitted for treatment of fluid volume excess. The nurse reviews the admitting lab work and the primary healthcare provider's prescriptions. Which prescription would be of concern to the nurse? Sodium 138 mEq/L Potassium 5.4 mEq/L Calcium 9.0 mg/dL Glucose 108 mg/dL Bedrest 2 gm Na diet Spironolactone 25 mg by mouth once per day KCL 20 mEq by mouth twice a day

1. Bedrest 2. 2 gm Na diet 3. Spironolactone 4. KCL 4

A client has been given information about several complementary therapies for the treatment of anxiety disorder. Which therapy selected by the client would require the nurse to check for allergies? 1. Aromatherapy 2. Biofeedback 3. Guided Imagery 4. Acupuncture

1. CORRECT. Aromatherapy is the use of essential oils from plants and herbs in the form of baths, inhalation, or compresses applied directly to the skin to promote relaxation, decrease depression and enhance sleep. Because these oils come in contact with the client's skin, or by inhalation, it would be important to verify any allergies the client may have prior to initiating therapy. 2. INCORRECT. Biofeedback is progressive muscle relaxation with the use of electrodes placed on the client's skin. This therapy has been used to treat medical issues such as migraines or chronic pain. Allergies would not be a concern with this complementary therapy. 3. INCORRECT. Guided Imagery, also called "visualization", uses words or sounds to direct the client on an imaginary journey within the mind. This technique for dealing with anxiety would not present any concerns about allergies. 4. INCORRECT. Acupuncture is a complementary therapy that entails stimulating certain areas of the body by penetrating the skin with a variety of tiny needles in order to treat a variety of physical and emotional disorders.The nurse would not be concerned about allergies with this therapeutic treatment.

A client with a suprapubic catheter is admitted for surgery and requires a catheter change before that procedure. What is the most important action for the nurse to take prior to changing this catheter? 1. Check size of existing catheter and balloon. 2. Ask client when the catheter was last changed. 3. Clamp and empty the present catheter bag. 4. Gather clean gloves and basin of hot soapy water.

1. CORRECT. It is important to maintain the same catheter size as the one currently in use since the surgical opening does not increase in size like a urethral opening. If the balloon is too small, urine can leak through the opening. If the balloon is too big, urine will not drain properly, leaving residual and the potential for infection. 2. INCORRECT. Though obtaining information directly from the client is often a good choice, the individual may not be able to recall a precise date or time. When a catheter change is scheduled at specific time intervals, the nurse needs to verify the correct time line. Generally, the primary healthcare provider can provide a current order to facilitate the changing of the catheter. 3. INCORRECT. Although the nurse may empty a catheter bag, if the client uses one, there is no need to clamp a suprapubic catheter. The standard procedure for replacing a suprapubic catheter does not include clamping since the catheter does not require long tubing like a regular catheter. Also, urine bags are generally emptied at scheduled times each shift. 4. INCORRECT. Replacing a suprapubic catheter requires the use of sterile gloves both while cleaning and inserting the new catheter. Also, care of the insertion site is completed with sterile normal saline before and after the reinsertion.

While making evening rounds, the nurse discovers an elderly, confused client standing next to the bed with the IV pulled out, gown wet with urine and the side rails still in the up position. The client's arm band is on the floor. To ensure client safety, what is the most important intervention for the nurse to include in the plan of care? 1. Provide for scheduled toileting intervals. 2. Apply a restraining vest on the client at night. 3. Cover the IV site with a gauze dressing. 4. Remind client to ring call bell for the nurse.

1. CORRECT. The client is confused and likely will not remember any verbal instructions. Therefore, the safest priority action would be to check on the client at regular intervals and assist the client with any bathroom needs at those times. 2. INCORRECT. A restraining vest would not guarantee client safety. This client was able to crawl out of bed over a raised side rail; therefore, this client could struggle against the vest with the potential to get entangled and become seriously injured. 3. INCORRECT. Placing gauze over the IV site does not address client safety. The issue is we do not want the client to fall. 4. INCORRECT. This action would not ensure safety because the client is confused. So, it is very unlikely the client would remember to ring for the nurse before getting out of bed.

What action by the nurse is most helpful when responding to a bomb threat phone call? 1. Ask where and when the bomb is going to explode. 2. Quickly terminate the conversation and call in the bomb threat. 3. Document on the hospital Bomb Threat Checklist. 4. Immediately seek cover and warn others.

1. CORRECT. The nurse should keep the caller on the phone for as long as possible and try to obtain information, while being alert for voice characteristics and background noises. While keeping the caller on the line, the nurse should motion to another employee to call in the bomb threat. 2. INCORRECT. You should keep the caller on the line and signal someone to call in the threat. Keeping the caller on the line keeps them busy and may allow enough time for law enforcement to trace the call. 3. INCORRECT. It is important to document on the hospital Bomb Threat Checklist, but the most immediate action is to keep the caller on the line. 4. INCORRECT. While your initial response may be to run for cover, you should remain calm and not panic, continuing to keep the caller on the line.

The nurse is observing a new LPN insert an indwelling foley catheter for a client. The nurse knows it is necessary to intervene when the new LPN initiates what action? 1. Applies sterile gloves prior to opening catheter kit. 2. Pours iodine solution over the sterile cotton balls. 3. Lubricates catheter by dipping into water-soluble gel. 4. Identifies client and elevates bed to waist height.

1. CORRECT: A catheter kit is removed from the plastic bag and opened up without any gloves at all. The use of sterile gloves would not be necessary and would be a waste of money as the outside of the kit is not sterile. 2. INCORRECT: Once the sterile gloves in the kit are applied, the LPN would then open the iodine and pour over the cotton balls in the kit. No errors noted here. 3. INCORRECT: The lubricant will minimize discomfort and possible trauma to the urethra. 4. INCORRECT: The first action prior to any invasive procedure is to identify the client. Because this procedure is done at the client's bedside, the LPN must raise the bed to the proper working height once all supplies are collected.

The nurse manager of a long-term care facility notes an increase in pressure ulcers over the last six months. What new protocol developed by the nurse manager is most likely to decrease the occurrence of decubiti? 1. Bedfast clients must be repositioned every two hours. 2. All clients should have egg crate mattress on the bed. 3. Clients bathed in bed need lotion applied to all joints. 4. Provide back massage daily to all clients on bed rest.

1. CORRECT: Repositioning clients every two hours prevents excessive, prolonged pressure on skin and bony prominences. Such an action also provides an opportunity for visible inspection of the client by staff. This repositioning applies not only to bedfast clients, but also to those who sit in a chair for prolonged periods of time. 2. INCORRECT: An egg crate, foam mattress topper can be useful, both on a bed or a chair seat, to decrease shearing forces and cushion skin. But padding a surface does not guarantee the client will not develop a pressure sore. 3. INCORRECT: Applying lotion to body will help lubricate dry skin. However, massaging the skin directly over joints is not advised, since that skin is generally thinner and more fragile. Additionally, this action alone would not ensure a reduction in the occurrence of pressure ulcers. 4. INCORRECT: A daily back massage does stimulate circulation and allow for inspection of the spine, particularly for clients on bed rest. But this action alone would not decrease the occurrence of decubiti.

A client arrives by ambulance after being thrown from a horse. The client is pale, clammy and tachycardic with bruising over left upper abdominal quadrant. The nurse is aware what prescription by the primary healthcare provider takes priority? 1. Obtain blood for type and cross match. 2. Administer hydromorphone IV for pain. 3. Increase Lactated Ringers to 150 mL/hour. 4. Send client to radiology for stat CAT scan.

1. CORRECT: The signs and symptoms displayed by the client suggest a ruptured spleen and shock. The greatest concern in this situation is internal bleeding and possible emergency surgery. The client will need blood; therefore, the nurse should immediately obtain blood for type and cross match. 2. INCORRECT: There is no indication in the scenario the client has pain. Pain medication should never be administered while the client is still being assessed or is in shock. 3. INCORRECT: Fluids are crucial for clients in shock and increasing the Lactated Ringers to 150 mL/hr. is important to help maintain blood pressure. However, this is not the nurse's priority action. 4. INCORRECT: A CAT scan is often prescribed prior to surgery to verify the extent of splenic injury and the amount of blood in the abdominal cavity. Though the order is written as 'stat', this is not the nurse's priority. Transporting an unstable client to another department requires preparation.

1. Correct. These clients can be in the same room as neither has an infection or is immunocompromised. 2. Incorrect. The client scheduled for a bone marrow transplant is immunocompromised and should not be placed in the room with another client. 3. Incorrect. This client is at risk for infection and should be in a private room. 4. Incorrect. This client will be emitting radiation to the external environment and should be in a private room.

A client at 31 weeks gestation is being seen by the primary healthcare provider for reports of generalized illness. When assessing the client, the nurse would immediately report what symptom to the primary health care provider? 1. Right upper quadrant pain 2. Nausea with vomiting 3. Severe headache 4. Blurred vision

1. CORRECT: The symptoms being reported by the client indicates hemolysis of blood cells, elevated liver enzymes and low platelet count (HELLP) Syndrome, a life-threatening liver disorder related to preeclampsia. Occurring generally in the third trimester, or even right after birth, the exact cause is unknown. The only treatment is to deliver the fetus. 2. INCORRECT: Nausea and vomiting are generally complaints reported early in the first trimester. The return of these symptoms could indicate a general illness and would need to be investigated. However, nausea and vomiting is not the greatest concern with this client. 3. INCORRECT: A severe headache would lead the nurse to investigate blood pressure, as preeclampsia could cause elevated blood pressure. However, this is not the most serious reported symptom by the client. 4. INCORRECT: Blurred vision is definitely alarming and should be reported to the primary healthcare provider by the nurse. Combined with a severe headache, the nurse will need to report these findings. But there is another finding that is more urgent to report.

Which client should the RN assess first?

1. Client experiencing unstable angina. 2. Client with chronic emphysema experiencing mild shortness of breath. 3. Client five days post right-sided cerebral vascular accident. 4. Client diagnosed with Bell's palsy scheduled to be discharged. 1

An emergency department nurse has just received report on assigned clients. Which client should the nurse assess first?

1. Client reporting back pain of 6 on a scale of 0/10 after falling down from a patch of ice. 2. Client reporting a stiff neck and has a fever of 103 ° F (39.4 ° C). 3. Client vomiting after eating at a restaurant. 4. Client with a history of migraines reporting a headache. 2

What is the nursing priority for the client experiencing hyperparathyroidism crisis?

1. Continuous cardiac monitoring for arrhythmias. 2. Initiate fall precautions. 3. Diagnostic testing and imaging studies to find the cause. 4. Hurried preparations for emergency parathyroidectomy. 1

A nurse is observing two unlicensed assistive personnel (UAP) changing sheets for an immobile, obese client. What unacceptable action by the UAPs would require the nurse to intervene? 1. Stands straight with feet together. 2. Asks client to lift head off the bed. 3. Pulls draw sheet with both hands. 4. Faces slightly towards head of bed.

1. Corect: When moving a client, the most important safety action for the staff doing the lifting is to spread their feet apart to shoulder width, with knees slightly bent, to prevent back injury. The feet should never be placed together. The most stable part of the body is at the hips, and moving feet apart stabilizes the lifter. The nurse would intervene in this scenario before the UAPs are injured. 2. Incorrect: The UAPs are aware when sliding a client up in bed, if the client does not lift their head, the sudden movement could hyperextend the client's neck, causing severe trauma. The client must lift head off bed just before the staff moves the draw sheet to prevent neck injury. This is a correct action. 3. Incorrect: When moving an obese client, there should be at least two staff members on each side of the bed, grasping the draw sheet with both hands. With a firm grasp on the draw sheet, the staff then slides the client upward in the bed. The UAPs completed this action correctly. 4. Incorrect: Before moving the client upward, all staff should turn slightly toward the head of the bed, feet planted shoulder width apart and firmly grasp the draw sheet with both hands. This position is correct for both client and staff safety.

Which assessment finding by the nurse is most indicative of fluid volume overload? 1. Client has pitting edema in lower extremities. 2. Client's blood pressure is 120/80. 3. Client's CVP measurement is 6 mmHg. 4. Weight gain of 1.5 pounds (0.68 kg) in one day.

1. Correct. A client in fluid volume overload may experience pitting edema in lower extremities, a bounding pulse, increased blood pressure, and shortness of breath. 2. Incorrect. This blood pressure reading is considered normal and is not a characteristic of fluid volume overload. 3. Incorrect. This CVP is within the normal range therefore not indicative of a fluid volume excess. In a fluid volume excess, the CVP would be elevated.4. Incorrect. A weight gain in excess of 2 pounds (0.9 kg) is of concern for fluid volume excess. Any weight gain overnight is reason for concern; however, the stem asked which finding was most indicative.

A client was prescribed a monoamine oxidase inhibitor (MAOI) for the treatment of depression. Which comment by the client indicates adequate understanding of the tyramine restrictions that apply? 1. I cannot eat avocados or smoked ham. 2. I can eat sausage for breakfast, but not bacon. 3. At least I can still have my beer. 4. I can have blue cheese on my salad but not ranch dressing.

1. Correct. Clients taking MAOIs cannot consume foods containing large amounts of tyramine. MAOIs block monoamine oxidase which breakdown tyramine. Having a MAOI prescribed and eating a diet high in tyramine can cause a severe increase in blood pressure. Smoked ham and avocados are high in tyramine.2. Incorrect. Clients taking these medications cannot eat the following foods: sausage, salami, liver, or bologna which have high levels of tyramine. 3. Incorrect. Clients taking these medications cannot consume beer, sherry, chianti wines, or ales due to their high tyramine levels.4. Incorrect. Consuming blue cheese on a salad may result in a hypertensive crisis due to the presence of tyramine.

1. Start an IV with D5W at 125 mL/hr 2. Insert a nasogastric tube 3. Contact the primary healthcare provider 4. Obtain a stool specimen 3

The nurse is preparing to transfer a client from the delivery room to the postpartum unit. Which statement by the client would cause the nurse to re-assess the client prior to transfer? 1. "I just felt something gushing." 2. "I feel like I am still having contractions." 3. "When I stand up I feel dizzy for several moments" 4. "My nipples hurt since I breastfed my baby."

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 contractins 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. This statement does not require the client to stay in the delivery room. . 4. Incorrect. The breast may become tender after breast feeding the infant. This is not the priority and can be dealt with on the postpartum unit.

A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to do what? 1. Remove air from the pleural space 2. Create access for irrigating the chest cavity 3. Evacuate secretions from the bronchioles and alveoli 4. Drain blood and fluid from the pleural space

1. Correct: A chest tube placed in the upper chest is to remove air from the pleural space. Remember air rises and fluid settles down low. 2. Incorrect: Chest tubes are placed in the pleural space to get rid of air, blood, fluid, or exudate so that the lung can re-expand. The purpose is not to create an access for irrigating the chest cavity. 3. Incorrect: The chest tube is inserted into the pleural space because the lung has collapsed due to air, blood, fluid, or exudate. The chest tube does not go into the lung so secretions can not be removed from the bronchioles and alveoli by way of the chest tube. 4. Incorrect: You have to know the purpose of the upper chest tube. Fluid drains down, so the lower one is for fluid.

Because of over-crowding, the charge nurse of a busy unit has been instructed to place two clients in each private room. An elderly client with early dementia is currently in one of the private rooms recovering from pneumonia. The nurse knows what client would make the most appropriate roommate? 1. A young adult for evaluation of severe recurrent migraines. 2. An adolescent s/p appendectomy going home tomorrow. 3. A terminal adult client admitted for pain management. 4. A bipolar client in the manic phase of major depression.

1. Correct: A client admitted for evaluation of migraines will most likely need a quiet environment with minimal visitors during the hospitalization. An elderly client with dementia may be the ideal roommate. 2. Incorrect: Adolescents generally enjoy the companionship of other teens, even if it is by phone conversation. Despite recent surgery, the adolescent may be too lively for this elderly client. 3. Incorrect: When admitting an individual for pain management, the client is usually uncomfortable and may even cry out till the pain is finally controlled. Combine that with "pain behaviors" such as restlessness or moaning, and it's easy to see how the other individual may not get much rest. Also, as a terminal client, the individual may have frequent family members visiting. 4. Incorrect: A bipolar client experiencing the manic phase of this disease process is not a good roommate. The excess activity occurring during mania, including pacing and creating confusion or noise, would most likely disturb or stress the elderly individual in the room.

A client has been admitted voluntarily to the psychiatric unit. During the admitting interview, the client confides to the nurse that they have a lethal plan for committing suicide. At the end of the interview the client asks the nurse, "How long will I have to stay here?" What should the nurse say to this client? 1. "Let's discuss this after the health team has assessed you." 2. "Since you signed papers to be admitted, you cannot leave until the primary healthcare provider discharges you." 3. "A lawyer will have to make that decision." 4. "You can leave when you are no longer suicidal."

1. Correct: A client may sign out of the hospital at any time, unless following a mental status examination the healthcare professional determines that the client may be harmful to self or others and recommends that the admission status be changed from voluntary to involuntary. 2. Incorrect: A client may sign out of the hospital at any time, unless following a mental status examination the healthcare professional determines that the client may be harmful to self or others and recommends that the admission status be changed from voluntary to involuntary. 3. Incorrect: Lawyers do not make that decision. This client was voluntarily admitted, not involuntary. Involuntary admission can be from three different commitment procedures: judicial, administrative and agency determination. Involuntary admission can be further categorized as emergency, observational/temporary or indeterminate/extended. 4. Incorrect: This is not the best response, since the client has told you of a plan. They might decide to tell you they have no plan when in fact they do.

Which assigned postpartum client should the nurse identify as being at highest risk for hemorrhage? 1. C-section delivery 2. Vaginal delivery of twins 3. Vaginal delivery of premature baby 4. Precipitous delivery of gravida 5

1. Correct: A client with a surgical wound is at risk for hemorrhage and is at greater risk than birth from a vaginal delivery. The surgical opening of the abdomen and the uterus makes this the highest risk. 2. Incorrect: If the placenta is removed and the fundus massaged properly, risk of hemorrhage decreases. The risk of hemorrhage goes up with multiple births, such as twins, as compared with a single birth, but it is still not as high a risk as a c-section.3. Incorrect: Premature does not place the client at higher risk of bleeding. The premature newborn is generally smaller with less risk of damage to the uterus and perineum of mom. 4. Incorrect: A precipitous delivery could make you think tear, but the client is Gravida 5. Tearing is less likely after having 5 children.

The housekeeper and a nurse, having lunch together in the staff lounge, begin discussing the housekeeper's neighbor who has been admitted to the floor. The housekeeper occasionally helps the neighbor with shopping and cleaning. The conversation is overheard by the unit secretary, though no names were mentioned. The conversation is reported to the nurse manager, who determines the situation reflects what HIPAA criteria? 1. Not permissible because the housekeeper is not medical personnel. 2. Is permissible since the housekeeper does help care for the neighbor. 3. Not permissible despite family stating housekeeper is "like family". 4. Is permissible given that no other family members are available now.

1. Correct: A client's medical diagnosis or treatments can only be discussed with those hospital personnel involved directly with that individual's care. The housekeeper does not meet these criteria, and this conversation is not permissible since it violates HIPAA regulations. 2. Incorrect: Despite the fact the housekeeper provides assistance to the neighbor at home, sharing private medical details is definitely not permitted, even if there were no names heard by the unit secretary. 3. Incorrect: An individual considered "like family" is still not legally entitled to discuss any medical details unless the client gives specific written permission to do so. Additionally, a family member is not permitted to give consent for medical facts to be revealed without the client's direct consent. 4. Incorrect: Whether family members are available or not, only the client or the client's designated power of attorney may give permission to reveal medical data to anyone not directly involved with the client's care.

The nurse walks into a client's room and finds the client exposed while the unlicensed assistive personnel (UAP) is giving the bath. After covering the client with a sheet, what should the nurse do first? 1. Tell the UAP to keep the client covered at all times. 2. Talk with the UAP about providing appropriate care for all clients. 3. Provide teaching to the UAP about privacy for clients. 4. Use the call light to ask for additional assistance in the room.

1. Correct: A comment should be made about keeping the client covered. This instruction is the first action after covering the client. 2. Incorrect: The nurse should talk with the UAP but the discussion should focus specifically about providing privacy for clients. 3. Incorrect: The nurse may want to provide teaching, but this is not first action. Teaching would require allowing enough time to give instructions and then arranging time for return demonstration. 4. Incorrect: The UAP should be allowed to finish the bath. Additional assistance is not needed.

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 nurses best response? 1. This is a common side effect of antidepressant medications. Perhaps a different antidepressant would cause less side effects. 2. Excessive sweating can have many causes. 3. I think that 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 also gives the client an explanation. 2. Incorrect: This response shows a lack of understanding of the side effects of anti depressant 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 antipsychotic medication.

The out patient surgical unit has admitted multiple clients currently awaiting early morning procedures. What client should the nurse assess first? 1. The client awaiting repair of hiatal hernia reporting chest pain. 2. The client with a torn right rotator cuff reporting shoulder pain. 3. The client with an inguinal hernia repair reporting skin irritation. 4. The client awaiting a hemorrhoidectomy reporting rectal bleeding.

1. Correct: A hiatal hernia occurs when a portion of the stomach pushes up through the esophageal ring (hiatus) of the diaphragm. Surgical intervention is generally a last resort and only when there is evidence of serious complications. Although chest pain could be the result of reflux within the esophagus, it could also indicate a strangulated hiatal hernia. The nurse needs to assess this client immediately. 2. Incorrect: A torn rotator cuff is generally only repaired when other treatment options have been ineffective, such as rest, ice, NSAIDs and even steroid injections. This client has been ordered a surgical repair, indicating other therapies have failed. Shoulder pain on the affected side is to be expected and not an urgent need. 3. Incorrect: An inguinal hernia is the protrusion of intestine through abdominal muscles, creating a painful bulge which worsens with lifting, bending, or straining. Skin irritation usually results from wearing a supportive garment known as a truss. The purpose of this belted device is to apply pressure and provide support to the area of the hernia until surgical repair. Skin irritation is not the nurse's priority. 4. Incorrect: Large or engorged rectal hemorrhoids may require surgical repair because of excessive bleeding, pain, or prolapse. This type of bleeding is not unexpected nor does it present any major concerns about shock. This client would not need to be seen first.

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 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.

Which room assignment would be most therapeutic for the nurse to make for a client with bipolar disorder in manic phase who is hyperactive and has difficulty sleeping? 1. A private bedroom. 2. A semi private room with a roommate who has a similar problem. 3. Either a private or a semi private room. 4. Direct admission to the seclusion room until his activity level becomes more subdued.

1. Correct: A private room will help to decrease stimulation. The client with bipolar disorder needs a calm environment especially when in the manic phase. Avoid excessive stimulation. 2. Incorrect: Don't put two manics together. This room assignment will not help to decrease stimulation which is what the manic client needs. 3. Incorrect: They need a private room. The client with psychosis maybe suspicious and have delusion or hallucinations. 4. Incorrect: There's no need for this right now. The client is hyperactive and has difficulty sleeping. A seclusion room is needed for severe agitation and acute aggression.

What term should the nurse use to document that a woman is pregnant for the first time? 1. Primigravida 2. Multigravida 3. Primipara 4. Multipara

1. Correct: A woman pregnant for the first time. The prefix "primi" means first. "Gravida" refers to a woman who is or has been pregnant, regardless of the duration or outcome of the pregnancy. 2. Incorrect: A woman who has had 2 or more pregnancies. The term "multi" means more than one. "Gravida" refers to a woman who is or has been pregnant. 3. Incorrect: A woman who has completed 1 pregnancy with a fetus or fetuses who have reached 20 weeks of gestation. The term "primi" means first. "Para" refers to the number of pregnancies that have progressed to 20 or more weeks at delivery. 4. Incorrect: A woman who has completed 2 or more pregnancies to 20 or more weeks of gestation. The term "multi" means more than one. "Para" refers to the number of pregnancies that have progressed to 20 or more weeks at delivery whether the fetus was born alive or still born: refers to the number of pregnancies, not the number of fetuses.

The client has been taking divalproex for the management of bipolar disorder. The nurse should give priority to monitoring which laboratory test? 1. Alanine aminotransferase (ALT) 2. Serum glucose 3. Serum creatinine 4. Serum electrolytes

1. Correct: ALT levels will increase primarily in liver damage/disorders. A side effect of administering divalproex is drug-induced hepatitis. 2. Incorrect: Divalproex is not expected to alter glucose metabolism. 3. Incorrect: Divalproex should not cause a change in renal function. 4. Incorrect: Divalproex should not interfere with electrolytes balance.

A 40 year old client reports a diminished ability to visually focus on close objects and has also noticed a need for a well lit environment to enhance vision. To what would the nurse attribute these changes? 1. Normal changes associated with aging. 2. A cataract is forming. 3. Symptoms of a brain tumor. 4. Precipitated by diabetic retinopathy.

1. Correct: Aging results in stiffening of the lens, thus lessening the ability to focus. The retina is less sensitive to light, making accurate vision in low-light situations more difficult. Pupillary response diminishes, affecting the ability to adjust to changing light levels. 2. Incorrect: Cataracts present with blurred vision and a glare from lights. 3. Incorrect: Brain tumors increase intracranial pressure, resulting in blurring of vision. 4. Incorrect: Diabetic retinopathy is caused by changes in retinal blood vessels and results in blurred vision and outright impairment in some fields.

A 35 year old client asks a clinic nurse how to find out if the client is overweight or obese. The client weighs 135 pounds and is 5 feet 2 inches tall. What should the nurse educate the client about? 1. Calculating body mass index 2. Measuring abdominal circumference 3. Determining lean body mass 4. Finding the nearest hydrostatic testing location

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

The nurse is reviewing sequential lab results on a newly admitted client with multiple health issues. Critical changes in which body system require the nurse to immediately notify the primary healthcare provider? Exhibit 1. Renal 2. Endocrine 3. Pulmonary 4. Cardiovascular

1. Correct: All lab values are fluctuating, but those most significantly outside of normal range are the BUN and Creatinine levels, reflecting possible renal failure. The nurse would need to immediately notify the primary healthcare provider of possible complications in the client's renal system. The sodium, potassium, and glucose are within normal limits. 2. Incorrect: Several lab readings could relate to the endocrine system, but most specifically are glucose and chloride. Both these electrolytes have fluctuating levels but remain well within normal limits. Therefore, the endocrine system is not the nurse's concern at this time. 3. Incorrect: The carbon dioxide levels listed reflect venous, NOT arterial, blood. Norms for venous carbon dioxide are 23 to 29 mEq/L (milliequivalent units per liter of blood), indicating these results are all within normal levels. Although chloride could also reflect the pulmonary system, there are no irregular results in chloride levels. 4. Incorrect: Many of these elements could affect the cardiovascular system, but most specifically sodium and potassium. At present, these levels are all within normal limits, although the potassium has risen to the upper most levels of normal. If those levels continue to climb, this could become a concern; however, this would not require a call to the primary healthcare provider at this time.

The nurse leader is planning to change the method of client documentation on the unit. Some employees accept the change without difficulty; however, some of the employees are resistant to change and try to sabotage the plans for change. Which action should the nurse leader take to reduce resistance to change on the unit? 1. Allow staff on the unit a voice in the plan for change. 2. Discourage discussion between supporters and resisters. 3. Set an implementation date and begin the new method. 4. Announce that the plan for change is set by administration

1. Correct: Allowing everyone an opportunity to speak may reveal the reasons behind the resistance. If everyone has a voice, each person is more likely to buy into the new method. 2. Incorrect: Supporters and resisters should communicate. Perhaps the supporters can persuade the resisters. Encouraging discussion keeps communication lines open and is more likely to decrease resistance.3. Incorrect: Setting a date for implementation should come after discussion and training on the new process. A target date must be set; however, the groundwork for change must occur first. 4. Incorrect: Staff is more likely to accept change that affects them if they have a voice. Administration can take staff suggestions and possibly make a better plan.

The parents of a 4 year old child have recently had a new baby and the parents report that the 4 year old had been dry all night for 8 months and is now wetting the bed again. What should the nurse assess first? 1. Urinalysis 2. Normal urination habits. 3. Adjustment to the new baby. 4. Fluid intake after 6 pm.

1. Correct: Always assess the physiologic problem first to rule out a urinary tract infection (UTI). Once a physiologic cause is removed as the cause other assessment should be performed. If a UTI is present, treatment should start immediately. 2. Incorrect: Assessing the normal urination habits is not first. Assessing the urinalysis is priority. 3. Incorrect: Regression is the likely cause but the physiologic problems should be assessed first. 4. Incorrect: The child's fluid intake may be too high after 6 pm, but ruling out a urinary tract infection is the first assessment and requires immediate treatment if there is an infection.

What is priority for the client experiencing hyperparathyroid crisis? 1. Support for airway and breathing. 2. Continuous cardiac monitoring for arrhythmias. 3. Provide safety precautions. 4. Prepare for emergency tracheostomy.

1. Correct: Always remember ABC, if it is relevant, and it is with hyperparathyroid crisis. 2. Incorrect: Circulation is important. This priority comes after attention has been directed toward airway and breathing. What good would come of circulating deoxygenated blood, and how long can the heart muscle last without oxygen? Always remember ABC when prioritizing in emergency situations. 3. Incorrect: Muscle weakness, thus risk for falls is a concern, but airway takes priority! 4. Incorrect: Trach would be more likely with hypoparathyroidism. Remember, in hypoparathyroidism, the client would have rigid and tight muscles which would cause laryngospasms.

A new nurse is preparing an injection from an ampule. What action by the new nurse would require the precepting nurse to intervene? 1. Snaps the neck of the ampule gently towards the body. 2. Uses a filter needle when drawing up the ampule contents. 3. Folds gauze around the ampule neck before snapping open. 4. Avoids touching edges of the ampule when inserting needle.

1. Correct: An ampule is a glass vial with a narrow, scored neck that must be snapped off to open. Even if the neck of the ampule is covered with gauze, the proper procedure is to snap the top away from the body, not toward the body. If the new nurse attempts to snap the top of the ampule toward the body, the charge nurse would need to intervene immediately. 2. Incorrect: This is a correct action. When a glass container is broken, there is the potential for tiny glass shards to fall into the solution and subsequently be infused into the client. To avoid this situation, a filter needle must be utilized to draw up the solution from the ampule. Once drawn up, the filter needle is removed and a regular needle utilized to inject the solution into the client. This is a correct action. 3. Incorrect: The use of an alcohol wipe or small gauze sponge, wrapped around the neck of the ampule prior to snapping the top open is crucial to prevent injury to the nurse. Exposure to the jagged glass top could easily cut a thumb or finger while holding the vial. No intervention needed here. 4. Incorrect: The scenario asks for an incorrect action requiring intervention by the charge nurse. However, this action is appropriate. It is always important to avoid touching the edges of the opened ampule when inserting the needle to prevent possible contamination of the solution.

A client has arrived in the emergency department with partial thickness burns to 52 percent of the body. Which central venous pressure (CVP) reading would the nurse anticipate? 1. 1 mm of Hg 2. 2 mm of Hg 3. 6 mm of Hg 4. 10 mm of Hg

1. Correct: Normal CVP is 2-6mmHg. This CVP reading indicates fluid volume deficit. A client with 52 percent of the body burned with partial thickness burns would lose fluid from the vascular space out into the tissues resulting in fluid volume deficit. 2. Incorrect: This is a normal CVP reading. Normal CVP is 2 to 6 mm of Hg. 3. Incorrect: This is a normal CVP reading. Normal CVP is 2 to 6 mm of Hg. 4. Incorrect: An increased CVP reading indicates fluid volume excess. There is no indication in the stem that the client is experiencing a fluid volume excess.

The nurse is assessing the injection site of a healthy client who received a Mantoux skin test 48 hours ago. Which finding at the injection site indicates a need for further evaluation? 1. 16 mm induration 2. 4 mm erythrokeratodemia 3. 0.1 mL bluish colored hard wheal 4. Multiple fluid-filled vesicles

1. Correct: An induration of 15 mm or greater is usually considered positive in people who have normal or mildly impaired immunity. A client with a positive reaction of 15mm or greater will need further evaluation by a primary healthcare provider. 2. Incorrect: This is a small, red, hard area that is smaller than 10 mm. Therefore the size is not considered significant. Induration is roughness, not hardness. The induration is what nurses assess to determine significance. 3. Incorrect: When administering a Mantoux skin test, 0.1 mL of solution is injected under the top layer of the skin to produce a wheal. The presence of the 0.1 mL wheal is not expected at this time. 4. Incorrect: This is the significant reaction that one would find with a multiple puncture tine, which is sometimes used with mass screening for TB. This is not expected with a Mantoux skin test.

The nurse is assessing the injection site of a healthy client who received a Mantoux skin test 48 hours ago. Which finding at the injection site indicates a need for further evaluation? 1. 15 mm induration 2. 4 mm erythrokeratodemia 3. 0.1 mL bluish colored hard wheal 4. 0 mm induration

1. Correct: An induration of 15 mm or greater is usually considered significant in people who have normal or mildly impaired immunity. 2. Incorrect: This is a small, red, hard area that is smaller than 10 mm. Therefore the size is not considered significant. Induration is roughness, not hardness. The induration is what nurses assess to determine significance. 3. Incorrect: When administering a Mantoux skin test, 0.1 mL of solution is injected under the top layer of the skin to produce a wheal. The presence of the 0.1 mL wheal is not expected at this time. 4. Incorrect: This is normal finding in someone who has not been exposed to TB.

Which referral would the nurse anticipate that the primary healthcare provider would make for a client who has difficulty eating using regular utensils? 1. Occupational therapist 2. Physical therapist 3. Rehabilitation nurse 4. Registered Dietitian

1. Correct: An occupational therapist helps physically disabled clients adapt to physical limitations and is most qualified to help clients improve their ability to perform activities of daily living. OT's help clients learn to approach tasks differently, use assistive devices or equipment, make adaptations to the home or work environments and find ways to assist the client in meeting personal goals. 2. Incorrect: The physical therapist is trained to deal with problems that limit their abilities to move, perform daily functions, or remain active and independent. However, physical therapists do not assist with special adaptations needed to perform activities of daily living such as eating. 3. Incorrect: A rehabilitation nurse can help a client eat, but isn't trained in modifying utensils. The rehabilitation nurse assists clients as they adapt to altered lifestyles and assists clients to attain and maintain the highest level of functioning. Some of the aspects included in the role of the rehab nurse includes encouraging self care, preventing complications and further disability, setting goals for independent functioning, and assisting clients to access additional care needed. The rehabilitation nurse would work collaboratively with the occupational therapist (OT). The OT is the one who will best meet the needs of this client who is experiencing difficulty eating with regular utensils.

A client is diagnosed with a duodenal ulcer due to Helicobacter pylori (H Pylori). In addition to antibiotic therapy, the nurse anticipates that the client will also receive what class of pharmacologic agent? 1. Proton pump inhibitor 2. Mitotic inhibitor 3. Serotonin antagonist 4. Acetylsalicyclic acid

1. Correct: Antisecretory agents like proton pump inhibitors are indicated for the treatment of peptic ulcer disease. Antisecretory agents decrease the secretion of gastric acids. Protein pump inhibitors, a combination of antibiotics and bismuth salts are most commonly used for treatment of H Pylori.2. Incorrect: Mitotic inhibitors are chemotherapeutic agents that are indicated for the treatment of malignancies and cancerous cells. They are most often used in combination chemotherapy regimens to enhance the overall cytotoxic effect. 3. Incorrect: Serotonin antagonists are antiemetic agents that are indicated for the treatment of nausea and vomiting. Serotonin antagonists block the serotonin receptor sites located throughout the body responsible for the mediation of nausea and vomiting. 4. Incorrect: Acetylsalicylic acid is a non narcotic analgesic that inhibits the cox-2 protective mechanisms to the gastric mucosa. This could make the ulcer worse. Clients are advised to avoid the use of NSAIDs and acetylsalicylic acid due to increased bleeding potential.

The nurse is caring for a client with questionable loss of consciousness in the emergency department following a motor vehicle crash. Which action should the nurse take first? 1. Assess airway patency, breathing, and circulation. 2. Assess level of consciousness and movement. 3. Cover wounds with a sterile dressing. 4. Maintain cervical spine immobilization.

1. Correct: Any time a nurse is faced with emergency management, the primary survey should be followed. The beginning order of the primary survey is airway, breathing, circulation. 2. Incorrect: After completion of airway, breathing and circulation assessment, the nurse should assess for neurologic disability. This would include assessment of the client's level of consciousness (LOC). 3. Incorrect: Measurement of a full set of vital signs would occur after assessment of airway, breathing and circulation. 4. Incorrect: The secondary survey includes stabilization of the neck and assessment for signs of neck injury.

A 9 month old with asthma symptomology has montelukast sodium oral granules prescribed. What is the most appropriate way for the nurse to instruct the parent on how to administer the medication? 1. Mix the granules with a spoonful of baby food such as applesauce. 2. Pour the granules directly on the back of the infant's tongue. 3. Dissolve the granules in an 8 ounce (240 mL)bottle of juice. 4. Administer the medication in the morning mixed in a bowl of rice cereal.

1. Correct: Applesauce is an appropriate baby food for a 9 month old infant. The medication is being mixed with a very small amount of baby food to facilitate all of the medication being consumed. 2. Incorrect: Although the medication can be administered directly into the mouth, a 9 month old is not likely to tolerate medication granules being placed in the back of the mouth and would likely spit the medication out or gag when the medication is placed in the back of the mouth, 3. Incorrect: The medication is being placed in too much juice. The infant might not drink this amount and would not receive all of the medication ordered. 4. Incorrect: If the child does not eat the entire amount of the cereal, the child would not receive the prescribed dose of the medication.

A five year old is in kindergarten and goes to the nurse's office where she reports a "stomachache". While there, the nurse observes that the child has a large bruise on her upper arm and bruises on both ears. What should the nurse do first? 1. Ask the student about the bruises on the arms and ears. 2. Do nothing as bruises are common in 5 year old children. 3. Report the injuries immediately to the parents. 4. Discuss the findings with the child's teacher.

1. Correct: Assessment and gathering information should be the first response. The child may have experienced a severe accident that does not indicate abuse. The nurse needs further information before assuming abuse in the family. 2. Incorrect: Bruises on the upper arms and ears are not typical for a child of this age. 3. Incorrect: The parents may have inflicted the injuries on the child which will be important to assess later, but is not the first action for the nurse. 4. Incorrect: The nurse should discuss the observations with the teacher to determine if other indicators of abuse are present. The first step is to communicate with the child and further assess the situation.

A client on the in-patient psychiatric unit was found to have lacerations on the wrist when the nurse made rounds. Which change in routine on the unit is most likely to prevent such an event from occurring in the future? 1. During the end-of-shift report, assign specific staff to check on each client. 2. Place newly admitted clients close to the nursing station. 3. Monitor level of suicide precaution needed on each client daily. 4. Ask clients to check on each other throughout the shift.

1. Correct: Assigning specific staff to perform client checks during the shift will assure that the clients, that the staff are concerned about their welfare. In addition, it assures that someone is specifically monitoring the client each shift, therefore, promoting the clients right to a safe environment. Client safety is a priority in Maslow's Hierarchy of Needs. The nurses will play a key role in reducing these self-harming behaviors through recognition of the problem, being alert to risk factors when assessing the client, and ultimately guiding the client into more acceptable outlets for stress, anxiety, anger, low-self esteem, or other related causes. 2. Incorrect: This routine may or may not prevent an injury. The clients may learn the "routine" of the nurses and will perform the self-harming behaviors when the nurses are not likely to be making individualized checks on them. 3. Incorrect: Each client should be monitored daily at irregular intervals. Self-harming behaviors typically increase the risk of suicide in the client. The nurse should determine the level of imminent risk of suicide in the client. This should be routinely performed with client checks, not simply assessed on a daily basis. 4. Incorrect: It is not the clients' responsibility to check on each other. All clients have the right to a safe environment, and it is the responsibility of the nurses and healthcare team to provide this safety.

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 to 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. 2. Incorrect: This is not the best option. Some pre-surgical procedures may be difficult to draw or difficult to understand. 3. Incorrect: This is called "Getting by" and may have to be used when the nurse cannot speak the client's language, without interpreters, audiotapes, or written materials available to inform the client in their language. This is not the best option. 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. They may leave out important words, add words, or substitute terms that make communication inaccurate.

A nurse observes a psychiatric client sitting alone. The client is talking, but occasionally stops and leans to the side as if listening to someone. The client then laughs. What is this client most likely experiencing? 1. Auditory hallucinations 2. Delusions 3. Catatonic excitement 4. Anergia

1. Correct: Auditory hallucinations are false sensory perceptions of sound not associated with real external stimuli. When the client begins to respond to a stimuli that is not visible to the nurse, this is a hallucination. 2. Incorrect: Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background. These beliefs are not consistent with reality and guide the client's behavior. Typically the client thinks they are all powerful, or have unrealistic fears. 3. Incorrect: Catatonic excitement is manifested by a state of extreme psychomotor agitation. This client is not showing any symptoms of agitation. 4. Incorrect: Anergia is a deficiency of energy to carry out activities of daily living. There are no indications in the question that this client cannot carry out activities of daily living.

FUNDALMENTAL Which is the correct method for removing personal protective equipment (PPE)? 1. Contaminated gloves should be removed in the client's room. 2. The glove that is removed first should be placed in the waste basket before the other glove is removed. 3. Remove face shield or goggles first. 4. Shoe covers should be removed last.

1. Correct: Avoid contaminating self, others, or environment when removing equipment. 2. Incorrect: The first glove is held in the still gloved hand and the second glove is slid over the first removed glove. 3. Incorrect: Hand hygiene is performed before removing face shield or goggles. 4. Incorrect: Shoe covers are removed with gloved hands.

Which is the correct method for removing personal protective equipment (PPE)? 1. Contaminated gloves should be removed in the client's room. 2. The glove that is removed first should be placed in the waste basket before the other glove is removed. 3. Remove face shield or goggles first. 4. Shoe covers should be removed last.

1. Respiratory Acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 3

The nurse is having an education class for pregnant women. A question is raised about exercise. What is the nurse's best response? 1. Discuss with healthcare provider your current exercise regimen and history. 2. You can continue any exercise that you have been doing before pregnancy. 3. If you haven't already started an exercise program, you should wait until after delivery. 4. Exercise is required during pregnancy for a minimum of 15 minutes each day.

1. Correct: Best advice for pregnant women. The healthcare provider can individualize according to the physical condition of the woman and the stage of pregnancy. 2. Incorrect: As pregnancy progresses, the exercise program may need modification because the change in the woman's center of gravity makes her more prone to falls. Therefore, an activity that is safe in the first trimester may not be safe in the third trimester. Those women who have been exercising strenuously before pregnancy should consult the healthcare provider but may be able to continue much of their usual routine. Recreational sports generally can be continued if no risk of falling or abdominal trauma exists. 3. Incorrect: Exercise during pregnancy is generally beneficial and can strengthen muscles, reduce backache, reduce stress and provide a feeling of well-being. The amount and type of exercise recommended depend on the physical condition of the woman and the stage of pregnancy. 4. Incorrect: Women who have no medical or obstetric complications should exercise in moderation each day for 30 minutes or more during pregnancy.

The nurse initiates cardiac monitoring on a 6 year old immediately after the child has a seizure. How should the nurse document the rhythm? Exhibit 1. Sinus arrhythmia 2. Sinus bradycardia 3. Sinus tachycardia 4. Sinus pause1.

1. Correct: Both the atrial and ventricular rates are 68-88 bpm. The rhythm is irregular. There is a P wave before every QRS and they are the same. The PR interval is normal at 0.12 seconds. The QRS is normal at 0.08 seconds. This is a sinus arrhythmia typically seen in children and adolescents where the heart rate increases with inspiration and decreases with expiration. 2. Incorrect: With sinus bradycardia, the rhythm would be regular and the rate would be below 60 bpm 3. Incorrect: With sinus tachycardia, the rhythm would be regular and the rate would be greater than 100 bpm. 4. Incorrect: With sinus pause there is a prominent pause of at least 3 seconds in the ECG rhythm.

The nurse assessing clients in a pediatric clinic would refer which child for further assessment? 1. A 20 month old who only says "no." 2. A 1 year old who says three words 3. A 9 month old who says "dada" and "mama" 4. A 4 month old who laughs out loud

1. Correct: By 18 months of age, a child should be able to speak 10 or more words. 2. Incorrect: By 1 year of age, a child should be able to say "mama," "dada," and an additional 3 to 5 words. 3. Incorrect: By 9 months of age, a child should be able to say "mama" and "dada." 4. Incorrect: By 4 months of age, a child should be able to laugh out loud.

The nurse is performing a Denver Developmental Screening Test II on a 4 ½ year old. What behavior should the nurse expect the child to demonstrate? 1. Prepares own cereal without help. 2. Correctly copies a square. 3. Draws a person with at least 5 body parts. 4. Balances on each foot for more than 6 seconds.

1. Correct: By age 4 1/2, a child should be able to prepare a bowl of cereal without help, copy a circle, speak clearly, and draw a person using at least three body parts. 2. Incorrect: Less than 25% of 4 year old children can correctly copy a square. 3. Incorrect: At the age of 4 1/2, a child should be able to draw a person with at least 3 body parts. 4. Incorrect: Most children don't achieve balancing on each foot for 6 seconds until about age 5 ½.

A client who was diagnosed with paranoid delusions has been prescribed a chest x-ray. The client refuses the chest x-ray and states "No, they want to kill me with the rays from the x-ray machine." Which nursing response is appropriate? 1. "Do you think people want to kill you with rays?" 2. "You don't have to worry that someone is going to kill you." 3. "I don't want you to talk about the x-ray technicians." 4. "Where did you get the idea that someone was trying to kill you?"

1. Correct: By restating the client's primary idea this reinforces to the client that statement has been heard. This allows the client to clarify the statement or realize that the nurse has understood the comment. This is the therapeutic communication technique of restating. 2. Incorrect: The nurse is using the nontherapeutic communication technique of giving reassurance. The nurse is stating that the client has nothing to worry about. The client may feel the nurse is moderating their intense concern of the possibility of being killed. 3. Incorrect: The nurse is disregarding the client's concern about possibly being killed. The nurse is redirecting the conversation about the client to concern for the x-ray technicians. The nurse is preferring the conversation to be focused on another topic. This is an example of the nontherapeutic communication technique of introducing an unrelated topic. 4. Incorrect: Demanding a reason from the client about their thoughts or feelings is an example of the nontherapeutic communication technique of requesting an explanation. This is a direct question. The client will need to defend their feelings or thought. The client may feel intimidated and stop communicating with the nurse.

The nurse is performing a home assessment of a two year old. Which behavior by the toddler does the nurse identify as normal development? 1. Drinks from a cup. 2. Cuts food with a knife. 3. Pours juice into a cup. 4. Eats with a fork.

1. Correct: By the time toddlers are 2-years old, they should be able to use cup. 2. Incorrect: By age 5, normal development includes using a knife. 3. Incorrect: By age 5, normal development includes pouring. 4. Incorrect: Forks are used by 3-4 years old.

Which comment made by a new nurse regarding calcium gluconate 1000 mg (10 mL) IV indicates to the charge nurse that further education is needed? 1. "Infusion rate should be 5 mL/minute." 2. "Calcium gluconate will counteract the effects of the client's hyperkalemia." 3. "I will monitor for hypophosphatemia after administering this medication." 4. "This medication is given to reverse the effects of hypermagnesemia."

1. Correct: Calcium gluconate is administered IVP very slowly. Rapid injection may cause vasodilation, decreased blood pressure, bradycardia, cardiac arrhythmias and even cardiac arrest. The max rate is 1.5- 2 mL/min. Administration at a faster rate would indicate further education is needed. 2. Incorrect: This is a correct statement by the new nurse, indicating that the nurse understands the use of this medication. It counteracts the effects of hyperkalemia on cardiac excitability. 3. Incorrect: This is a correct statement. Calcium and phosphorus have an inverse relationship to each other. As calcium goes up, phosphorus goes down. Hypophosaphetemia may occur after administration. 4. Incorrect: This is a correct statement. Calcium gluconate is used to treat calcium deficiencies as well as magnesium sulfate overdose.

A client newly diagnosed with insulin dependent diabetes mellitus is started on regular insulin. The nurse would teach the client that the insulin should start to lower the blood sugar within how many minutes? 1. 15 2. 30 3. 45 4. 90

1. Incorrect: Insulin aspart mixture is a rapid-acting insulin and starts to work within 15 minutes after given subcutaneously. 2. Correct: Regular insulin has an onset of 30 minutes to 1 hour. 3. Incorrect: Long acting insulin has an onset of 45-48 minutes. An example of long acting insulin would be lantus. 4. Incorrect: Intermediate acting insulin such as NPH insulin has an onset of 90 minutes.

The nurse is planning care for four clients with different medical issues. With which diagnosis would a client benefit most from an integrative medicine healthcare strategy? 1. Chronic fatigue syndrome who has had no relief of fatigue. 2. Diabetes whose blood sugars are out of control and refuses to take the prescribed oral and injection medications. 3. Cholecystitis who wants surgery to treat the symptoms definitively. 4. Productive cough with green sputum, fever of 104.2 degrees Fahrenheit (40.1 degrees C), and chest pain.

1. Correct: Chronic fatigue syndrome is a chronic health problem that is difficult to treat using only traditional medicine and responds well to the use of an integrative medicine healthcare strategy by using a combination of traditional and holistic therapies. Integrative medicine is an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person's health. 2. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies. 3. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies. 4. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies.

A client admitted to the inpatient mental health unit asks if mail can be received from family. Which statement by the nurse indicates adequate understanding of client rights? 1. Clients can receive and send mail, but staff must check for hazards. 2. Clients are not allowed to receive mail while hospitalized. 3. Receiving mail from family is not encouraged. 4. Clients are allowed to send or receive mail after the first 72 hours after admission.

1. Correct: Clients are allowed to send and receive mail. Mail must be checked for hazards to protect the client and the safety of others on the unit. 2. Incorrect: This statement indicates lack of understanding of client's rights. This includes the right to send and receive "sealed, unopened, uncensored mail." If the client is present, staff may open and check mail for contraband, but may not read it. The superintendent, director, or designee of the superintendent or director must document with specific facts the reason for opening the mail. 3. Incorrect: This statement indicates lack of understanding of client's rights on the mental health unit. 4. Incorrect: The client has a right to send and receive mail throughout their hospital stay.

The nurse is assigned a group of clients on the inpatient psychiatric unit. Which client presents the greatest risk for violence toward others? 1. 24 year old man with paranoid delusions 2. 62 year old woman with bipolar disorder 3. 72 year old man with major depression 4. 28 year old woman with borderline personality disorder

1. Correct: Clients with paranoid delusions believe that others may harm them. Because they cannot determine what is accurate, they may react in a violent manner. The clients age falls within the range for males who are most likely to present a risk of violence toward others. 2. Incorrect: The client with bipolar disorder may exhibit mood changes from elated to hopeless episodes. 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 themselves than others. The client may exhibit sadness, anxiety or exhaustion. 4. Incorrect: The client with borderline disorder may exhibit impulsive and dangerous behavior. This client is more likely to hurt herself, perhaps through self-mutilation.

The nurse instructs a client about deep breathing and coughing exercises that will be performed postoperatively. Which statement by the client indicates that teaching has been effective? 1. "Coughing and deep breathing should be performed hourly to prevent pneumonia." 2. "Coughing and deep breathing are needed to prevent blood clots." 3. "Coughing and deep breathing will aide with healing by increasing available oxygen." 4. "Coughing and deep breathing will help resolve any blood clots that have formed. "

1. Correct: Coughing and deep breathing exercises are done to expand the lungs and prevent pneumonia and atalectasis. After surgery, due to the pain, clients are prone to shallowly breath which can lead to atelectasis and thick secretions and increased risk of pneumonia. 2. Incorrect: Coughing and deep breathing exercises are done to expand the lungs and prevent pneumonia and atalectasis after surgery. Coughing and deep breathing will not prevent blood clots. 3. Incorrect: Coughing and deep breathing will increase available oxygen. The main reason client's should cough and deep breath however, is for lung expansion and pneumonia prevention. 4. Incorrect: Coughing and deep breathing exercises are done to expand the lungs and prevent pneumonia and atalectasis after surgery. Coughing and deep breathing will not resolve blood clots.

What is the priority nursing action for a pregnant client who has dilated to 6 centimeters while receiving an epidural? 1. Continuous monitoring of maternal blood pressure. 2. Frequent auscultation of the fetal heart rate. 3. Administer an IV fluid bolus of at least 500 mL. 4. Frequent monitoring of the maternal temperature.

1. Correct: Decreased blood pressure is dangerous to both the laboring mother and fetus because of the decrease in cardiac output and placental perfusion. The most common negative side effect of epidural anesthesia is a precipitous drop in blood pressure. 2. Incorrect: The fetal heart rate should be continuously monitored, but with an epidural, the first priority is maternal circulation. 3. Incorrect: Even though an IV fluid bolus may prevent hypotension, it should be administered before the epidural placement. 4. Incorrect: We are not worried about infection at this time.

The nurse, performing an initial physical assessment on a client determines that the client has difficulty hearing questions. The nurse also notices an empty eyeglass case. Based on this information, which action should first be taken by the nurse? 1. Determine which ear the client hears best from or if there is a hearing deficit is bilateral. Then ask about the empty eyeglass case. 2. Ask client about use of any assistive devices and document the client's response. 3. Look through client's belongings to determine if there is a pair of glasses and a hearing aid. 4. Notify the primary healthcare provider of client's difficulty hearing and the empty eyeglass case.

1. Correct: Determine out of which ear the client hears best or if there is a hearing deficit is bilateral. Ask if the client uses glasses and how often the glasses are used at home. Assessment is a first action many times. 2. Incorrect: This answer is very similar to option 1. Documenting the client's response is not going to intervene. 3. Incorrect: Inappropriate to look through client's belonging without asking. This is an invasion of privacy unless the client gives permission to do so. This should not be the first action either. Assessment should be first. 4. Incorrect: This is not first action to be taken by the nurse. Notifying the physician should not be the first action. The nurse should take steps to help the client directly

The school nurse suspects that a 5 year old has been physically abused. What would be the best way for the nurse to establish trust with this child? 1. Using play therapy. 2. Asking the mother to come to the school. 3. Hugging the child. 4. Conducting an in-depth interview with the child.

1. Correct: Establishing a trusting relationship with an abused child is extremely difficult. He or she may not even want to be touched. Play activities can provide a nonthreatening environment that may enhance the child's attempt to discuss painful issues. 2. Incorrect: The child is less likely to talk about an event in front of the parent or possible abuser. 3. Incorrect: The child may not even want to be touched, so trying to hug the child would not help to establish trust and potentially could scare the child away. 4. Incorrect: This is not developmentally appropriate for the child. This may be done with the parent but may cause defensiveness.

After reviewing the client assignments, the LPN/VN tells the RN the assignment is very unfair and requests that some of the clients be redistributed to the other staff. What should the RN do first? 1. Ask the LPN/VN how the client assignment should be adjusted. 2. Assign one of the LPN/VN's clients to another nurse. 3. Encourage the LPN/VN to use teamwork skills in caring for the clients. 4. Develop a strategic plan to assist with client assignments.

1. Correct: Explore her concerns; this is most therapeutic and helpful response. Finding out what are LPN/VN's concerns first will help the RN address the LPN/VN's request and build trust in the healthcare team relationship. 2. Incorrect: This statement does not help the RN understand the LPN/VN's concern about the assignment, an negates the confidence in the LPN/VN's abilities and skills. 3. Incorrect: This answer does not acknowledge the LPN/VN's concern. 4. Incorrect: This action will not help address the LPN/VN's immediate concern with the assignment and makes resolution of the issue much more complicated than it should be.

Which victim would the nurse decontaminate first in a biological terrorist event? 1. Client who was exposed but is exhibiting no symptoms 2. Client who has an open leg fracture and head injury 3. Client who is not breathing and has no palpable pulse 4. Client with minor cuts and abrasions

1. Correct: Exposed victims with no symptoms are first priority 2. Incorrect: Victims needing maximum medical care are third priority 3. Incorrect: Deceased victims are the last priority 4. Incorrect: Those with minor injuries are second priority

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? 1. Puffy hands and face 2. Reports indigestion 3. Pedal edema 4. Trace proteinurea

1. 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 3rd trimester of pregnancy. 3. Incorrect: Pedal edema should be assessed but is common in 3rd trimester of pregnancy. 4. Incorrect: Trace proteinurea is a benign sign in 3rd trimester of pregnancy.

An elderly, bed-bound client receiving G-tube feeding at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway? 1. Initiate seizure precautions 2. Discontinue G-tube feeding 3. Administer oxygen 4. Obtain blood work for troponin level

1. Correct: Feeding tube clients tend to get dehydrated, especially clients on bed rest, because bed rest induces diuresis! If the client is already having neurological signs, a grand mal seizure may be next! Better take seizure precautions while awaiting the serum sodium results. 2. Incorrect: You may do this; however, seizure precautions will take priority. 3. Incorrect: The priority here is seizure precautions. 4. Incorrect: This data should lead to the suspicion of dehydration and hypernatremia, not suspected MI, which would be the reason a troponin level would be obtained.

What is the first nursing action that should be taken in caring for a client with suspected tuberculosis? 1. Identify the client's symptoms promptly. 2. Instruct the client to cover the mouth and nose with tissues when sneezing. 3. Isolate the client in a negative pressure room. 4. Place a surgical mask on the client.

1. Correct: First, identify the client's symptoms. 2. Incorrect: Not before proper identification of client's symptoms. 3. Incorrect: Not before proper identification of client's symptoms. 4. Incorrect: Not before proper identification of client's symptoms.

A client with schizophrenic disorder believes that all of their organs have been replaced and is discussing this belief with others. What would be the most appropriate nursing action? 1. Encourage the client to focus on reality-based issues. 2. Allow the client to continue to talk about the delusions. 3. Ask the client to explain the meaning behind what is being said. 4. Ask the client to take a deep breath to relax.

1. Correct: Get them out of the fantasy and into the real world. 2. Incorrect: Do not allow client to continue in a fantasy....this is reinforcing it. 3. Incorrect: This is not appropriate as the client is talking about a delusion. 4. Incorrect: This is not the appropriate time for stress reduction techniques. Yes, the client should use stress reduction techniques but not during the auditory delusion.

Which statement by the client with children ages 5 months to 8 years old requires follow up by the clinic nurse? 1. "I give all my children a spoonful of honey at night when they have a cough." 2. "I serve my 8 year old a glass of orange juice with breakfast before school." 3. "I have children use Lavender scented soap to wash their hands before they eat. 4. "I play music for my children when it is time for them to take a nap."

1. Correct: Giving honey to children younger than 1 year should be avoided because it is a reservoir of Clostridium botulinum spores. Clostridium botulinum produces toxins which may cause botulism. 2. Incorrect: Vitamin C stimulates the immune system and helps to reduce the risks of cardio vascular disease, cancer and eye disease. 3. Incorrect: Lavender is an aromatherapy used for relaxation and has been also been found to be useful in treating wounds and burns, and for skin care. 4. Incorrect: Music therapy has been shown to help achieve relaxation. Music should not be limited to adults; it can be used for infants and children.

Which information should the nurse plan to teach family members of a client diagnosed with hepatitis B? 1. Do not share personal items with the client, such as razors or toothbrushes. 2. Wash dishes separately from the rest of the family's. 3. Wear a surgical mask when in close proximity to the client. 4. Use a separate bathroom from the client.

1. Correct: Hepatitis B is a bloodborne pathogen that can spread via sharing personal items, such as razors or toothbrushes where infected blood can get into a person's cut, mucous membranes, etc.2. Incorrect: Unlike some forms of hepatitis, Hepatitis B is not spread through sharing eating utensils, contaminated food or water. Hepatitis B is spread by infected blood or body fluids. 3. Incorrect: Hepatitis B is not airborne, therefore, there is no need to wear a mask. 4. Incorrect: Hepatitis B is not spread by sharing a bathroom. It is blood borne, not spread by the fecal route.

When assessing for the development of an infection following the application of a plaster cast to the leg, the nurse should teach the client to observe for the presence of which sign of infection? 1. Hot spots 2. Cold toes 3. Warm toes 4. Paresthesia

1. Correct: Hot spots is the best answer. Redness and increased warmth are indicators of localized infection. If the cast covers the extremity, redness cannot be visualized, but the client can feel more warmth (a "hot spot") in an area becoming infected. 2. Incorrect: "Cold toes" is a neurovascular check, not an indication of infection. 3. Incorrect: "Warm toes" is a neurovascular check, not an indication of infection. 4. Incorrect: Paresthesia is a neurovascular check, not an indication of infection.

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: Lifestyle modifications 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.

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

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

Which client would be most appropriate for the emergency department charge nurse to obtain a social service consult? 1. Six year old who ingested diluted bleach. 2. Ten year old who suffered burns in a house fire. 3. Twelve year old who fractured his arm in a fight at school. 4. A 16 month old without any oral intake for the last 12 hours.

1. Correct: In most areas, laws mandate certain situations/circumstances involving children be reported to social services/child protection. Among these things are: ingestion of toxic substances, fractures, suspected neglect or abuse, burns. For older children and adults, the healthcare provider uses their judgment as to whether the situation indicates neglect or abuse by the parents or caregivers. 2. Incorrect: The child in a burned house would be reported only if the story were inconsistent as to how the house caught on fire, or if foul play is suspected. 3. Incorrect: A child fighting at school is inappropriate, but this doesn't mean there is family abuse/neglect at home. 4. Incorrect: A 16 month old who is sick may not take liquids, but the fact that the mother brought the child in means she is attentive and concerned. The nurse would determine why the 16 month old is not drinking liquids then rehydrate the child to prevent dehydration.

The nurse is reviewing the immunization record of a 3 month old. Which immunization does the nurse expect the child to have received by this age? 1. First Hepatitis B vaccination. 2. Second diphtheria vaccination. 3. Third Hib vaccination. 4. Influenza vaccination.

1. Correct: In the US the first dose is recommended at birth. In Canada, the first dose is recommended between birth and two months. 2. Incorrect: In both the US and Canada, the first diphtheria vaccination is recommended at 2 months, and the second at 4 months. 3. Incorrect: In both the US and Canada, the first Hib vaccination is recommended at 2 months, the second at 4 months, and the third at 6 months. 4. Incorrect: In both the US and Canada, all healthy children ages 6 months and older should receive a yearly influenza vaccination.

What room assignment by the charge nurse is most appropriate for a client who is being admitted with poor appetite, malaise, and temperature of 101.5ºF (38.6ºC)? 1. Private room. 2. Room with a client who has biliary colic. 3. Room with a client who is 3 days post operative hip replacement. 4. Room with a client who is in skeletal traction due to broken femur.

1. Correct: In this particular situation, a private room is best due to the elevated temperature. This could mean the client has an infection and is contagious. All of the often clients do not need to be exposed to this client with fever of unknown cause. 2. Incorrect: Does not need to be exposed to infection. Biliary colic is pain due to a gallstone blocking the bile duct. The client may need surgery and definitely should not be exposed to infection. 3. Incorrect: Post op client already at risk for infection. This is not the most appropriate client to room with the new admit. 4. Incorrect: Does not need to be exposed to infection. The client is already at risk for infection due to the skeletal traction. Complications of skeletal traction include risk for bone infection due to a screw being placed in a bone.

Which client should the nurse assess first? 1. Client who reports increasing size, firmness, and discomfort in the abdomen. 2. Client who develops a headache and dizziness after being started on losartan. 3. Client with a chest tube whose pulse oximeter reading is 92 mmHg while on 2 liters of oxygen per nasal cannula. 4. Client who is receiving total parenteral nutrition (TPN) and has a blood glucose level of 140 mg/dL (7.8 mmol/L).

1. Correct: Increasing size and firmness of the abdomen can be an indicator of a serious issue such as peritonitis, bowel obstruction, or other abdominal issue that would require immediate notification of the healthcare provider.This is an unexpected change in the client's status that would require the nurses immediate respond. 2. Incorrect: Headache and dizziness are some of the common side effects of angiotensin receptor blockers (ARBs), such as losartan. The BP should be carefully monitored on all clients taking ARBs, but this client would not be a priority over the client with increasing abdominal girth, firmness, and tenderness. 3. Incorrect: The client with a pulse oximetry reading of 92 mmHg on 2 liters of oxygen does not take priority over the client with a possible life threatening abdominal problem. This reading is acceptable. 4. Incorrect: The increased amounts of dextrose in TPN can cause hyperglycemia. The client's insulin may need adjusting. But this level is not so high that it would take priority over the client with a possible abdominal complication.

A client newly diagnosed with insulin dependent diabetes mellitus is started on insulin aspart protamine suspension/insulin aspart solution mixture. The nurse would teach the client that the insulin should start to lower the blood sugar within how many minutes? 1. 15 2. 30 3. 45 4. 90

1. Correct: Insulin aspart mixture is a rapid-acting insulin and starts to work within 15 minutes after given subcutaneously. 2. Incorrect: Regular insulin has an onset of 30 minutes to 1 hour. Aspart is a rapid-acting insulin, and begins to work within 15 mnutes.3. Incorrect: Long acting insulin has an onset of 45-48 minutes. An example of long acting insulin would be lantus. 4. Incorrect: Intermediate acting insulin such as NPH insulin has an onset of 90 minutes.

The client is being admitted for a myocardial infarction. Which assessment finding is expected?

1. Initial increase in BP and HR followed by a decrease. 2. Elevated temperature to 102 degrees F (38.89 degrees C) in the first 24 hours. 3. Pain relieved by two nitroglycerin tablets five minutes apart. 4. Myoglobin will be negative. 1

A client with sleep apnea has been ordered a Continuous Positive Airway Pressure (CPAP) machine. Which action could the RN delegate to an unlicensed assistive personnel (UAP)? 1. Reminding the client to apply the CPAP at bedtime 2. Obtaining oxygen saturation levels every three hours 3. Teaching the client how to turn on the CPAP machine 4. Assessing for fatigue or depression caused by poor sleep

1. Correct: It is appropriate delegation for a UAP to remind the client to do a previously taught intervention. The UAP cannot perform actual teaching because this is outside the scope of practice, but reminding the client about what was taught may help with compliance. 2. Incorrect: This is an assessment function and may be outside the UAP's scope of practice in some states. Since oxygen saturation requires every three hour monitoring, it is best not to assign this to the UAP. The nurse should be the one to check the oxygen saturation levels every three hours because additional assessment of the client status may be warranted. 3. Incorrect: Initial teaching about the CPAP machine is the responsibility of the RN. The LPN can reinforce this teaching, but teaching is outside the UAP's scope of practice. 4. Incorrect: Assessment is outside the UAP's scope of practice. Independent assessment requires additional education and skills and should be carried out by the RN.

A teenage client asks the nurse, "Do you think I should tell my parents about my sexuality?" What is the nurse's best response? 1. "What do you think you should do?" 2. "Absolutely, I think you should tell your parents." 3. "Don't you think your parents have the right to know about your sexuality?" 4. "I do not think now is the right time to tell your parents. Wait until you are 21."

1. Correct: It is better to say "What do you think you should do?" This helps the client reflect on options and does not have the nurse tell the client what to do. It is much more therapeutic to help the client make the decision for themselves, instead of the nurse. This prevents any biases from impacting the outcome. 2. Incorrect: All of these responses give advice to the client. Telling the client what to do or how to behave which implies that the nurse knows what is best and that the client is not capable of making any decisions. 3. Incorrect: All of these responses give advice to the client. Telling the client what to do or how to behave which implies that the nurse knows what is best and that the client is not capable of making any decisions. 4. Incorrect: All of these responses give advice to the client. Telling the client what to do or how to behave which implies that the nurse knows what is best and that the client is not capable of making any decisions.

A non-English speaking client arrives in the emergency room with a 2 inch head laceration. The nurse attempts to complete the assessment but is unable to understand information provided by client or family. The facility interpreter lives several hours away; however, a UAP is available and willing to help translate. The nurse should be most concerned about what situation? 1. The UAP is not trained to interpret medical terminology for a client. 2. The facility translator is best qualified, but waiting causes delay of treatment. 3. Obtaining consent through an unofficial interpreter is not considered legal. 4. The UAP is not providing direct care, which violates HIPAA privacy regulations.

1. Correct: Language service providers, or interpreters, require special training and qualification regarding HIPAA regulations as well as medical terminology. Such an individual is also tested regarding fluency in languages and knowledge of medical facts. Though not specifically licensed, interpreters are registered in a database, including those utilizing the American Sign Language to interpret for the deaf. 2. Incorrect: The facility language service provider, or translator, would indeed be trained in specific methods of presenting medical facts to families or clients unable to speak English. Although there are few details in the scenario regarding the head laceration, delaying care for several hours could result in complications to the client. Lacerations must be sutured within a specific timeframe to avoid problems such as infection, poor healing or increased scarring. 3. Incorrect: Language service providers hold a unique position under HIPAA regulations. Utilizing such services does not require informed consent; that is, agreeing to speak through an interpreter is considered consent under HIPAA Privacy Rule 45-CFR-160-103. If the client agrees to use even an unofficial translator, that is considered acknowledgement of "consent" under HIPAA regulations. 4. Incorrect: HIPAA regulations regarding language service providers, or interpreters, are unique. The interpreter does not have to provide direct care to the client. Therefore, the UAP could assist in translating, even if not directly involved in the care.

The nurse is caring for a client that is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery the mother asks to see the infant. What is the nurse's best response? 1. Bring the swaddled baby to the mother. 2. Explain that the cause of death must be determined before she can see the baby. 3. Ask her if she is sure she wants to see the baby. 4. Tell her it would be better to wait until she is in her room before she sees the baby.

1. Correct: Let the grieving mother see the infant to continue the grieving process. The mother has the right to make her own decision. 2. Incorrect: This is an untrue statement. In some cases, the cause may never be found. 3. Incorrect: This is non-therapeutic and implies that the nurse disagrees with the mother's decision to see the infant. 4. Incorrect: This is non-therapeutic and delays the mother's request. This response may also cause additional fear and anxiety.

In which client should the nurse question the prescribed medication levofloxacin? 1. History of myasthenia gravis. 2. Has a prescription for verapamil. 3. Thrombocytopenic 4. Admitted with renal arterial stenosis.

1. Correct: Levofloxacin is contraindicated in clients with a history of myasthenia gravis because it may cause the condition to become worse. Myasthenia gravis results in a breakdown in the communication between muscles and nerves and is characterized by muscle weakness. The most commonly affected muscles are those of the eye, face, throat, neck and limbs. 2. Incorrect: Levofloxacin and verapamil are not known to be incompatible. Levofloxacin is a quinolone antibiotic and there are no contraindications for use with verapamil, a calcium channel blocker. 3. Incorrect: You would worry about thrombocytopenia in clients taking anticoagulants. Thrombocytopenia is a decrease in platelets in the blood. 4. Incorrect: ACE inhibitors are contraindicated with renal arterial stenosis. There are no contraindications of using levofloxacin with renal arteral stenosis.

A female client with a history of frequent exacerbations of asthma asks the nurse to explain to her why she is at greater risk for fractures than other women her age. What is the nurse's best response? 1. "The steroids you are taking decrease calcium in the bone by sending it to the blood." 2. "Taking steroids causes bone calcium to increase, thus causing osteoporosis." 3. "Clients who have asthma are not able to exercise enough to prevent fractures from occurring." 4. "Asthma should not put you at increased risk for fractures but you are at risk for decreased blood glucose levels."

1. Correct: Long term use of steroids decreases serum calcium, so the body takes calcium from the bone and puts it in the blood in order to bring the serum calcium back to a normal level. Every time a steroid is given, calcium is removed from the bone, thus leading to a greater risk for osteoporosis and fractures. 2. Incorrect: Osteoporosis is a decrease in bone calcium not an increase. 3. Incorrect: There are many types of exercise that asthma clients may participate in, including walking at short intervals. 4. Incorrect: Drug therapy for asthma (not asthma itself) may put a client at risk for osteoporosis, but not hypoglycemia.

A client is admitted to the hospital with acute exacerbation of COPD following an upper respiratory infection. His daughter found him at home, confused and in respiratory distress, a day after he developed a cold. He was placed on 4 L/min of oxygen via nasal cannula, but oxygen saturation remains at 89%. Based on this assessment, the nurse suspects that the client has developed which acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. Correct: Look at all the hints in this stem: COPD, upper respiratory infection, respiratory distress, confused, oxygen saturation of 89%. This client is having lung problems. So you should be able to identify the acid base imbalance as a respiratory problem, right? Yes. Why is it acidosis? Poor gas exchange! Respiratory failure, COPD, and muscular weakness can lead to respiratory acidosis. So you would expect the pH to be < 7.35, and the pCO2 to be > 45. The HCO3 would be normal. 2. Incorrect: Not alkalosis. You would expect respiratory alkalosis with a client who is hyperventilating, such as the hysterical client. The client in this question would be hypoventilating and having poor gas exchange. 3. Incorrect: Not a metabolic related acid/base imbalance. Metabolic problems do not start with a respiratory problem. Metabolic acidosis is seen with diabetic ketoacidosis or starvation. 4. Incorrect: This is not a metabolic problem but a respiratory problem. Metabolic alkalosis may be seen with prolonged vomiting and hypokalemia.

A client with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue and fever. A urinalysis reveals proteinuria and hematuria. The primary healthcare provider prescribes corticosteroids. During the acute phase of the client's illness, what is most important for the nurse to do? 1. Monitor intake and output and daily weight. 2. Allow for frequent, uninterrupted rest periods. 3. Institute seizure precautions. 4. Protect client from injury that may cause bleeding.

1. Correct: Look at the clues in the stem. Proteinuria and hematuria. When you see proteinuria what do you need to worry about? The kidneys! Protein is a great big molecule. The only way for protein to be seen in the urine is if there are holes in the glomerulus. So the kidneys are being damaged. Thus, the nurse knows that the biggest problem to "worry" about here is renal failure. The best methods for monitoring fluid status and renal status for a client are to monitor I and O and daily weights. (Also, remember that one weight doesn't mean anything. The hematuria indicates that there has already been glomerular damage.) 2. Incorrect: Systemic lupus erythematosus (SLE) is an autoimmune disease. In this disease, the body's immune system mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs. Fatigue is a major symptom so allowing for frequent, uninterrupted rest periods is important for this client but monitoring for renal failure is more acute.3. Incorrect: Seizures are a potential problem with SLE, but the ACTUAL problem depicted in the stem of the question, renal failure, takes priority. Look for the option that relates to the renal system. 4. Incorrect: Hemolytic problems can occur with SLE, but this is not the ACTUAL problem depicted in the stem of the question. The stem is indicating a renal problem, so look for a renal answer.

The nurse is caring for a client diagnosed with alcohol dependence who is prescribed a benzodiazepine. Which potential side effect of benzodiazepine has a higher priority for the nurse to monitor? 1. Sedation 2. Drowsiness 3. Drug dependence 4. Impaired coordination

1. Correct: Maintaining a client's airway is always a priority. The nurse should observe the client for excessive sedation. After a benzodiazepine is administered, the client may fall asleep, transition into respiratory depression and apnea. 2. Incorrect: A side effect of benzodiazepine is drowsiness. Though the actions of the client may be slower, and the client may feel drowsy, the nurse's priority is to assess the client's sedation level. 3. Incorrect: Benzodiazepine therapy can result in substance abuse which can result in physical dependence. Maintaining a client's airway or apnea is a life-threatening situation. The priority intervention is to monitor the client's sedation. 4. Incorrect: The client may experience impaired coordination when prescribed benzodiazepine. Benzodiazepine depresses the central nervous system (CNS). The nurse's priority is to monitor the sedation level of the client.

A client diagnosed with renal failure has been admitted to the medical unit. An arterial blood gas (ABG) analysis has been prescribed by the primary healthcare provider. Which ABG interpretation by the nurse is appropriate? Exhibit pH - 7.33 (7.35-7.45) PaCO2 - 36 (35-45) HCO3 - 20 (22-26) 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Correct: Metabolic acidosis pH - 7.33 (normal value 7.35 - 7.45) less than 7.35 PaCO2 36 mm Hg (normal value 35 - 45 mm Hg) within normal range HCO3 20 mEq/L (normal value 22 - 26 mEq/L) less than 22 mEq/L Metabolic acidosis is reflected in a reduction of the HCO3 and pH levels.

A client diagnosed with hypertension has been prescribed metoprolol. Which statement by the client indicates that the client's medication instruction for metoprolol has been effective? 1. "I should not stop taking this drug immediately." 2. "I will need to rinse my mouth with water 3 times a day." 3. "I can decrease my aerobic exercises from 3 to 2 times per week." 4. "I will report irregular heartbeats, if they continue for more than 3 days."

1. Correct: Metoprolol, a beta-adrenergic antagonist, should not be discontinued abruptly. This action may have the serious result of precipitating angina. Metoprolol should be gradually discontinued. 2. Incorrect: Dry mouth is not a side effect of metoprolol. This drug does not stimulate anticholinergics to block acetylcholine from binding to its receptors on certain nerve cells. 3. Incorrect: Lifestyle modifications by the client should be continued. The client should not reduce the number of aerobic exercises after metoprolol has been prescribed. 4. Incorrect: The client should monitor their pulse rate, quality and rhythm daily. If changes in the quality and rhythm of the pulse occur, the primary healthcare provider should be notified immediately. A cardiovascular side of effect of metoprolol is bradycardia.

A client presents to the emergency department (ED) with tachycardia, elevated blood pressure, seizures, and a history of chronic alcoholism. Which electrolyte imbalance should be the nurse's priority concern?

1. Magnesium deficit 2. Sodium deficit 3. Potassium excess 4. Calcium excess 1

A client with type II diabetes reports normal blood glucose levels at bedtime and high blood glucose levels in the morning for the past week. What instruction would the nurse give the client? 1. Monitor blood sugar around 2am. 2. Decrease bedtime snacking. 3. Decrease intermediate acting insulin. 4. Increase intermediate acting insulin.

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

A first time mother-to-be shares with the nurse a sense of indifference towards the impending birth of the infant. The client is concerned about "being a good mother" because of current lack of interest. What response by the nurse would be most appropriate at this time? 1. Such feelings are not unusual for first time mothers." 2. "Once you hold your new baby, you will be just fine." 3. "Would you like to discuss this problem with the doctor?" 4. "Describe the fears you have regarding your new baby."

1. Correct: Most women are excited at the prospect of having a baby, whether it is the first baby or a subsequent birth. It is another life transition fueled by hormonal changes, emotional excitement and generally eager anticipation. However, there are those individuals seemingly unmoved by the sight of baby clothing, little toys, or another newborn. That does not mean the mother will not respond to the birth of her own baby or remain indifferent. Such feelings are not abnormal, particularly in a primigravida. The nurse should reassure the mother. 2. Incorrect: There is truth in the statement that mothers often respond differently upon seeing or holding the newborn for the first time. However, this comment by the nurse dismisses the client's concerns and fears without validating or providing specific information. The nurse has not addressed the client's statement regarding 'lack of interest', or client fears about providing care to the infant. 3. Incorrect: It is not appropriate to transfer care of the client, including discussions and teaching, to another individual - not even the healthcare provider, unless an emergency occurs. Client feelings, fears or concerns should be addressed by the nurse at the time rather than transferred to another individual. 4. Incorrect: The client did not actually verbalize "fear", and for the nurse to use that term may unduly cause the client more distress. The client has expressed concerns about a personal response to this situation and the nurse needs to therapeutically focus on that specific issue.

Which action by a nurse requires intervention by the charge nurse? 1. The two-handed method is used to recap a needle. 2. A needleless system is used to give medication through an intravenous (IV). 3. A blunt cannula is used to withdraw medication from a vial. 4. An engineered sharp injury protective device is used to recap a used needle.

1. Correct: Needles should be recapped using a one hand scoop method to prevent accidental sticks. Two-handed method increases the risk that the nurse's non-dominant hand will be punctured with the needle. Think about it. You do not want the hand holding the cap to get close to the needle. What if you miss the needle and stick your hand. The best solution is to not recap at all. Place the needle in the sharps container at once. But if the sharps container is not close by then the one hand scoop method is appropriate. You are not exposing one hand to the needle. 2. Incorrect: This is a correct method to use. To prevent injury during injection administration or body fluid retrieval, use a one-handed scoop method, needleless system, blunt cannula for medication withdrawal from a vial, or an engineered sharp injury protective device whenever possible. 3. Incorrect: This is a correct method to use. To prevent injury during injection administration or body fluid retrieval, use a one-handed scoop method, needleless system, blunt cannula for medication withdrawal from a vial, or an engineered sharp injury protective device whenever possible. 4. Incorrect: This is a correct method to use. To prevent injury during injection administration or body fluid retrieval, use a one-handed scoop method, needleless system, blunt cannula for medication withdrawal from a vial, or an engineered sharp injury protective device whenever possible.

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

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

Which ethical principle is involved when a nurse reports a medication error to the primary healthcare provider? 1. Nonmaleficence 2. Beneficence 3. Justice 4. Fidelity

1. Correct: Nonmaleficence is best illustrated with the nurse's action, as the goal is to do no harm to the client. With timely reporting of an error, further complications may be prevented. 2. Incorrect: Beneficence refers to doing good. This may include compassion and kindness. 3. Incorrect: Justice refers to equitable distribution of resources. Triage in the ED is one action that illustrates justice. 4. Incorrect: Fidelity refers to truth-telling. If the client were to ask if a medication error was made, the nurse would answer yes to the question as a way of demonstrating fidelity.

What potential contributing factors for transient urinary incontinence should a nurse assess for in an elderly female client?

Select All 1. Fecal impaction 2. Use of a diuretic 3. Diabetic 4. Urinary retention 5. Vaginitis 1,2,3,5

A nurse is caring for a nonambulatory client who must be decontaminated after a chemical exposure event. What nursing action will prevent further chemical exposure? 1. Don appropriate personal protective equipment (PPE). 2. Remove only contaminated clothes. 3. Avoid decontaminating the eyes. 4. Use hot water during decontamination.

1. Correct: PPE should be donned prior to contact with the client to prevent contamination of the healthcare worker. The nurse must protect themselves from exposure of the chemical. 2. Incorrect: All clothes, jewelry, and personal belongings should be removed and placed into appropriate containers. There is no way to be certain which articles of clothing are contaminated and which are not. 3. Incorrect: Decontaminate the eyes with a saline solution via nasal cannula or Morgan lens. Preventing cornea damage is very important. 4. Incorrect: Hot water is unnecessary unless the client is hypothermic during decontamination procedures. Hot water causes vasodilation.

A nurse is planning to conduct parenting classes for first time parents in an attempt to decrease child abuse in the community. What type of prevention is the nurse utilizing? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Case management

1. Correct: Primary prevention is aimed at reducing the incidence of mental disorders within the population. Primary prevention targets individuals and the environment. Emphasis: assisting individuals to increase their ability to cope effectively with stress and targeting and diminishing harmful forces (stressors) within the environment. Teaching parenting skills and child development to prospective new parents is primary prevention. 2. Incorrect: Secondary prevention services are aimed at reducing the prevalence of psychiatric illness by shortening the course or duration of the illness. 3. Incorrect: Tertiary prevention services are aimed at reducing the residual effects of severe or chronic mental illness. 4. Incorrect: Case management occurs at the secondary level of prevention and is a way to organize client care so that specific outcomes are achieved within an allotted time frame.

The nurse is transferring the client from the bed to the wheelchair. Which nursing intervention would the nurse implement after assisting the client to a sitting position on the side of the bed. 1. Assess the client for lightheadedness. 2. Move the wheelchair closer to the bed. 3. Lower the bed to the lowest position. 4. Position the foot of the stronger leg closer to the bed.

1. Correct: Prior to moving the client from the side of the bed to the wheelchair, assess the client for orthostatic hypotension or postural hypotension. The client may experience a sudden decrease in blood pressure after changing the position form lying down to sitting up. 2. Incorrect: The wheelchair should be positioned in the correct position prior to positioning the client on the side of the bed. Client safety has priority. The nurse should not leave the client to move the wheelchair to the bedside. 3. Incorrect: The bed should have been lowered to the position prior to moving the client to the side of the bed. The client's feet should rest on the floor. This will assist the client in supporting themselves. 4. Incorrect: Positioning the foot of the stronger leg closer to the bed is a transfer step after assessing the client for orthostatic hypotension. Whether the stronger or weaker leg is positioned closer to the bed will not affect the client's blood pressure status.

The nurse is providing prenatal education for a couple expecting a first child. The expectant mother asks about fetal movements. What is the best explanation by the nurse? 1. "You should feel activity between weeks 16 to 20." 2. "The fetus is too small to feel any movements." 3. "Maybe around the end of the 1st trimester." 4. "It is different for each individual woman."

1. Correct: Quickening is the term used to refer to fetal movement when first sensed by the expectant mother. It is challenging for first time mothers to differentiate between actual fetal movement and other sensations, but usually between weeks 16 and 20, actual kicks or changes in fetal body position are noted by the mother. 2. Incorrect: As a first time mother, the client is requesting information about fetal movement. This response by the nurse does not provide the healthcare facts needed by the mother. While this is statement is accurate, the nurse has not addressed the client's question. 3. Incorrect: Not only is this response vague, it is also incorrect. The end of the first trimester is too soon, even though there is in fact movement, because the fetus is too small. 4. Incorrect: Though this is an accurate statement, the nurse has not specifically addressed the client's question. Expectant parents have many questions, and the mother in particular is anxious about changes or sensations within her body. The nurse needs to provide specific and detailed information when teaching clients.

The nurse has been teaching a client diagnosed with diabetes about self-administration of regular insulin. The first injection was noted by the number 1. The nurse knows that education regarding site rotation was successful when the client chooses which site next?

1. Correct: Regular insulin is a short acting insulin that is absorbed best in the abdomen. The first injection was given in the right upper abdomen, so the next injection should be given approximately 1 inch from the first one. Site 2 is the correct location. 2. Incorrect: Although this site is in the abdomen, it is best to follow a more specific pattern. Move 1 inch from the previous injection site. Done properly, there will be approximately 24 days for each site to heal prior to another injection. 3. Incorrect: For best results, it is important to stick with a consistent body part for injections to avoid variations in insulin action. 4. Incorrect: For best results, it is important to stick with a consistent body part for injections to avoid variations in insulin action.

While making rounds, the nurse discovers a small fire in a client's room. What should the nurse do first? 1. Remove the client from the room immediately. 2. Leave the client's room to obtain a fire extinguisher. 3. Instruct the unlicensed assistive personnel (UAP) to pull the fire alarm. 4. Evacuate all clients from the unit.

1. Correct: Rescue/Remove the client; first step in Rescue, Alarm, Contain, Extinguish (RACE). 2. Incorrect: Never leave the client in an unsafe environment. Remove the client from the area. 3. Incorrect: Not first action in RACE. Get the client out of the area first. The UAP may need to help you with this. Don't send the UAP away. 4. Incorrect: Not first action in RACE. Remove the client in immediate danger first. All clients may not have to be evacuated if the fire is contained and extinguished.

A 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." What is the nurse's best response? 1. "That is inappropriate behavior. You will have to go to your room if you say that again." 2. "You've got to be kidding! You can't get me fired for not sleeping with you." 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. The nurse needs to set limits on and control dangerous behavior. 2. Incorrect: Do not argue with the client. The behavior of a manic client is often aimed at decreasing the effectiveness of staff control. 3. Incorrect: This is confrontational and does not set appropriate boundaries or consequences. The manic client can elicit numerous intense emotions even in the nurse caring for them. 4. Incorrect: Remember to set limits without demeaning the client, and do not encourage this behavior. Don't acknowledge that the client is seeking attention.

A 6 year old admitted from the emergency department (ED) with a fractured tibia is scheduled for surgery in the morning. All of the private rooms are full so the child must be admitted to a semi-private room. What room assignment is appropriate for the nurse to make for this client? 1. Rooming with an 8 year old in sickle cell crisis. 2. Rooming with a 2 year old admitted with bacteremia. 3. Rooming with a 3 year old with pneumonia. 4. Rooming with a 4 year old with gastroenteritis.

1. Correct: Sickle cell disease and a child in a sickle cell crisis is not considered contagious. This is the only option that does not have an infectious process, so this would be the best room assignment for the child with the fracture. In addition, the children are close in age with the same development tasks, so activities for the children may be similar. 2. Incorrect: Bacteremia is an infectious process in which there is viable bacteria in the blood stream. The source of the infection is not noted. The child with a fracture who will be having surgery should not be placed in a room with a child who has a known infection. 3. Incorrect: The child with pneumonia has an infectious process that may be viral or bacterial. The child with the fracture should not be assigned to this room due to the risk of air-borne exposure to the infectious agent. 4. Incorrect: Gastroenteritis is a diarrheal illness with inflammation in the stomach and small intestine. This is contagious, so if all possible, this child should be kept in a private room, so other children would be less likely to contract the gastroenteritis. It may be viral, bacterial, or parasitic in origin. The child with the fracture should not be assigned to the room with the child with gastroenteritis.

A client has been prescribed sodium polystyrene sulfonate 30 grams rectally every 6h times 2. Which laboratory value would indicate that the prescribed sodium polystyrene sulfonate has been effective? 1. Potassium 4.8 mEq/L (4.8 mmol/L) 2. Sodium 148 mEq/L (148 mmol/L) 3. Calcium 8.9 mg/dL (2.2207 mmol/L) 4. Magnesium 1.2 mEq (0.6 mmol/L)

1. Correct: Sodium polystyrene sulfonate's action is to reduce the serum potassium level. The normal range for potassium is 3.5 - 5.0 mEq/L (3.5 - 5.0 mmol/L). The potassium level is 4.8 mEq/L (4.8 mmol/L) which is within the normal range. The potassium level would indicate that the prescribed sodium polystyrene has been effective. 2. Incorrect: A side effect of sodium polystyrene sulfonate is sodium retention. The normal range for sodium is 135 - 145 mEq/L (135-145 mmol/L). The client's sodium level of 148 mEq/L (148 mmol/L) indicates sodium retention. This is not the desired outcome of sodium polystyrene sulfonate. 3. Incorrect: The normal range of calcium is 9.0-10.5 mg/dL (2.25 - 2.62 mmol/L). The calcium level of 8.9 mg/dL (2.2207 mmol/L) indicates hypocalcemia. This is a side effect of sodium polystyrene sulfonate. 4. Incorrect: The magnesium level of Magnesium 1.2 mEq (0.6 mmol/L) indicates hypomagnesemia. This is a side effect of sodium polystyrene sulfonate. The normal range of magnesium is 1.3-2.1 mEq/L (0.65-1.05 mmol/L)

A client is admitted from the emergency department to a medical unit. What acid base imbalance do the lab values indicate? pH = 7.44 PaCO2 = 30 HCO3 = 20

1. Metabolic acidosis 2. Compensated metabolic alkalosis 3. Respiratory acidosis 4. Compensated respiratory alkalosis 4

The nurse is reviewing medications for a client who is being treated for major depression. The client is prescribed a selective serotonin reuptake inhibitor (SSRI). Which over the counter medication/supplement taken by the client should be reported to the primary healthcare provider immediately? 1. Daily intake of St. John's Wort. 2. Daily intake of a multi-vitamin. 3. Occasional use of ibuprofen. 4. Twice daily intake of an antacid.

1. Correct: St. John's Wort is an herbal supplement often used in the treatment of mild depression. It should not be taken in combination with a selective serotonin reuptake inhibitor due to the risk of serotonin syndrome, which can be fatal.2. Incorrect: A multi-vitamin taken with an SSRI poses no risk.3. Incorrect: This medication taken with the SSRI would not warrant immediate reporting to the primary healthcare provider.4. Incorrect: Antacids would not require immediate reporting.

Which action by a nurse would indicate that this nurse is following standard precautions? 1. Clean gloves while performing a heel stick on an infant. 2. Sterile gloves to empty a indwelling urinary catheter bag. 3. Shoe covers when entering the room of a client with influenza. 4. Clean gloves while inserting a urinary catheter.

1. Correct: Standard precautions when drawing blood is to wear gloves so blood will not get on the nurse's hands. Clean gloves are appropriate. 2. Incorrect: Clean gloves for the nurse's protection are needed. Sterile gloves are not needed as part of standard precautions. 3. Incorrect: Shoe covers are not a standard precaution and not needed when entering the room of a client with influenza. 4. Incorrect: Sterile gloves are needed to insert a urinary catheter. Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. They are the basic level of infection control precautions which are to be used, as a minimum, in the care of all clients.

Which activity should the nurse recognize as increasing the risk for a client developing a community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection? 1. Taking wrestling classes at the gym once a week. 2. Traveling on an airplane next to someone coughing. 3. Eating raw fruits without washing them. 4. Working in close proximity to several co-workers.

1. Correct: Staphylococcus aureus is easily transmitted from one person to another on the hands of individuals. Transmission of MRSA most frequently results from direct skin-to skin contact or contact with shared items or surfaces that had come into contact with the infected site of someone else. This client works out at the gym in the community and has intentional skin-to-skin contact during wresting class. If the client's skin is broken or becomes broken, the risk increases for acquiring the infection from other individuals or from contact with infected surfaces. 2. Incorrect: CA-MRSA is not an airborne spread infection and is therefore, not spread by droplets from someone who is coughing. 3. Incorrect: Eating raw fruits that have not been washed is not associated with Staphylococcus aureus. Bacteria more commonly linked with consuming raw fruits that have not been washed include E-coli and Salmonella. 4. Incorrect: Working in close proximity to others may increase the risk of airborne diseases, but CA-MRSA is not an airborne transmitted illness.

A client with Cushing's disease is in a semi-private room. When considering room assignments, which client would be the safest choice to assign to this room? 1. Status asthmaticus receiving respiratory therapy. 2. Newly admitted client with shingles. 3. Client with 50% burn of both arms. 4. Client who is post emergency appendectomy.

1. Correct: Status asthmaticus is not infectious and would be the best roommate for the client with Cushing's disease who is immunosuppressed due to excessive secretion of glucocorticoids. 2. Incorrect: Shingles is a contagious infectious disease and not the best choice to room with the client who has Cushing's disease. Remember, the client with cushing's is immunosuppressed. 3. Incorrect: Burns are always contaminated wounds, and the client has a decreased immune system, so a high probability for an infected burn would make this client a poor choice to occupy a room with the client who has Cushing's disease. This client is also immunosuppressed. 4. Incorrect: A client post emergency appendectomy is prone to peritonitis or wound infection and not the best client choice.

The adult child of a client diagnosed with bipolar disorder asks the nurse if they will one day be diagnosed with the same disorder. What is the nurse's best response? 1. "There is a familial tendency for developing this disorder; however, it doesn't mean you will definitely develop this disorder." 2. "You should not worry about developing this disorder. You are young and healthy." 3. "If you were going to develop this disorder, you would have it by now." 4. "You have not been exposed to anything that would contribute to the development of this disorder, so you will not develop this disorder."

1. Correct: Studies to determine if an illness is familial compare the percentages of family members with the illness to those in the general public or within a control group. Bipolar disorder is an example of a psychiatric illness with familial tendencies. Other psychiatric illnesses include schizophrenia, major depression, anorexia nervosa, panic disorder, somatization disorder, antisocial personality disorder, and alcoholism. 2. Incorrect: This adult child has a predisposing risk of developing this disorder. Do not give the adult child false assurance. Awareness of the family tendency will promote early detection and treatment. 3. Incorrect: There is no particular time frame for developing this disorder. You are brushing off the adult child here and not providing accurate information. 4. Incorrect: Exposure to outside elements is not indicative of development of this disorder. Do not dismiss the adult childs concern ever but surely not with inaccurate information.

How should the nurse interpret the ABG results of a client admitted with dehydration? pH - 7.49 PaO2 - 99% PaCO2 - 29 HCO3 - 23

1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 4

On morning rounds, the nurse finds a somnolent client with a blood glucose of 89 mg/dL(4.9 mmol/L). A sulfonylurea and a proton pump inhibitor are scheduled to be administered. What is the nurse's best action? 1. Give the proton pump inhibitor and hold the sulfonylurea until the client eats. 2. Hold the medications and notify the primary healthcare provider. 3. Arouse the client and give some orange juice with sugar packets added. 4. Give the medications as prescribed and re-check the blood sugar in one hour.

1. Correct: Sulfonylureas are a class of oral hypoglycemics and should be held until after a meal in a client with a blood glucose of 89mg/dl. 2. Incorrect: It is not necessary to call the primary healthcare provider; you are just waiting until the client eats. Also, the proton pump inhibitor does not affect blood glucose levels and should be administered. 3. Incorrect: A blood glucose of 89mg/dl is not hypoglcemia, do not treat unless the blood glucose drops to or below the 70-80 range. 4. Incorrect: If you administer the sulfonylurea, you are going to cause the client to secrete insulin from their pancreas, causing the blood sugar to drop and cause hypoglycemia.

What should the nurse teach the mother about appropriate sleep in teenagers? 1. Teens need about 8 to 10 hours of sleep each night. 2. Biological sleep patterns shift toward earlier wakening. 3. Typically do not require as much sleep as adults. 4. Teenagers do not exhibit the normal signs of sleep deprivation.

1. Correct: Teens need approximately 8 to 10 hours of sleep per night.2. Incorrect: Teens tend to go to bed later and wake up later. A natural shift in a teens circadian rhythm is called "sleep phase delay". The need for sleep is delayed about two hours. They naturally get sleepy later in the evening. 3. Incorrect: Teens need adequate sleep. The adolescent period is a time of biological, psychological, and social change. Sleep is necessary to support this important stage of growth and development. The sleep deprivation can affect brain and bodily development. 4. Incorrect: When teens are deprived of sleep, they become irritable, fall asleep in class, or experience anxiety. Teens may display even more signs of sleep deprivation than adults. Depression, issues with learning and behavior, substance use or abuse and obesity can be long term effects on a teenager's health.

The nurse assesses bruises on a child's face, the hands, and the feet. When questioned, the parents state their child is so clumsy. What action by the nurse demonstrates client advocacy? 1. The nurse reports the incident to the Child Protective Services. 2. The nurse notifies the parent's clergy. 3. The nurse reports the assessment to the primary healthcare provider. 4. The nurse speaks to the parents privately about any concerns.

1. Correct: The action is appropriate. The nurse is serving as an advocate for the child who cannot advocate for self. Early identification of possible child treatment by the nurse is crucial. A pattern or combination of indicators should arouse suspicion and cells for further investigation. Incompatibility between the reported cause the injuries noted is the most important criterion to base decision to report suspected abuse. All states as well as the provinces in North America have laws that require child maltreatment or suspected child abuse to be reported. Therefore, the nurse has an obligation to report any suspicions of child maltreatment. An advocate pleads the cause of another person. In this case, the nurse pleads the cause of the child to help protect the child's human rights.2. Incorrect: The nurse should not contact the parent's clergy without their permission. This would be a violation of HIPAA. 3. Incorrect: The nurse is acting in the caregiver role. Although client finding will be documented and reported to the primary healthcare provider, client advocacy would involve proper reporting to the appropriate child protection agency and authorities. 4. Incorrect: If abuse is occurring, the parents will usually deny it. If a child is old enough to talk, the history of the injuries may be reported if the child id separated from the parents for this discussion.

A 15 year old is being admitted with pelvic inflammatory disease. Which client could the charge nurse assign the new admit to room with? 1. 18 year old who sustained a compound fracture. 2. 15 year old diagnosed with anorexia nervosa. 3. 13 year old admitted with pneumonia. 4. 14 year old who is taking steroids for chronic asthma.

1. Correct: The best choice would be the client with a fracture who is also an adolescent. Neither of these clients require visitor limiting or potential to transmit infections. 2. Incorrect: Usually adolescents with anorexia nervosa losing weight are put on a behavior modification program, and visitors are limited. Therefore, it would probably be best if this client did not have a roommate. 3. Incorrect: Pneumonia could be contagious and should not have a roommate. This client could be on contact or droplet precautions. 4. Incorrect: Long term steroid therapy could make this client immunosuppressed. Visitors should be limited and a private room would be recommended.

The nurse is caring for a postoperative client. The client asks the nurse the purpose of anti-embolic stockings. What is the nurse's best response? 1. Promotes the return of venous blood to the heart and assists in preventing blood clots. 2. Stabilizes any clots to prevent embolization. 3. To increase the blood pressure in the venous system in the legs to promote perfusion. 4. Promotes lymphatic drainage to prevent swelling and arterial congestion.

1. Correct: The anti-embolic stockings promote return of venous blood to the heart and assist in preventing the stasis of blood that can lead to blood clots. 2. Incorrect: The purpose of the anti-embolism stockings is to promote venous return and prevent blood stasis which can result in blood clot formation. Anti-embolitic stockings will not stabilize existing blood clots. 3. Incorrect: Anti-embolism stockings are used to increase venous return. They are not used to increase blood pressure or perfusion to the legs. 4. Incorrect: Compression garments, not anti-embolitic stockings, are used by persons with lymphedema to reduce edema by promoting the flow of lymph fluid out of the affected limb. Anti-embolitic stockings are to help with venous return and preventing stasis of blood and blood clots.

The home health nurse is concerned about the safety of the client who lives alone in a poorly maintained home. The nurse convenes the interdisciplinary team to discuss the situation. Which action should occur first? 1. Share the assessment findings with the interdisciplinary team. 2. Suggest that the social worker visit the client in the home. 3. Ask the primary healthcare provider about possible nursing home placement. 4. Suggest a "meals on wheels" solution to nutrition.

1. Correct: The assessment findings from the home health nurse will allow each person of the team to offer input based on their particular expertise. After assessment findings have been discussed, the problem solving approach can begin. The interdisciplinary team works together and shares their expertise, knowledge and skills to improve client care. 2. Incorrect: Suggesting a social worker visit may be appropriate; however, this situation would best be served by a discussion with the entire team first. 3. Incorrect: Nursing home placement may be appropriate; however, this is not the first step in collaboration with the team. The team will discuss the home health nurse's concerns and problem solve to provide solutions. 4. Incorrect: Nutrition is a pertinent issue that may need to be addressed; however, the entire team's input is needed at this point. Also the nurse's concern in the safety of the client in a poorly maintained home.

An emergency room nurse is assessing a child with a suspicious spiral fracture to the right arm. The nurse is aware the best evidence to support possible child abuse is what? 1. Inconsistency between injury and explanation of the cause. 2. Child withdraws when the parent tries to hug or comfort. 3. Parents leave the room when questioned about the injury. 4. Lack of parental concern with injury or pending treatment.

1. Correct: The best evidence to support suspicion of child abuse is an inconsistent story between how the injury occurred and the injuries noted in the child. There may be additional signs noted by the nurse, but specific details about what led to the injury, compared to the physical assessment, provides clear evidence for possible abuse. 2. Incorrect: While most children become clingy when an illness or injury occurs, withdrawing from a parent is not clear evidence of abuse. It could be an indication of dysfunctional parenting or incomplete bonding, but not necessarily child abuse. 3. Incorrect: Though most parents seem very concerned and are overly attentive, others may be overcome with grief that the incident happened. When questioned about the cause of the injury, a parent may exit the room, overcome by a sense of guilt and responsibility for the occurrence. This action is not true evidence of child abuse. 4. Incorrect: Parental response to an injured child widely varies and can be inconsistent based on multiple factors, such as sex and age of child, personal perceptions, cultural practices and even the circumstances of the event. Parents can become so overwhelmed by the incident that even non-abusive parents may seem indifferent while trying to remain strong.

The charge nurse walks into the client's room as the staff nurse is preparing the client for discharge. The charge nurse overhears the staff nurse giving the client her phone number. The staff nurse says, "Call me when you get home, and maybe we can get together sometime." What should the charge nurse do first? 1. Interrupt the staff nurse and complete the discharge. 2. Tell the staff nurse in the client's presence that the action is inappropriate. 3. Make no comment, and let the staff nurse continue to talk with the client. 4. Stay with the client until ready to leave the unit.

1. Correct: The charge nurse should make sure that professional boundaries are maintained; therefore, the charge nurse should interrupt the process and continue with the discharge procedure. Then the nurse should be counseled immediately so that further inappropriate behavior does not occur. 2. Incorrect: The nurse should be counseled; however, counseling does not need to be done in front of the client. The better option is to counsel the staff nurse in private. 3. Incorrect: The charge nurse must make sure that professional boundaries are maintained. To make no comment indicates acceptance of the behavior. 4. Incorrect: No, the charge nurse interrupts the staff nurse and completes the discharge then counsels the staff nurse on professional boundaries.

A client with an automated internal cardiac defibrillator (AICD) was successfully defibrillated. The telemetry technician shouts out that the client was in ventricular fibrillation (VF). What should the nurse do first? 1. Go to the client to assess for signs and symptoms of decreased cardiac output. 2. Call the primary healthcare provider to report that the client had an episode of VF so medication adjustments can be made. 3. Notify the "on call" person in the cath lab to re-charge the ICD in the event that the client has a recurrence. 4. Document the incident on the code report form and follow up regularly.

1. Correct: The client comes first. Check to see how they are doing by completing a head to toe cardiac output assessment. make sure to include LOC, vital signs, skin and urinary output assessment. 2. Incorrect: Do not call before you assess the client who may be unconscious if the arrhythmia has decreased their cardiac output. 3. Incorrect: This is not needed because there is a battery that keeps it charged, so that they don't have to re-charge after each shock. 4. Incorrect: Documentation is not appropriate until the client has been assessed first.

After receiving report from the previous shift nurse, Which client should the nurse assess first? 1. Client diagnosed with an ischemic stroke who is exhibiting increased restlessness. 2. Client diagnosed with dementia who needs assistance with ambulating. 3. Client with a halo device requesting to be transferred to the bedside chair. 4. Client diagnosed with a traumatic brain injury who cannot recall portions of the accident.

1. Correct: The client diagnosed with an ischemic stroke needs to be assessed first to be evaluated for signs of increased intracranial pressure (ICP). A neurological assessment should be initiated. Increased restlessness is an early sign of increased ICP. 2. Incorrect: Client safety should be evaluated. The client does require assistance with ambulating. But the client with potential increased ICP requires an immediate neurological assessment. 3. Incorrect: A client with a halo traction may require assistance to transfer to the chair. The nurse identifies that a neurological assessment on another client has priority. 4. Incorrect: The client with the traumatic head injury cannot recall portions of the accident, but is not presenting with any life-threatening symptoms.

A client on a surgical unit frequently quarrels with the staff. Which nursing intervention should the charge nurse implement? 1. Involve the client in their plan of care. 2. Delegate 2 nurses to work with the client. 3. Accept the client's behavior as confrontational. 4. Encourage the client to be more cooperative.

1. Correct: The client has the right to be involved in the decision making of their care. The healthcare team should recognize the client as the center of the team. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. 2. Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. This action is a defensive intervention, and does not address the quarrelsome behavior. 3. Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. 4. Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns.

A client is admitted to the unit from the ED department. What acid base imbalance do the lab values indicate to the nurse? pH 7.48 PaCO2 38 HCO3 30

1. Metabolic alkalosis 2. Compensated metabolic alkalosis 3. Respiratory alkalosis 4. Compensated respiratory alkalosis 1

A client is admitted to the surgical unit with cholelithiasis and a history of psychosis and a known allergy to phenothiazines. Which prescription should the nurse discuss with the primary healthcare provider? Exhibit Allergies:Phenothiazines Penicillin Prescriptions: Clear liquid diet Gallbladder ultrasound today IV of LR with KCL 20 mEq at 125 ml/hr Thioridazine 50 mg PO TID Ciprofloxicin 200 mg IVPB every 12 hours Haloperidol 5 mg by mouth twice daily Ondansetron 4 mg IM as needed for nausea or vomiting 1. Thioridazine 50 mg PO tid 2. Ciprofloxicin 200 mg IVPB every 12 hours 3. Haloperidol 5 mg PO bid 4. Ondansetron 4 mg IM prn nausea or vomiting

1. Correct: The client is allergic to phenothiazines. Thioridazine is a phenothiazine and should not be given to this client. 2. Incorrect: Ciprofloxicin is an antibiotic but is not a penicillin drug; therefore, it can be administered to this client. 3. Incorrect: Haloperidol is an antipsychotic medication. The classification is butyrophenone, not a phenothiazine. 4. Incorrect: Ondansetron is an antiemetic and is an appropriate drug for this client.

A client with a history of peptic ulcer disease arrives at the emergency department reporting weakness, and vomiting "a lot of dark coffee-looking stomach contents." The client's skin is cool and moist to the touch. BP 90/50, HR 110, RR 26, T 98, O2 sat 88%. Which primary healthcare provider prescription should the nurse perform first? 1. Initiate oxygen at 2 liters/nasal cannula. 2. Start an IV of NS at 150 ml/hr. 3. Insert nasogastric (NG) tube to low suction. 4. Attach client to the electrocardiography (ECG) monitor.

1. Correct: The client is showing signs of shock and needs all of the above interventions. However, go back to the ABC's. Oxygen needs to be initiated first because the O2 sat and the increased respiratory rate.2. Incorrect: Fluids are needed to increase blood pressure and tissue perfusion. If O2 sats were above 90 then this would be the first priority. 3. Incorrect: The "coffee looking" contents indicate GI bleeding. The NG tube will empty the stomach and monitor the bleeding but is not the top priority to prevent harm to the client. 4. Incorrect: The client has an increased heart rate and if the oxygen and circulation are not improved, problems could occur. Attaching the client to an ECG monitor will allow you to monitor thew heart for arrthymias or impending damage due to decrease oxygen. Necessary but not the first priority.

Which client should the nurse see first? 1. 53 year old client with chest pain scheduled for a stress test today 2. 62 year old client with mild shortness of breath and chronic obstructive pulmonary disease 3. 66 year old client with angina scheduled for a cardiac catheterization this AM 4. 78 year old client who had a left hemispheric stroke 4 days ago

1. Correct: The client may be experiencing a myocardial infarction and requires further assessment. Therefore, this client would not be a priority over a client who may be experiencing a MI. 2. Incorrect: Dyspnea is one of the three (chronic cough, sputum production, and dyspnea) primary symptoms characteristic of chronic obstructive pulmonary disease. 3. Incorrect: The client is scheduled for the procedure needed for further assessment of angina. This client would be considered more stable than the client who may be having a MI. 4. Incorrect: After a stroke has occurred, medical management is aimed at preventing a second stroke from occurring and rehabilitation. This client may have significant sequelae related to the stroke, but would not be considered acute nor a priority over the client possibly having a MI.

Which client should the nurse see first after receiving report on assigned clients? 1. Having dyspnea after surgery. 2. Needing an IV started for the administration of blood. 3. Crying with pain after back surgery. 4. Vomiting dark brown, granular material.

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

A client diagnosed with cirrhosis is being treated for ascites and increased ammonia levels. Prior to discharge, the nurse reviews dietary instructions. The nurse knows teaching was successful when the client selects what menu plan? 1. High calorie, low protein 2. High protein, low sodium 3. Low calcium, low potassium 4. Low carbohydrates, high fat

1. Correct: The client will have a poor appetite and difficulty eating full meals because of the ascites. Therefore, small frequent meals of nutritious high calorie foods are most appropriate. Protein is needed for healing and building up muscle mass. Ordinarily, protein is broken down in the body and becomes ammonia, which is converted into urea by the liver, and excreted by the kidneys. An impaired liver cannot complete this function, so low potassium is necessary in the diet. 2. Incorrect: Although the client does need some protein in the diet, large amounts of protein will increase ammonia levels in the body and impair brain function. Low sodium in the diet is appropriate, since ascites represents a fluid issue. 3. Incorrect: Calcium has nothing to do with cirrhosis and is not necessary to mediate in the diet. However, because the client is retaining fluid, sodium is retained, resulting in lower potassium levels in the body. The HCP would most likely order extra potassium for the diet to prevent hypokalemia. 4. Incorrect: Since the liver metabolizes carbs, protein and fats, these nutrients must be carefully monitored in any diet. Low carbs is appropriate, unless the client is diabetic. But a diet high in fat would overstress the liver and cause further problems.

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

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

A client returns to the clinic two days after receiving treatment for diarrhea caused by a Campylobacter jejuni infection. The client reports a tingling sensation that began in the toes yesterday and has spread to the feet and legs today. The nurse notes muscle weakness in the legs and that the client is having difficulty walking steadily. Based on this data, what does the nurse suspect is wrong with the client? Guillain-Barré Syndrome 2. Multiple Sclerosis 3. Myasthenia Gravis 4. Systemic Lupus Erythematosus

1. Correct: The clues in this stem are diarrhea from Campylobacter jejuni, tingling sensation that began in the toes, spread to the feet and legs today, muscle weakness in the legs, and difficulty walking steadily. These s/s point to Guillain-Barré Syndrome. 2. Incorrect: Multiple Sclerosis damages nerves but not in an ascending progression from toes to head. 3. Incorrect: Myasthenia gravis is caused by a breakdown in the normal communication between nerves and muscles. Myasthenia gravis is characterized by weakness and rapid fatigue of any of the muscles under voluntary control. 4. Incorrect: Systemic lupus erythematosus, the most common form of lupus, is a chronic autoimmune disease that can cause severe fatigue and joint pain.

While in the emergency department, a 68 year old client being treated for flu symptoms, became symptomatic with an episode of atrial tachycardia which was successfully treated with cardioversion. After stabilization, the client was admitted to the telemetry unit with a diagnosis of the flu, and a history of angina. Primary healthcare provider prescriptions were received. What is most important for the nurse to ensure prior to administering Peramivir? Exhibit Bedrest with bathroom privileges. Continuous cardiac monitoring. ½ Normal Saline at 75 mL/hour. 2 gm Low sodium diet. Peramivir 600 mg IVPB times one dose. ECG every 8 hours times three. Lab: CBC, sodium, potassium, BNP, Troponin, Creatinine clearance, Urinalysis 1. Creatinine clearance is greater than 50 mL/min. 2. Pulse greater than 70 beats/min. 3. Cardiac rhythm showing normal sinus rhythm. 4. Oral temperature less than 101° F (38.3° C)

1. Correct: The dose of this medication needs to be decreased if the creatinine clearance of a client is less than 50 mL/min, so the nurse must know the prescribe creatine clearance level of this client prior to administering peramivir. 2. Incorrect: Few side effects or adverse reactions are noted with peramivir. There is no need to monitor the heart rate prior to administration. 3. Incorrect: Few side effects or adverse reactions are noted with peramivir. There is no need to monitor the cardiac rhythm prior to administration. 4. Incorrect: Few side effects or adverse reactions are noted with peramivir. There is no need to monitor the temperature prior to administration.

A nurse is caring for a poorly controlled type 2 diabetic client. The client is noncompliant with diet and for the past 3 months HbA1c has been 8%. The serum glucose at this visit is 218mg/dl (12.09 mmol/L). The client is currently taking metformin and exenatide. Based on this history, what should the nurse anticipate will be the first strategy implemented to improve glucose control for this client?

1. Nutritional counseling to help improve his diet compliance 2. Addition of the alpha-glucosidase inhibitor, acarbose to his current medications 3. Client teaching for a new prescription of insulin using the basal/bolus dosing method 4. A prescription for detemir, once daily SQ 1

An unlicensed assistive personnel (UAP) is assisting a client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention by the nurse? 1. Holds chest drainage unit (CDU) at the level of the chest. 2. Disconnects the chest tube from suction. 3. Allows the client to ambulate. 4. Helps client use a walker.

1. Correct: The drainage system should be held below the level of the chest to promote drainage and prevent backward flow of drainage back into the pleural space. 2. Incorrect: The chest tube system can function because of gravity and does not have to be attached to suction when the client ambulates. Leaving it connected to suction would be a safety hazard as the client could trip and fall over the tubing. 3. Incorrect: There is nothing in the stem to indicate that the client cannot ambulate. Having a chest tube does not mean the client must not ambulate. 4. Incorrect: There is nothing wrong about having the client use a walker while ambulating. This could potentially prevent a fall.

A client arrives at the Emergency Department after receiving 3rd degree burns to the upper chest, neck, and face area. What would be the priority nursing intervention? 1. Prepare for endotracheal intubation. 2. Monitor hourly urinary output. 3. Treatment of the open burn wounds. 4. Assessment and management of pain.

1. Correct: The evaluation and maintenance of the airway should always be the first priority with upper body burns. Edema may develop due to the increased capillary permeability that occurs with burn injuries. Since the burn is so close to the airway, the priority would be rapid assessment and management of the airway. The healthcare provider may need to perform tracheal intubation prophylactically to prevent airway occlusion in this client. If the airway becomes too edematous before intubation can be performed, the client will need an emergency tracheostomy. 2. Incorrect: Monitoring urinary output in burn clients is important due to the possibility of FVD occurring secondary to fluid loss from the burn area and 3rd spacing of fluids. This could result in shock, and decreased renal perfusion. Although this is a very important intervention, it is not priority over the airway. 3. Incorrect: Burn injuries can be disturbing to look at due to the extensive skin injury, but the priority of care would not be the treatment of the wound. The priority must be the airway. 4. Incorrect: Clients with burns may experience severe pain, and will very likely be requesting pain relief. However, the priority of this client must be focused on the airway, not pain. Always consider what can kill the client or cause the most harm.

A nurse with less than one year of experience reports to an experienced nurse, "The charge nurses are always checking up on me and evaluating my client care. I feel as if the charge nurses do not trust me to give good care to my clients." Which response by the experienced nurse demonstrates an understanding of appropriate staff supervision? 1. The charge nurses are accountable for supervising client care and client safety after delegating the client care assignments. 2. The charge nurses do that to everyone. It can be annoying sometimes, when they ask about your client care. 3. Why don't you speak to the charge nurses about your perception of not being trusted to care for your clients? This is probably not their intention. 4. You are a new nurse, and the charge nurses know that you do not have the experience and knowledge base yet to handle some of your assignments.

1. Correct: The experienced nurse demonstrates an understanding of appropriate staff supervision by answering that the charge nurses are accountable for supervising client care and safety after they have made client care assignments, and by clarifying that the charge nurses are probably attempting to be supportive of the new graduate nurse. 2. Incorrect: This answer does not address the nurse's question correctly. This answer is an example of nontherapeutic communication. The nurse is giving the opinion that the charge nurse's supervision technique is annoying. 3. Incorrect: The nurse is making a statement about the charge nurse's intentions, but does not know what the nurse's intentions are. The role of the charge nurse should be addressed. 4. Incorrect: This is a negative statement about the nurse's job performance. A more positive approach is to explain the charge nurse's role.

A client arrives in the emergency department reporting signs and symptoms of nausea, numbness, prolonged muscle spasms, muscle twitching, and hand tremor. Current medications include furosemide 40 mg by mouth every morning. What acid/base imbalance does the nurse anticipate this client as having?

1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 4

A nurse with less than one year of experience reports to an experienced nurse, "The charge nurses are always checking up on me and evaluating my client care. I feel as if the charge nurses do not trust me to give good care to my clients." Which response by the experienced nurse demonstrates an understanding of appropriate staff supervision? 1. The charge nurses are accountable for supervising client care and client safety after delegating the client care assignments. 2. The charge nurses do that to everyone. It can be annoying sometimes, wwhen they ask about your client care. 3. Why don't you speak to the charge nurses about your perception of not being trusted to care for your clients? This is probably not their intention. 4. You are a new nurse, and the charge nurses know that you do not have the experience and knowledge base yet to handle some of your assignments.

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.

Which action by a nurse would require the charge nurse to intervene? 1. Walking in the hallway outside the operating room without a hair covering. 2. Putting on a surgical mask, gown and cap shoe cover before entering the operating room (OR). 3. Wearing a surgical mask into the holding area. 4. Wearing scrubs from home into the nursing station.

1. Correct: The hallway outside the OR is restricted to personnel with surgical attire and coverings. This area requires boot covers and hair covering. 2. Incorrect: Putting on a surgical mask, gown, cap and shoe covers are all required prior to entering the OR. You are walking into a sterile area that requires these coverings. 3. Incorrect: Surgical mask may be worn in the holding area, but is not required. This area is a clean area, but not sterile.4. Incorrect: Wearing scrubs into a nursing station is appropriate. This area is not considered part of the surgical suite.

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

1. Correct: The incidence of pancreatic cancer increases with age. Cigarette smoking, exposure to industrial chemicals or toxins in the environment, and a diet high in fat, meat, or both are associated risk factors. 2. Incorrect: Diabetes and pancreatitis are associated with pancreatic cancer. 3. Incorrect: Diabetes and pancreatitis are associated with pancreatic cancer. 4. Incorrect: The inherited risk is small.

An experienced RN and LPN are working with a new nurse who has just recently passed NCLEX®. The team is assigned to care for 12 clients on the medical-surgical unit. Which factor is most important for consideration when delegating? 1. Lack of experience of the new nurse. 2. The preferences of the LPN who has experience. 3. RN's desire to avoid confrontation. 4. Assignment of equal number of clients to the RN, LPN and new nurse.

1. Correct: The lack of experience of one of the team members (the new RN) must be considered when delegating for client safety. The new nurse may not have the knowledge, assessment skills, and experience needed to care for clients who are unstable or have complex health issues. 2. Incorrect: Preferences by nurses should not guide delegation decisions. This takes the focus off what is best for the clients and places the focus on the nurse. 3. Incorrect: The possibility for conflict when delegation decisions are made should not influence these decisions which are made in the best interest of the client. 4. Incorrect: Although it seems like the "fair" thing to do by each nurse caring for the same number of clients, the delegation decisions should be based on the experience of the new RN. Client safety could be compromised by assigning the new nurse to clients who are unstable or have complex health issues. Delegation to the LPN must include consideration of the LPN's scope of practice.

While reviewing the prescriptions written by a primary healthcare provider, the nurse notes that ibuprofen 30 mg by mouth every 6 hours is prescribed for a child weighing 6 kg. The drug information book states that the appropriate dosage range is 20-30 mg/kg/24 hours. What action should the nurse take? 1. Administer the ibuprofen at 30 mg by mouth every 6 hours. 2. Contact the nursing supervisor regarding the prescription. 3. Ask the pharmacist to calculate the appropriate dose. 4. Notify the primary healthcare provider.

1. Correct: The maximum dose in 24 hours would be 30 x 6 = 180 mg. 30 mg every 6 hours is a safe dose. 2. Incorrect: The nursing supervisor does not need to be notified. This is a safe dose. 3. Incorrect: The nurse can calculate the appropriate dose based on the information provided. The primary healthcare provider does not need to be notified. The prescription is within the safe range. 4. Incorrect: The primary healthcare provider does not need to be notified since the prescription is written within the safe range.

The nurse tries to notify the primary healthcare provider (PHP) that the dosage of newly prescribed medication is higher than recommended. The PHP cannot be located and the medication is scheduled to be administered in 30 minutes. Which intervention should the nurse implement next? 1. Inform the charge nurse. 2. Administer the medication as prescribed. 3. Document the prescribed medication dosage in the nursing notes. 4. Administer the recommended dosage until the PHP is contacted.

1. Correct: The medication that was prescribed is higher than the recommended dosage. Since the PHP cannot be notified, the charge nurse should be notified to clarify what is the next action for the nurse to initiate. 2. Incorrect: It is beyond the scope of practice for a nurse to independently decide to administer a medication dosage that is higher than recommended. The nurse should not administer the medication. 3. Incorrect: The prescribed medication that is higher than recommended should not be documented in the nursing notes. The medication has not been administered, and the nurse is following the appropriate steps to clarify the dosage of the medication. 4. Incorrect: Client safety is always a priority. It is beyond the scope of practice for a nurse to independently decide to administer a different medication dosage without a prescription from the PHP. The nurse should not administer the medication.

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

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

When providing instructions, the nurse asks the client to repeat the techniques for crutch walking. The nurse is aware that further teaching is needed when the client makes which statement? 1. "The elbows should be flexed at 10 degrees." 2. "I should not lean on the crutches with my armpit." 3. "When going upstairs, my non-surgical leg goes up first." 4. "Both crutches are held in one hand when sitting down".

1. Correct: The nurse is looking for an incorrect statement from the client. This statement indicates the client will need further instruction prior to discharge. When using crutches, the client's elbows should be flexed at 30 degrees. 2. Incorrect: This is a correct statement by the client. The weight of the body is placed on the hands and handgrips rather than being supported by the armpits, which could cause axillary nerve damage. This is a correct statement by the client; however, the question asks for an incorrect statement by the client. 3. Incorrect: The client is aware that the non-surgical "good" leg should be placed on the steps first when going upstairs, while the surgical "bad" leg is placed on the stairs first when coming down steps. This is a correct statement, indicating that the client did understand teaching; however, this question is looking for an indication that the client needs further instructions. 4. Incorrect: When sitting down in a chair, the client would indeed place both crutches in one hand while safely reaching for the chair with the free hand. This is a correct statement and does not indicate the need for further teaching.

A client who is Chinese comes to the clinic for a follow-up appointment following cardiac bypass surgery. The client's father accompanies the client into the examination room. What is the most appropriate action by the nurse? 1. Ask the client's father if he has any questions regarding his son's condition. 2. Ask the client's father to leave the examination room due to confidentiality. 3. Perform needed assessments and care without interacting with the father. 4. Inform the father of the assessment findings and plan of care

1. Correct: The nurse is responsible for providing culturally sensitive client care. In the Chinese culture, it is important to show respect to the elders of the family. This option respects the client's father by addressing him personally and providing a sense of involvement in the client's health. This option does not ignore the client's father nor does it violate the client's confidentiality. In addition, questions about certain conditions can be answered without direct reference to the client. 2. Incorrect: Asking the father to leave the exam room would be disrespecting not only the father, but also the client who allowed the father to be present. 3. Incorrect: By failing to acknowledge the presence of the father, this demonstrates a lack of respect for the elder of the family. The nurse should not ignore the presence of others in a client room. 4. Incorrect: By providing information of assessment findings and plan of care, this could violate the client's rights to confidentiality. The client would need to provide expressed permission for specific information to be shared in the presence of another individual.

The home health nurse is assessing a client whose spouse died in a motor vehicle accident 6 months ago. The client says, "I feel all alone now". Which response by the nurse is therapeutic? 1. "You are feeling all alone." 2. "Why do you say you are lonely?" 3. "Your feelings of loneliness will decrease." 4. "I know other people who lost someone feel this way."

1. Correct: The nurse is utilizing the therapeutic communication technique of restating. The central statement by the client is restated. The client is able to identify that their thoughts or feelings have been received correctly. This also allows the client to clarify their thoughts or feelings if needed. 2. Incorrect: The nurse is requesting an explanation from the client. This is a nontherapeutic communication technique which can cause the client to have to defend their behavior or feelings. 3. Incorrect: The nurse is conveying to the client that their feelings of loneliness will decrease. This response is nontherapeutic communication technique of giving reassurance. The nurse is downplaying the client's feelings of loneliness. 4. Incorrect: The client is expressing their loneliness of losing a spouse. When the nurse states others have experienced loss, the nurse is utilizing the nontherapeutic communication technique of belittling feelings. This response causes the client to question their loneliness.

A client who is suicidal confides to the night nurse, "I will try again when I get out of this place." What is the nurse's best response? 1. "What do you plan to do?" 2. "You will try what again?" 3. "Why would you want to do that? You have everything to live for." 4. "Are you trying to get back at your family for sending you here?"

1. Correct: The nurse must assess the seriousness of the client's intent. Does the client have a plan and the means? How lethal are the means? Direct questions are appropriate when suicide is a possibility. 2. Incorrect: Inappropriate. This is an indirect question. The nurse needs to get to the point when suicide is a possibility. This question does not address the plan. 3. Incorrect: Inappropriate. This is also an indirect question. Get to the point. The nurse is making a judgment about the client's life. The nurse does not know the specifics of the client's life. 4. Incorrect: Inappropriate. Although this is a direct question, it does not explore the ability of the client to successfully accomplish the task. Get to the point. This type of question could cause the patient to become defensive.

A client diagnosed with pancreatic cancer is being discharged home to live with an adult child. What action should the nurse take to promote continuity of care? 1. Identify community services available for the client and family. 2. Refer client for hospice care. 3. Advise family that client would benefit more from nursing home placement. 4. Make arrangements for around the clock home health aides.

1. Correct: The nurse promotes continuity of care at discharge by providing a smooth transition from one level of care to another. The nurse should include in the discharge plan appropriate community support services available to the client and family so that they can obtain support as needed. 2. Incorrect: This may be premature at this point. Hospice referral is provided when any person with a life threatening illness, which measures life in months rather than years, qualifies for hospice care. 3. Incorrect: It is not appropriate for the nurse to impose personal opinions about what is best for the client. 4. Incorrect: This may be premature at this point. Further assessment is needed and can be provided as the cancer progresses.

The nurse is checking a nine month old's developmental status. What finding would be of concern to the nurse? 1. Unable to transfer a toy from one hand to the other hand. 2. Cannot stand without support. 3. Does not notice or mind when a parent leaves. 4. Has not acquired a 6 word vocabulary.

1. Correct: The nurse should be concerned if a 9 month old cannot transfer a toy from one hand to the other hand. 2. Incorrect: By twelve months the nurse should be concerned if the baby can't stand when supported. 3. Incorrect: The nurse should be concerned if the 18 month old doesn't notice or mind when a caregiver leaves or returns. 4. Incorrect: The nurse should be concerned if the 18 month old doesn't have at least a 6 word vocabulary.

A client with an ischemic stroke was prescribed warfarin 5 mg daily by mouth 48 hours ago. At 0830 the international normalized ratio (INR) reading was 2.0. What action should the nurse take? 1. Administer warfarin. 2. Administer phytonadione. 3. Request the lab to run another INR. 4. Notify the primary healthcare provider about the INR level.

1. Correct: The nurse should continue to monitor the client, and administer the warfarin. The normal range for INR is 0.8 - 1.1 for a client not prescribed an anticoagulant. The optimal therapeutic INR range for a client on warfarin should be 2.0 - 3.0. 2. Incorrect: Phytonadione is administered to reverse the anticoagulant effects of warfarin. Since the INR is within the acceptable therapeutic INR range (2.0 - 3.0) for a client prescribed an anticoagulant, the phytonadione should not be prescribed. 3. Incorrect: The INR reading of 2.0 is not within the critical level for a client prescribed an anticoagulant. It is not necessary to notify the lab to run another INR. 4. Incorrect: There are client situations where the primary healthcare provider should be consulted. In this situation the primary healthcare provider does not need to be notified since the INR of 2.0 is within the acceptable range of a client prescribed warfarin.

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

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

A client becomes progressively cyanotic and unresponsive post central line insertion. Which action should the nurse take? 1. Place the client on the left side with the client's head down. 2. Administer a thrombolytic agent. 3. Auscultate the client's heart sounds. 4. Have the client bear down and perform valsalva maneuver.

1. Correct: The nurse should immediately place the client in the left side-lying position with the client's head down. This position will trap a bubble in the right ventricle preventing it from passing into the pulmonary circulation. 2. Incorrect: Thrombolytic agents are not indicated in this scenario. 3. Incorrect: Auscultation of heart sounds would be an assessment performed after the client has stabilized. 4. Incorrect: The client would not be able to perform valsalva because the client is unresponsive.

The nurse is supervising the care of a client on bedrest with a skull fracture from head trauma. Which action, when performed by an unlicensed assistive personnel (UAP), should the nurse interrupt? 1. Assisting with turn, cough, and deep breathing (TCDB) 2. Elevating the head of the bed to 30 degrees. 3. Measuring urinary output every hour. 4. Turning off room lights.

1. Correct: The nurse should interrupt the UAP assisting with TCDB because this may increase intracranial pressure (ICP). TCDB increases intrathoracic pressure which then increases ICP. 2. Incorrect: Maintain client with head trauma in the head up position. This position promotes drainage from the head and decreases vascular congestion. 3. Incorrect: This is an acceptable action and one the UAP can do. 4. Incorrect: You want to decrease stimulation and turning off room lights will provide restful environment in an effort to decrease ICP.

The nurse is teaching the parents of a child with impetigo about care. Which statement by the parents indicate further teaching is needed? 1. "We will not allow bathing until the scabs are healed." 2. "The skin and crusts will be washed daily with soap and water." 3. "Lotions should not be applied to the lesions, so they remain dry." 4. "We will apply the antibiotic ointment to the lesions after removing the crusts."

1. Correct: The parents need further teaching. The crusts and debris should be washed at least daily. 2. Incorrect: The parents understand teaching and do not need further teaching. The crusts and debris should be washed with soap and water at least daily. 3. Incorrect: The parents understand teaching and do not need further teaching. Antibiotic ointment should be applied to the lesions. 4. Incorrect: The parents understand teaching and do not need further teaching. The crusts should be removed so the antibiotic cream can reach the infected site.

To promote rapid diuresis in a client in acute pulmonary edema, which prescription should the nurse administer first? 1. Furosemide 40 mg IVP 2. Dopamine 15 mcg/kg/min 3. Hydrochlorothiazide 25 mg PO 4. Captopril 25 mg PO

1. Correct: Yes, there is a good bit of fluid overload with acute pulmonary edema, so the furosemide should be started first. Furosemine is a loop diuretic that prompts rapid loss of excess fluid. 2. Incorrect: Low doses of dopamine (0.5-5 mcg/kg/min) cause vasodilation and increased diuresis. High doses (5-10 mcg/kg/min) cause vasoconstriction to increase blood pressure and improve cardiac output. The low dose would be better here. 3. Incorrect: A loop diuretic given IVP will work faster than a potassium-sparring diuretic by mouth. 4. Incorrect: Give the furosemide first, then determine if the client needs an ACE inhibitor.

The nurse is caring for a client in the outpatient mental health clinic. The client recounts several incidences of spousal abuse. The client says to the nurse, "I know that he loves me. Sometimes I can be quite irritating." Which response is most appropriate by the nurse? 1. "You are not responsible for the abuse." 2. "Sometimes we can irritate our spouses." 3. "The worst is over now." 4. "You should think about leaving him."

1. Correct: The perpetrator is responsible for his/her own actions, but the abused partner may take responsibility or make excuses for them. This mindset needs to be clarified and corrected to prevent further abuse and keep the client safe. 2. Incorrect: Behavior of the perpetrator is not the responsibility of the victim. This statement reinforces the client's belief that they are at fault for the abuse. 3. Incorrect: The severity of the abuse is usually increases over time. This is giving false reassurance to the client. 4. Incorrect: The nurse is offering advice with the "should" statement. A decision to leave must bemade by the victim, and the victim should understand that, at the point of leaving, violence may become fatal.

A client comes to an obstetric clinic for a routine prenatal checkup at 32 weeks gestation. The nurse palpates the client's abdomen to determine fetal position so that fetal heart sounds can be assessed. It is determined that the fetal position is left occipital anterior (LOA). Where should the nurse place the Doppler to hear fetal heart sounds? 1. Below the umbilicus, on the mother's left side. 2. Below the umbilicus, on the mother's right side. 3. Above the umbilicus, on the mother's right side. 4. Above the umbilicus, on the mother's left side.

1. Correct: The point of maximal intensity of the fetus is on the mom's abdomen where the fetal heart tones (FHT) is the loudest, usually over the fetal back. Divide the mom's pelvis into 4 quadrants (right and left anterior and right and left posterior). The occiput of the head is the most common presenting part and is abbreviated O. The occiput and back are pressing against left side of mom's abdomen; FHT would be heard below umbilicus on left side. 2. Incorrect: Fetal heart sounds (FHS) would be found below the umbilicus, but not on the mother's right side if the fetal position is LOA. 3. Incorrect: FHS heard above the umbilicus indicate a breech presentation. If the fetal position is determined to be LOA the FHS would be on the mother's left side. 4. Incorrect: FHS heard above the umbilicus indicate a breech presentation, rather than LOA. The FHS would be heard on the mother's left side, but below the umbilicus.

The unlicensed assistive personnel (UAP) reports to the nurse that a client who received morphine sulfate 4 mg IVP 30 minutes ago has a respiratory rate of 10 breaths/ minute. What is the nurse's priority intervention? 1. Administer naloxone 0.4 mg IVP. 2. Notify the primary healthcare provider of respiratory status. 3. Deliver breaths at 20 breaths/ minute via a bag-valve mask. 4. Instruct the UAP to ambulate the client.

1. Correct: The problem is respiratory depression due to morphine sulfate IV. Giving naloxone will reverse the respiratory depression. 2. Incorrect: The primary healthcare provider needs to know what happened, however, fix the problem first if you can. And we can, by giving the naloxone. 3. Incorrect: Give naloxone first and the client may not even need ventilation with a bag-valve mask. 4. Incorrect: Ambulation will not reverse the effects of the narcotic. And this is a safety issue. The client could fall.

Based on the results of the ABGs, what imbalance does the nurse understand the client to be exhibiting? pH - 7.35 PaO2 - 95% PaCO2 - 49 HCO3 - 30

1. Respiratory acidosis compensated 2. Respiratory acidosis partially compensated 3. Metabolic acidosis compensateed 4. Metabolic acidosis paratially compensated 1

A client comes into the emergency department (ED) with intense abdominal pain. The nurse completes a physical assessment and evaluates the vital signs and lab work. Based on the information gathered, the nurse expects which diagnostic test will be priority? Exhibit 16 year old female admitted to treatment room 3, reporting "intense abdominal pain" at 10/10. States, "pain started 3 days ago, but got worse this morning". Confirms no injury to abdominal area. Rigid, board-like abdomen noted. Last menstrual cycle "6 weeks ago." Temperature - 100 degrees F (37.77 degrees C) Heart rate - 110/min Respirations - 28/min Blood Pressure - 90/62 Hemoglobin - 10 grams/dL (100 grams/L) Hematocrit - 32% (0.32) serum hcg - 27 mIU/mL 1. Transvaginal ultrasound 2. Esophagogastroduodenoscopy (EGD) 3. CAT Scan of the abdomen 4. KUB (Kidney, Ureter, and Bladder)

1. Correct: The serum hCG indicates that the client is pregnant. The Hgb and Hct along with a BP of 90/62, and a rigid board like abdomen indicates bleeding in the peritoneum. Intense pain at 10/10 without injury can lead the nurse to thinking tubal pregnancy. How do determine if the client has a tubal pregnancy? With an ultrasound. A transvaginal ultrasound is a type of pelvic ultrasound used to examine the uterus, fallopian tubes, ovaries, cervix, and vagina. 2. Incorrect: No, an EGD looks into the stomach and small intestine. All clues lead to tubal pregnancy.3. Incorrect: No, tubal pregnancy can be seen quickly by ultrasound. 4. Incorrect: Kidney, Ureter, and Bladder-general picture of the abdomen-less specific than the Ultrasound. The focus is not on the fallopian tubes.

The nurse is caring for a client taking digoxin. Which electrolyte imbalance should be of most concern? 1. Hypokalemia 2. Hyponatremia 3. Hypomagnesemia 4. Hypocalcemia

1. Correct: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity could occur. 2. Incorrect: Hyponatremia, hypomagnesemia, and hypocalcemia do not interfere with digoxin. Any electrolyte imbalance can predispose the client to digoxin toxicity, but hypokalemia is the imbalance that can potentiate digoxin toxicity the most. 3. Incorrect:Hyponatremia, hypomagnesemia, and hypocalcemia do not interfere with digoxin. Any electrolyte imbalance can predispose the client to digoxin toxicity, but hypokalemia is the imbalance that can potentiate digoxin toxicity the most. 4. Incorrect: Hyponatremia, hypomagnesemia, and hypocalcemia do not interfere with digoxin. Any electrolyte imbalance can predispose the client to digoxin toxicity, but hypokalemia is the imbalance that can potentiate digoxin toxicity the most.

The client has been prepared for surgery. As the nurse is discussing the post-op expectations, the client says to the nurse, "I am not sure what other options are available to me." What should the nurse do? 1. Request the surgeon visit the client again before surgery. 2. Check client records to see if the client signed the consent form. 3. Explain that the surgery is scheduled for 30 minutes from now. 4. Tell the client that the surgeon explained those options yesterday.

1. Correct: The surgeon is responsible for informing the client about the surgical procedure, the options available,and the benefits and risks of each treatment modality. So, if the client has concerns the surgeon should be told and requested to see the client again prior to surgery. Surgery should be delayed until the client is sure of decision.2. Incorrect: The consent form signature is important; however, the client has the right to have questions answered and to change his mind.3. Incorrect: The client should not be encouraged to have the surgery if he still has questions about other options. The consent must be informed, so the client must have all questions answered. The surgery can be delayed until the client's concerns are addressed.4. Incorrect: The surgeon may have explained the options, however; it is obvious that the client did not understand the options. The client's concerns must be addressed prior to surgery.

The nurse is reviewing the medication prescriptions with a client for which English is a second language (ESL). Which nursing intervention most likely will prevent a medication error with this client? 1. Use the teach-back method so that client is repeating the instructions back to the nurse. 2. Give printed information to the client. 3. Ask the client if they have questions before the client leaves the healthcare setting. 4. Refer medication questions to the pharmacist.

1. Correct: The teach-back method of asking the client to repeat the teaching instructions to the nurse will most likely reveal any misunderstanding. This allows the nurse to reinforce any areas where clarification is needed. 2. Incorrect: Printed information may or may not be helpful, depending on the client's level of understanding. 3. Incorrect: The client may not know which questions to ask regarding the medication, particularly if there is a language barrier. 4. Incorrect: The client may not ask another person for help. There has been no relationship established with the pharmacist since the nurse has been providing the teaching. The nurse should not put this responsibility on someone else in the interdisciplinary team.

An elderly male client's wife recently died unexpectedly. During the clinic visit, the client appears tearful, lacks eye contact, and the clothing appears disheveled. What would be a priority nursing assessment for the client? 1. Adaptive and coping skills for dealing with loss 2. Intellectual capacity to make personal decisions 3. Socioeconomic status for independent living 4. Spiritual awareness for emotional comfort.

1. Correct: The unexpected death of a spouse can elicit a wide variety of emotions due to the grief that is being experienced. Individuals who are grieving often find it difficult to seek help, even from close family members. Elderly clients tend to wish to retain their independence. They often do not want to be burdens to the family members, but may find themselves unable to cope effectively. In this case, the signs of ineffective coping is the lack of eye contact and the personal appearance of the client. The nurse should assess the client's ability to adapt and cope with the unexpected loss and work through the grief process. 2. Incorrect: Although intellectual capacity in this elderly client could impact decision making, the priority assessment at this time is the client's ability to adapt to this sudden loss and determine if the client has the needed coping skills to effectively work through the grief process. 3. Incorrect: With the loss of the spouse, there may be a decrease in income. This could create a financial strain on the elderly client. However, this is not the priority assessment at this time. The nurse should focus on the client's ability to work through the grief. 4. Incorrect: Spiritual awareness can be paramount in the life of an individual, and can certainly be important during times of loss. However, this client does not seem to be coping well with the loss of the spouse, so the priority at this time would be focused on assessing the skills that the client possesses to help adapt to the loss and have the ability to cope.

The nurse is discharging the client after removing sutures from an abdominal wound. Which instructions should the nurse give the client at the time of discharge to reduce the risk of complications? 1. inspect the wound daily for any changes 2. Resume normal activities when you go home. 3. Keep the incision covered at all times. 4. Follow up with primary healthcare provider when scheduled.

1. Correct: The wound should be inspected daily for any signs of infection once the client goes home. Healing has only just begun by discharge. Signs of wound infection include: Increased pain, swelling, redness, or warmth around the affected area; Red streaks extending from the affected area; Drainage of pus from the area; Fever. 2. Incorrect: The client may be restricted in some activities, such as lifting, that would place undue strain on the suture line.3. Incorrect: It is likely that the incision can be uncovered, but the primary healthcare provider prescription would apply here. Look for words like "all" which generally make the option wrong. Things are not that definite. 4. Incorrect: This is true; however, the signs and symptoms of infection should be given to the client. If signs/symptoms develop, the primary healthcare provider should be notified prior to the next appointment.

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

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

A client presents to the after-hours clinic with reports of pain that occurs with walking but generally subsides with rest. The nurse's assessment reveals 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.

The nurse is developing a teaching plan for a female client who is taking one of the thiazolidinediones for the treatment of type 2 diabetes. What instruction should be included in the teaching plan? 1. Make sure that you use effective contraception while taking this drug. 2. The drug may lead to weight loss. 3. Therapeutic effect is reached within one to two weeks. 4. Therapeutic effect is reached within one month.

1. Correct: Thiazolidinediones may reduce the plasma concentration of the contraceptives. Additionally, post-menopausal women may resume ovulation.2. Incorrect: Thiazolidinediones may lead to weight gain and exacerbate congestive heart failure.3. Incorrect: With thiazolidinediones therapy, therapeutic effect may not be reached until 8 to 12 weeks of treatment.4. Incorrect: With thiazolidinediones therapy, therapeutic effect may not be reached until 2 to 3 months of treatment.

A client in a psychiatric unit tells the nurse, "I wanted to take the car to work, but the train station took all the tracks. Driving is the ticket when you want to go to the movies. No one needs money in heaven. We have money in our foods." How should the nurse document this conversation? 1. Associative looseness 2. Circumstantiality 3. Echopraxia 4. Anhedonia

1. Correct: Thinking is characterized by speech in which ideas shift from one unrelated subject to another in an unrelated manner. The person is not aware that the topics are unconnected. Speech may be incoherent at times. 2. Incorrect: With circumstantiality, the person is delayed in reaching the point of a communication because of unnecessary and tedious details. The point or goal is usually met, but only with numerous interruptions by the interviewer to keep the person on track. The person gets caught up in countless details and explanations. 3. Incorrect: The client who exhibits echopraxia may imitate or mimic the movements made by others. 4. Incorrect: Anhedonia is the inability to experience pleasure in acts that are normally pleasurable.

Two days after being prescribed enoxaparin the nurse notes hematemesis. Lab work has been obtained. Based on this data what action is most important for the nurse to take? Exhibit 1. Administer protamine sulfate. 2. Administer the next dose of enoxaparin. 3. Obtain vital signs. 4. Insert a nasogastric tube.

1. Correct: This client has a low hgb, hct, and platelet count and is actively bleeding. Protamine sulfate is the antidote for enoxaparin. 2. Incorrect: Administering another dose of enoxaparin would make the problem worse. The client is actively bleeding and has a low platelet count. 3. Incorrect: The client is actively bleeding. Obtaining vital signs is delaying treatment. The client needs protamine sulfate. 4. Incorrect: The client needs protamine sulfate to correct the problem.

A client admitted with somnolence has a history of chronic bronchitis and heart failure. Vital signs on admit are T 101.8ºF (38.8ºC), HR 106, R 26/shallow, BP 90/58. ABGs are pH 7.2, PCO2 75, HCO3 26. The nurse determines that this client has which acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. Correct: This client has a respiratory problem. Respiratory failure, COPD, and muscular weakness can lead to respiratory acidosis. Signs & symptoms: hypoventilation, sensorium changes, somnolence, semicomatose to comatose state. pH < 7.35, pCO2 > 45, HCO3 normal. 2. Incorrect: This is not alkalosis since the pH is 7.2 showing acidosis. 3. Incorrect: Not a metabolic related acid/base imbalance, because the HCO2 is 26 and within the normal range. 4. Incorrect: Not a metabolic related acid/base imbalance, because the HCO2 is 26 and within the normal range.

Twelve hours post coronary artery bypass surgery (CABG), the nurse notes the client's level of consciousness has decreased from alert to somnolent. BP 88/50, HR 130 and thready, resp 32, urinary output (UOP) has dropped from 100 mL one hour earlier to 20 mL this hour. What would be the nurse's first action? 1. Administer 100% oxygen per mask. 2. Lower the head of the bed. 3. Give furosemide STAT. 4. Re-check the BP in the other arm.

1. Correct: This client has developed signs of cardiogenic shock, one of the complications post CABG. Cardiac output is decreased, so the client needs more oxygen for the circulating blood volume. 2. Incorrect: Lowering the HOB will not help in cardiogenic shock but will actually make it harder for the heart to pump. 3. Incorrect: Poor kidney perfusion is the reason for the decreased UOP. The kidneys are trying to conserve what little volume the body has to maintain vital organ perfusion as long as possible. 4. Incorrect: Rechecking the BP will not help the problem. With the other symptoms, this BP is most likely accurate. This would only delay treatment and would not fix the problem.

The nurse is preparing to make initial shift rounds. Which primipara client should the nurse see first? 1. 39 weeks with a board like abdomen and scant dark red bleeding. 2. 38 weeks gestation with blood streaked vaginal discharge 3. 40 weeks gestation reporting urinary frequency 4. 36 weeks gestation with pitting pedal edema

1. Correct: This client has symptoms of a placental abruption (abruptio placentae). There is an extremely high risk for fetal loss and maternal disseminated intravascular coaculation (DIC) which is a potentially life threatening clotting disorder in which blood clots form throughout the body's small blood vessels. 2. Incorrect: This describes loss of the mucous plug, which is a normal occurrence at term. 3. Incorrect: Urinary frequency without dysuria at term indicates descent of the fetus. This is a normal occurrence at 40 weeks gestation. 4. Incorrect: Edema confined to the feet and ankles is a normal discomfort of pregnancy at term.

Which postpartum client should the nurse assign to a private room? 1. Has antibodies for Hepatitis C. 2. Is rubella non-immune. 3. Is rubella immune. 4. Has lupus antibodies.

1. Correct: This client should be in a private room for her protection and the protection of other postpartum women. The presence of antibodies for Hepatitis C indicates HCV infection and possibly impaired immune function due to liver damage. In addition, Hepatitis C is transmitted by contact with body fluids and it is likely that lochia will be found on toilet surfaces. It is also common for postpartum women to have some kind of wound (perineal laceration or episiotomy) and they will be at increased risk of HCV contaminated lochia coming into contact with their wound. 2. Incorrect: Rubella non-immunity carries risks only to an unborn fetus. If a non-immune pregnant woman contracts rubella during the first trimester, it can result in serious complications in the fetus. Being rubella non-immune is not of concern when making room assignments for postpartum clients. Being non-immune to rubella does not make this client a risk to other postpartum clients.3. Incorrect: Rubella-immune woman has no risks. Being rubella immune indicates that the client has developed antibodies in response to a previous rubella infection or immunization. Rubella immunity is desired for pregnant women or those planning to become pregnant. This will help to prevent a rubella infection during pregnancy which could cause birth defects. Being rubella immune would not prevent this client from being able to be placed in the room with other postpartal clients. 4. Incorrect: The woman with lupus antibodies is not at increased risk for infection to herself or to others. The pregnant woman with lupus antibodies requires more vigilant monitoring of the fetus because they may increase the risks of neonatal lupus syndrome, certain heart defects, and miscarriage or pre-term birth. However, these antibodies in the postpartal client does not pose any risks to other postpartal clients, so this would not be a factor when making room assignments.

All of the beds in a 10 bed Labor, Delivery, Recovery, Postpartum Unit (LDRP) are full when one of the nurses assigned that day calls in sick. A nurse from the Med surg unit is transferred to the LDRP unit. Which client should the charge nurse assign to this nurse? 1. Client at 32 weeks gestation on oral terbutaline with 4 contractions/hour. 2. One hour postpartum client with a continuous trickle of vaginal bleeding. 3. 2 hours postpartum client reporting intense perineal pain. 4. Client at 36 weeks gestation with a blood pressure of 148/92.

1. Correct: This client is at lowest risk for complications. She is having infrequent contractions and is not at high risk for preterm delivery. She is also receiving an oral tocolytic, terbutaline. Tocolytic agents are used to inhibit uterine contractions and suppress preterm labor. The medical surgical nurse should be able to safely provide care for this client. 2. Incorrect: Continuous vaginal bleeding (even a trickle) with a firm fundus indicates excessive bleeding and is suggestive of lacerations of the vagina, cervix or perineum. This client needs the assessment skills and nursing care of a trained LDRP nurse. The medical surgical nurse may not have the specialized assessment skills and knowledge needed to appropriately care for this client. 3. Incorrect: Intense perineal pain is a symptom of a genital tract hematoma. A client can lose 500 mL of blood into the perineal tissues in a very short period of time. Immediate intervention is also needed for this client. Small hematomas may be managed with ice packs and close observation. However, clients with enlarging hematomas may have to return to surgery for incision and removal of the clot. This client would need a trained LDRP nurse for close monitoring and care. This would not be a client to assign to the medical surgical nurse. 4. Incorrect: This client's blood pressure indicates the presence of a complication known as pregnancy induced hypertension (PIH). This condition is characterized by high blood pressure during pregnancy which can lead to a serious condition known as preeclampsia. Protein will be found in the urine. If not treated, serious complications for the mother and fetus can develop. This client would need the specialized care of the LDRP nurse.

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

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

A client delivered a term infant four hours ago. The infant was stillborn. Which room would be most appropriate for the nurse to assign to this client? 1. A private room on the gynocological unit. 2. A private room on the postpartum unit. 3. Discharge her home as soon as her condition is stable. 4. Room her with another client with a pregnancy loss.

1. Correct: This client needs a private room so she can feel free to grieve and have family members stay with her for support. She should be transferred to a gynocological unit so the sights and sounds of the maternity unit do not contribute to her pain. 2. Incorrect: Difficult for mother with stillborn to be on postpartum unit with mothers and their babies. The mother should not be surrounded by these reminders. 3. Incorrect: She does not need to be rushed out of the hospital. She needs to have time with her stillborn and also still needs to be assessed for postpartum complications. Remember that she is going through all of these postpartum stages of normal delivery and requires observations. 4. Incorrect: I know we say like illnesses go together but not here. This client needs privacy and time with her family.

A client is admitted to the pediatric unit with a diagnosis to rule out tuberculosis (TB). What room assignment should the charge nurse make? 1. Private room. 2. Private room and place on protective isolation. 3. Room with a client diagnosed with a respiratory infection. 4. Room with a client who is 24 hours post appendectomy.

1. Correct: This client should be in a private room to prevent the spread by airborne contamination. In addition, standard precautions should be implemented. Remember, you are trying to protect staff and others without the disease from contracting TB. 2. Incorrect: Airborne isolation is needed to protect staff and others. There are no indications for protective isolation. The term 'protective isolation' describes a range of practices used to protect highly susceptible hospital clients from infection. 3. Incorrect: A respiratory infection client needs a private room. Also, it is best for the client with suspected TB to be in a private room. 4. Incorrect: 24 hours postoperative client does not need exposure to infection. Cross contamination is always a concern with a surgical client.

The client is experiencing autonomic dysreflexia. What is the first action by the nurse? 1. Place in high Fowler's position 2. Find and remove the trigger source 3. Notify the primary healthcare provider 4. Check for fecal impaction

1. Correct: This first action provides some immediate relief to decrease the blood pressure while you are preparing for other interventions. This is one thing the nurse can do immediately to help fix the problem. 2. Incorrect: Later you will look for bladder or bowel distention which is a common precipitating cause of autonomic dysreflexia. 3. Incorrect: The primary healthcare provider will be notified after the nurse intervenes quickly with appropriate nursing measures. 4. Incorrect: Sit client up is the priority and then look for causes.

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 group of clients should she assign to the medical surgical nurse? 1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. 2. C-section planning discharge, post-partal infection, mastectomy. 3. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 4. 28 week gestation of bed rest, post-partal with HELLP syndrome, breast reconstruction.

1. Correct: This group of clients is primarily med surgical.2. Incorrect: This group of clients needs specific teaching.3. Incorrect: This group of clients needs specialized care.4. Incorrect: No, the monitoring is too specific for the med-surg nurse.

Which condition requires the nurse to discontinue an intravenous infusion of oxytocin to a laboring client?

1. Fetal heart rate baseline of 140-160 bpm 2. Contraction frequency of 1-1/2 minutes with a duration of 70-80 seconds 3. Maternal temperature of 101.2 degrees F (38.44 degrees C) 4. Early decelerations in the fetal heart rate 2

The school nurse has educated a group of teens concerned about acquiring the Ebola virus. Which statement by the students would indicate to the nurse that further teaching is necessary? 1. "I can get a vaccine to prevent getting the Ebola virus." 2. "Ebola is not spread through casual contact, so my risk of getting the virus is low." 3. "The Ebola virus is passed from person to person through blood and body fluid." 4. "Ebola viruses are mainly found in primates in Africa."

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

The nurse is caring for a client who is preparing to undergo a total hysterectomy for stage 4 cervical cancer. The client is crying and states, "I want to have more children, and I am unsure if I should have the procedure." What is the nurse's best action? 1. Allow the client to discuss her fears, and encourage her to talk more with her primary healthcare provider. 2. Discuss the fun things that she will be able to do after her surgery, and encourage her to make a list of positive things. 3. Explain to the client that her ovaries can be frozen for egg harvesting at a later time, and she can find a surrogate. 4. Advise the client to put off having the surgery until she is certain, and notify the surgeon of the decision.

1. Correct: This is likely anticipatory grieving and fear. Let the client talk and encourage her to talk again to the primary healthcare provider. The client needs reassurance that she is making the right decision. 2. Incorrect: This is not the client's fear and not helpful in this situation. The client may have a hard time thinking about fun and positive things while she is upset and crying. 3. Incorrect:This is not an appropriate answer, and we don't freeze ovaries. The nurse should not give false hope or information. 4. Incorrect: The cancer is already in stage 4. Postponing surgery is dangerous. It is not the nurse's place to advise the client to put off surgery. Postponing surgery is something that needs to be decided between the surgeon and client.

A Hispanic client is considering treatment options for cancer. The client says that she needs to discuss the options with her sons before she makes her final decision. What should the nurse say to the client? 1. You are wanting your sons to assist you in deciding about treatment options. 2. It is really your decision about which option you choose. 3. I will be happy to discuss this issue with you. 4. This shows that you are proud of your sons.

1. Correct: This is paraphrasing the client's statement and is a therapeutic response. Within this culture the family plays a very important role when making decisions about healthcare. 2. Incorrect: Although clients have the right to make autonomous decisions, it is important to remember cultural variations regarding the decision making process. 3. Incorrect: The nurse can discuss the issue; however, the males in the family have much influence on decisions. 4. Incorrect: This is giving an opinion on the relationship of the mother and sons. While this may be true, it does not focus on the cultural aspect of the question and is not the best response.

A nurse is caring for a client that is undergoing outpatient psychiatric treatment for somatization disorder. Which statement by the client indicates that teaching has been successful? 1. "I will keep a diary of times of stress and the appearance of physical symptoms." 2. "I will simply ignore any physical symptoms I get from now on." 3. "The best way for me to stop having physical symptoms is to avoid all the stress in my life." 4. "I will take a sedative when I start having physical symptoms."

1. Correct: This will help the client see the relationship between stress and physical symptoms, which is the first step in recognizing that the symptoms are related to stress. Somatization is the expression of psychological stress through physical symptoms. 2. Incorrect: The possibility of organic pathology must always be considered. Failure to do so could jeopardize client safety. The client should not ignore symptoms. The word "any" is too much like the word "all". 3. Incorrect: Stress cannot be totally avoided for the rest of one's life. The client needs to find more effective ways to cope with stress, such as relaxation exercises, physical activities, and/or assertiveness training. The word "all" is too limiting. 4. Incorrect: This will not solve the problem. The client needs to find more effective ways to cope with stress, such as relaxation exercises, physical activities, and/or assertiveness training. Remember, to stay away from medications on the NCLEX. Drugs should not be the first choice.

When administering an intravenous push (IVP) medication through a continuous intravenous infusion, which intervention is most important for the nurse to take? 1. Assess for drug and solution compatibility. 2. Clamp the tubing of the large volume infusion above the injection port. 3. Stop the large volume infusion and flush the tubing . 4. Use the port nearest the client to administer the IVP medication.

1. Correct: This would have the most life threatening affect on a client if it is not done and an incompatibility exists. Checking for incompatibility between the large volume solution and the medication is a safety issue.2. Incorrect: This is an action that can be taken when administering an IVP medication; however, clamping the tubing does not have to be done. If the tubing is not clamped when administering the IVP medication, the medication would first go up the tubing toward the large volume container, then go toward the client when the pressure from the push is stopped.3. Incorrect: This needs to be done if the large volume infusion solution is incompatible with the IVP medication. The action would not have to be implemented when administering all IVP medications. If incompatible, then it should be flushed.4. Incorrect: This is recommended when administering IVP medication, but would not cause the greatest life-threatening consequences. Using the port closest to the client minimizes the distance the medication must travel, so that the medication gets to the client's circulation faster.

The charge nurse is assigning an unlicensed assistive personnel (UAP) to take vital signs on a group of adult clients. The charge nurse would instruct the UAP that a rectal temperature is contraindicated for which client? 1. Client with thrombocytopenia. 2. Client with a fractured femur. 3. Client with an inguinal hernia. 4. Client with irritable bowel syndrome.

1. Correct: Thrombocytopenia is the deficiency of platelets in the blood. Due to the reduced platelet count, the clotting time of the client's blood will be reduced. Inserting a rectal thermometer increases the client's risk of rectal trauma. If there is rectal bleeding from the insertion of the rectal thermometer, the client may experience increased bleeding due to their decreased platelet count. 2. Incorrect: A client with a fractured femur can have their temperature assessed by a rectal temperature. There are no contraindications for a rectal temperature. 3. Incorrect: To evaluate a client's temperature by inserting a rectal thermometer is acceptable procedure for a client with an inguinal hernia. 4. Incorrect: There are no contraindications for clients with irritable bowel syndrome to have their temperature assessed by a rectal thermometer.

What is the most important action for the nurse to take in order to decrease an adverse drug reaction/interaction in an elderly client who takes multiple medications? 1. Implementing a thorough client assessment. 2. Instructing the client about adverse drugs reactions. 3. Explaining to the client that hospital admissions of older adults are often due to a drug reaction. 4. Teaching the client that adverse reactions are directly proportional to the number of medications taken.

1. Correct: To prevent complications of medication administration, such as adverse drug reactions and interactions, careful planning is priority. A thorough assessment of the client is vital when planning care. 2. Incorrect: Instructing the client about adverse drug reactions is a true statement that supports client education, but not more important than thorough client assessment.3. Incorrect: Explaining the prevalence of drug reactions in the elderly is a true statement that supports client education, but not more important than thorough client assessment. 4. Incorrect: Teaching the client that risk increases with the number of medications taken is a true statement that supports client education, but not more important than thorough client assessment.

A nurse is taking care of a client with major partial thickness burns. Tobramycin 125mg IVPB has been prescribed. What is the priority lab assessment prior to administering this medication? 1. Creatinine 2. Potassium 3. Magnesium 4. Blood urea nitrogen

1. Correct: Tobramycin can cause nephrotoxicity. 2. Incorrect: This will not tell us if the kidneys are damaged. 3. Incorrect: This will not tell us if the kidneys are damaged. 4.Incorrect: BUN can elevate for reasons other than renal problems.

Which food selections would need to be removed from the tray by the nurse for a client recovering from thyroidectomy? 1. Roasted almonds 2. Mashed vegetables 3. Scrambled eggs 4. Ice cream

1. Correct: Too hard and crunchy. Need soft diet because esophagus is right behind the thyroid and trachea. This would be difficult to swallow after surgery due to pain. 2. Incorrect: Mashed vegetables will be soft and easy to swallow. 3. Incorrect: This would be good for the client. The food is soft and easy to swallow. 4. Incorrect: Ice cream with neck surgery. Cold and soft.

A client receiving torsemide 20 mg every day reports an onset of cramping in the lower extremities. Based on this report, what current lab finding would the nurse expect? 1. Potassium level of 3.1 mEq/L (3.1 mmol/L) 2. Calcium level of 11 mg/dL (2.75 mmol/L) 3. Sodium level of 140 mEq/L (140 mmol/L) 4. pH level of 7.40

1. Correct: Torsemide is a loop diuretic, which causes the excretion of K+. Hypokalemia can result from use of this diuretic. Normal range for potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore the level of 3.1 mEq/L (3.1 mmoL/L) is hypokalemia, and a common sign and symptom includes muscle cramps. 2. Incorrect: Normal calcium levels in the serum are 9.0-10.5 mg/dL (2.25-2.62 mmol/L). The level of 11 mg/dL (2.75 mmol/L) is hypercalcemia. Calcium acts like a sedative, so you would expect the client's muscle tone to be weak and flaccid rather than experiencing muscle cramping. 3. Incorrect: The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Therefore, a level of 140 mEq/L (140 mmol/L) is WNL and would not be a factor in the client's report of muscle cramping. 4. Incorrect: The pH level of 7.40 is also WNL and is not a lab finding that would be consistent with muscle cramping.

A nurse is caring for a poorly controlled type 2 diabetic client. The client does not adhere to the diet and the latest HbA1c is 8%. The serum glucose at this visit is 218mg/dL (12.09 mmol/L). The client is currently taking metformin and exenatide. Based on this history, what should the nurse anticipate will be the first strategy implemented to improve glucose control for this client? 1. Nutritional counseling 2. Increased daily exercise regimen 3. Education regarding Insulin by basal/bolus dosing method 4. More frequent self-monitoring of blood glucose

1. Correct: True, nutritional teaching to promote diet compliance should be tried first because the client's HbA1c is 8% and his blood sugar is 218mg/dL (12.09 mmol/L) - not terribly bad for a type 2 diabetic who is non-compliant. Noncompliant is your big hint with this question! 2. Incorrect: No, this is not priority over nutritional counseling. Appropriate, moderate exercise, like walking, can overtime lower blood glucose. Increasing the daily exercise regimen is not appropriate based on the information provided in the question stem. 3. Incorrect: No, insulin is not indicated for a HbA1c of 8%, unless diet and oral hypoglycemics have failed long-term. Insulin is generally prescribed for a sustained HbA1c of 9% or >. 4. Incorrect: No,This is not the priority over nutritional counseling. More frequent self monitoring will be important once insulin therapy has begun.

A nurse is working in a walk-in clinic where a mother brings in her 6 year old child stating, "My child is just not right." The nurse notes an unusual odor to the child's breath, new onset of bed-wetting, and lethargy. What prescription by the primary healthcare provider should be performed first? 1. Blood glucose 2. Urinalysis for white blood cells (WBC) 3. Oxygen saturation 4. Toxicology screen

1. Correct: Type I diabetes usually has a sudden onset and many times diabetic ketoacidosis (DKA) is the first encounter. The symptoms in the stem: unusual odor to the breath, bed wetting, and lethargy are symptoms of DKA. The blood glucose is one of the most important tests for the diagnosis of DKA. 2. Incorrect: A urinalysis to assess WBC will not support the diagnosis of DKA. 3. Incorrect: In this case, oxygen saturation is not the priority. This child is not in respiratory distress. 4. Incorrect: A toxicology screen will not support a diagnosis of DKA; however, if the blood glucose was not elevated, it could provide further assessment data.

For a client with a major burn, which evaluation criterion identified by the nurse best indicates that fluid resuscitation has been effective during the first 24 hours of care? 1. Urine output of 860 mL / 24 hours. 2. Increase in weight from preburn weight. 3. Heart rate of 122 beats per minute 4. Central venous pressure of 18 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 had a suspicious area of the skin biopsied and sent to the lab for analysis. The client states "I am worried that the pathology report will indicate cancer." Which response would the nurse initiate to assist the client in reducing their anxiety? 1. "You are anxious about the pathology report?" 2. "Would you like me to recommend a movie for you to watch?" 3. "I will notify your daughter that you are concerned about the pathology report." 4. "Have you tried taking long, slow deep breaths and not thinking negative thoughts?"

1. Correct: Utilizing the therapeutic communication technique of restating encourages the client to continue expressing their thoughts and feelings. This correct response by the nurse will also encourage the client to continue verbalizing or clarify their statement if needed. Restating is an effective communication technique to reduce the client's anxiety. 2. Incorrect: The nurse is presenting another option for the client to discuss that is not related to the current conversation. Sometimes distraction, a nontherapeutic communication technique, is used by the nurse to reduce their anxiety which is not client driven communication. The focus of the nurse should be the client. Communication should be client-centered to explore client feelings, identify client preferences, empower the client, provide the client choices, or in some way put emphasis on the client. 3. Incorrect: The nurse is deciding for the client to notify the daughter about the pathology report. The nurse is not demonstrating empathy to the client. The client may feel insignificant, since the nurse wants to talk to her daughter. This will discourage the client to verbalize their feelings. In addition, the nurse must comply by the Health Insurance Portability and Accountability Act (HIPAA). 4. Incorrect: The nurse is giving advice which is a nontherapeutic communication technique. Introducing relaxation techniques such as taking slow deep breaths and clearing the mind of negative thoughts will block the client from expressing their thoughts and feelings. The questions does not identify that the client has negative feelings. The nurse is telling the client how to feel. This is an example of nontherapeutic communication technique of giving advice.

The client was admitted to CCU with a diagnosis of acute coronary syndrome. Continuous cardiac monitoring has been implemented. Which assessment finding is most significant? 1. Ventricular fibrillation 2. Ventricular tachycardia 3. Premature ventricular contractions 4. ST segment depression of 0.5 mm

1. Correct: V-fib is the most common lethal dysrhythmia in the initial period following a myocardial infarction. 2. Incorrect: V-tach is significant as it may occur prior to V-Fib. However, V-fib is most significant. 3. Incorrect: The client will still have a cardiac output in second degree heart block. There is no cardiac output with V-fib. The most lethal is V-fib. 4. Incorrect: Atrial fibrillation involves chaotic contractions of the atria, but there is a cardiac output. It is not life-threatening.

The nurse is working on the inpatient mental health unit and determines that one of the clients has suicidal thoughts. The nurse initiates suicide precautions. Which rationale best validates the action? 1. The client has the right to a safe care environment. 2. The nurse may be sued for malpractice if injury occurs. 3. All clients on mental health units are placed on suicide precautions. 4. Clients are most likely to act on suicidal thoughts when energy is low.

1. Correct: Verbalizing suicidal thoughts is a risk factor for client suicide. Safety must be maintained while the client is in this vulnerable state. The nurse identifies client at risk of suicide and intervenes to prevent harm for those identified as being at risk. 2. Incorrect: Client safety is the primary issue here. 3. Incorrect: This is not a true statement. All clients have the right to a safe environment; however, not all clients on the mental health unit are placed on suicide precautions. Only clients identified at risk for suicide are placed on suicide precautions. 4. Incorrect: This is an untrue statement. Clients are likely to act on suicidal thoughts as energy levels improve. The issue here is client safety, and the client's right to a safe environment.

The nurse routinely screens injury victims for the possibility of intimate partner violence (IPV). Which statement correctly supports the nurse's action? 1. Victims of abuse are likely to report injuries and causes that do not fit the normal profile. 2. IPV is not routinely seen in the upper socioeconomic level. 3. All women should be screened, but men are not routinely screened. 4. Only victims who enter the emergency department alone should be screened for IPV.

1. Correct: Victims of abuse most often report causes of injuries that don't fit with the type of injury observed. For example, a victim may report that a bruised eye came from "running into" a door. The victim may feel the abuse is a personal incident or is afraid of the abuser. 2. Incorrect: Though many IPVs are from low income families IPV occurs across all socioeconomic levels and cultures. All suspected IPV cases should be assessed and reported regardless of their socioeconomic levels and cultures. 3. Incorrect: Men are also victims of IPV, though not as frequently as women. All potential victims should be assessed and reported if needed. 4. Incorrect: Many times the perpetrator will come to the emergency department (ED) with the victim. The victim may be afraid to give an accurate report of the accident with the perpetrator in the ED exam room. If so, more discreet screening is necessary.

Parents of school-aged children are working toward a goal of healthy family TV viewing. Which parental statement indicates adequate understanding of appropriate use of TV in the family? 1. I don't allow my kids to watch violent TV shows. 2. They usually watch the kid shows on the kids' networks. 3. I don't usually worry about the time watching TV on weekends. 4. They can choose one TV show per day without my input.

1. Correct: Violent TV shows are not recommended for school-aged children. They may be disturbing and may desensitize them to violence. 2. Incorrect: Even shows on kids' networks may demonstrate values that are not congruent with the healthy family. Input from the parents is needed here as well.3. Incorrect: TV time should be limited each day to allow time for physical activity, social interaction, and development of hobbies and other skills.4. Incorrect: The child needs the input of the parents. Parents and children may have an agreed upon list of shows that the child may watch.

What assessment data is the priority nursing concern in a client receiving prednisolone for the treatment of nephrotic syndrome? 1. Weight gain of 2 lbs (0.907 kg) in 24 hours 2. Temperature 99.6°F (37.5° C) 3. Blood glucose 116 mg/dL 4. Blood pressure 138/88

1. Correct: Well, if my weight is going up rapidly, it is from fluid not fat. Edema is getting worse, then my kidneys are getting worse. Edema is more significant than an "expected" increase in glucose. I expect the glucose to be elevated. Remember, steroids inhibit insulin, so I expect the glucose to go up with prednisolone. Also, 116 mg/dL (6.44 mmol/L) is not that far from the top of the normal range. 2. Incorrect: Is this an abnormal temp? Not really. 3. Incorrect: The glucose is elevated. What's normal: 70-110 mg/dL (3.9-6.2 mmol/L). Edema is more significant than an "expected" increase in glucose. 4. Incorrect: Hypertension can be a sign of nephrotic syndrome. Remember, the client is retaining fluid. More volume, more pressure. But is this a BP that is worrisome? No

What is the primary electrolyte imbalance that the nurse should monitor for in a client who is receiving an insulin infusion?

1. Hypernatremia 2. Hypokalemia 3. Hypocalcemia 4. hypophosphatemia 2

Magement A nurse on the unit has had a disagreement with the family of a client regarding the client's dressing change. What is the best action by the nurse manager? 1. Meet with the family member and the RN to discuss the disagreement. 2. Assure the family member that the nurse followed the hospital procedure. 3. Discuss the dressing change procedure with the RN and compare to a current textbook. 4. Report the argument to the hospital administrator.

1. Correct: When conflict occurs, meet with both parties together to discuss the problem. Each party can hear what the other is saying and the nurse manager is not caught in the middle. They will be able to come up with solutions together or the manager can mediate.2. Incorrect: It is ok to clarify that the nurse followed hospital procedure. However, the nurse is sing the nontherapeutic communication technique of blocking. The family member may still believe that there is another procedure that could have been initiated. 3. Incorrect: You may want to do this as well, but it will not address the conflict. The conflict is that the family member disagrees with the nurse's procedure for dressing change. 4. Incorrect: The nurse manager must try to resolve the conflict between the family member and the nurse first. If the conflict cannot be resolved the nurse manager would notify the person that is next in the chain of command.

The nurse is caring for a burn client in the emergent phase. The client becomes extremely restless while on a ventilator. What is the priority nursing assessment? 1. Patency of endotracheal tube. 2. Adventitious breath sounds. 3. Fluid in the ventilator tubing. 4. Ventilator settings.

1. Correct: With restlessness, think hypoxia so the nurse should start assessment with airway first. Check for patency of the ET tube. If this is patent, then the other options would be next. 2. Incorrect: This is the next best answer, but hypoxia and airway comes first. 3. Incorrect: This is the third step. Rule out the other two before checking tubing for kinks or obstructions. 4. Incorrect: Start with the client first. Then move toward the ventilator. Always assess the client first.

How should the nurse respond to a pregnant client who asks, "How will I know when it is time to go to the hospital?" 1. "Go to the hospital immediately if your membranes rupture." 2. "You should leave for the hospital as soon as you lose your mucus plug." 3. "Go to the hospital when you have a burst of energy followed by a backache." 4. "You need to go to the hospital when contractions are 2 minutes apart."

1. Correct: Yes! This is the appropriate teaching. A gush or trickle of fluid from the vagina should be evaluated regardless of whether contractions are occurring. Infection and compression of the umbilical cord are possible complications. 2. Incorrect: No. The mucus plug is lost prior to the beginning of active labor, so too early to go to the hospital. Some women lose their mucus plug weeks before labor begins, others lose it right as labor starts. 3. Incorrect: Nesting? That's too early and not specific enough. This is not labor. 4. Incorrect: The client should go when contractions are 5 minutes apart, for 1 hour if it is her first pregnancy. Labor may be faster for the woman who has given birth before than for the nullipara. Multiparas are instructed to go to the hospital when contractions are regular, 10 minutes apart, for 1 hour.

The client with mania has repeatedly interrupted group session with the counselor. The client explains that they already know this information about family roles and paces around the room. What should the nurse do at this time? 1. Ask the client to take a walk with you and make another pot of coffee. 2. Ask the client to reflect on their behavior to determine if it is appropriate. 3. Ask the group to tell the client how they feel when they are interrupted. 4. Tell the client to perform jumping jacks and count out loud.

1. Correct: Yes, get them away from the group and do something purposeful. Purposeful activities help the client use energy and focus on something. Distractibility is the nurse's most effective tool. 2. Incorrect: That is embarrassing and humiliating to the client. Singling out the client during group activity, does not fix the problem. This may lead to arguing and escalate the client's mania. 3. Incorrect: Sometimes this will be helpful during times of therapy, but the client is manic at this time. They may not believe them. Also, the client may be aggressive toward other group members. 4. Incorrect: This is getting them active, but the group will be interrupted by this behavior. Do not let the client continue with this attention seeking behavior. Remove the client from the group activity. The purpose of the group is to work toward a common goal. The client performing jumping jacks is not working toward a common goal.

The schizophrenic client tells the nurse, "I am Jesus, and I am here to save the world!" The client is reading from the Bible and warning others of hell and damnation. The other clients on the unit are upset and several are beginning to cry. What nursing intervention is most appropriate? 1. Set verbal limits and have the client return to assigned 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 to share with the group how the client is Jesus.

1. Correct: Yes, the nurse must set limits. This is disrupting others and so the client needs to be redirected to their room for a cool down and then another activity shortly thereafter. This client is experiencing delusions of grandeur, which are not reality based, and require intervention that does not reinforce the behavior. 2. Incorrect: No, this will only reinforce the clients thought process of religion. 3. Incorrect: No, don't argue with the client. This is not therapeutic and does nothing to help resolve the disruption to the other clients. 4. Incorrect: This is ridiculing the client and also inflaming the situation. This is not desirable.

The nurse is planning care for a preschool child who is being treated in the hospital for respiratory syncytial virus (RSV). What should the nurse recognize as the child's likely view of this illness in order to properly plan care? 1. Punishment 2. Disturbance to body image 3. Rejection from parents 4. Change in routine with friends

1. Correct: Yes, the preschool child views illness as punishment. The preschooler may believe that the illness occurred because of some personal deed or thought or perhaps just because the child touched something or someone. 2. Incorrect: To the adolescent, appearance is crucial. Illness or injury that changes an adolescent's self-perception can have a major impact.3. Incorrect: The adolescent fears rejection and criticism from parents. 4. Incorrect: Friends are important to the school aged child and fear that friends will forget them while they are ill. They fear a change in routine.

What should the nurse monitor for when caring for a client receiving an IV of 1/2 Normal Saline at 100 mL/hr?

1. Hypertension 2. Fluid volume deficit 3. Hypernatremia 4. Pulmonary edema 2

Which client could the telemetry charge nurse safely transfer in order to admit a new client? 1. Twenty-four hour post operative carotid endarterectomy. 2. Unstable angina with onset of atrial fibrillation. 3. Status post coronary artery bypass grafting (CABG) with atrial flutter. 4. Myocardial infarction with a history of heart failure.

1. Correct: Yes, this client is the least critical. The carotid endarterectomy is to open or clean the carotid artery and hopefully prevent a stroke. Since no evidence of complications or being unstable is presented, this client should be able to be cared for on a general nursing unit. 2. Incorrect: Needs a telemetry bed with new onset of atrial fibrillation. The description provided also tells you that the client is experiencing unstable angina. Unstable angina can occur at rest and may develop suddenly, progressively worsening in a short time period. Unstable angina should be treated as an emergency because the client is at increased risk for a myocardial infarction (MI). 3. Incorrect: The client who had a CABG and is experiencing an should be considered unstable and requires further cardiac monitoring. Arrhythmias are common complications after CABG and are major causes of morbidity and longer hospital stays. The client should be carefully assessed for how well the rhythm is being tolerated. Ventricular response to the rapid rate from the atria may be slower and the cardiac output can be reduced. 4. Incorrect: Myocardial infarction and history of heart failure needs telemetry. This client is considered unstable. The client needs to be monitored for arrhythmias, signs of decreased cardiac output and for any signs of recurring infarction.

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

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

The nurse is caring for a client who sustained a head injury with possible seizure activity. The primary healthcare provider prescribes an EEG. Which item on the breakfast tray, delivered prior to the EEG, should the nurse remove from the tray?

1. Eggs 2. Orange juice 3. Bacon 4. Hot tea 4

A client with schizophrenic disorder begins to talk about fantasy material. What would be the most appropriate nursing action?

1. Encourage the client to focus on reality-based issues. 2. Allow the client to continue to talk so as not to interrupt the fantasy. 3. Ask the client to explain the meaning behind what he is saying. 4. Persuade the client that his thoughts are not true. 1

What is indicated when caring for a client admitted with meningitis? 1. The client should be placed in a negative pressure room and health care providers should wear a N95 protective mask when in contact with the client. 2. The client's room door may remain open and health care providers should wear a facemask within 3 to 6 feet of the client. 3. The client should be placed in a private room and no face mask is needed. 4. The only precaution needed is hand hygiene.

1. Incorrect: Meningococcal infections are not spread by small airborne organisms. Meningococcal infection is spread by large particle droplets. 2. Correct: Meningococcal infections are transmitted by large particle droplets. Meningitis can be spread by respiratory and throat secretions or lengthy contact. 3. Incorrect: Meningococcal infections are not spread by contact with a person's skin or contaminated items. Meningococcal infection is spread by large particle droplets. 4. Incorrect: Meningococcal is not spread by contact with a person's skin or contaminated items, but by large particle droplets. Hand hygiene alone is not sufficient to prevent the spread of meningococcal infections.

A nurse notes late decelerations in the fetus of a client who is receiving oxytocin via IV infusion. What nursing interventions should the nurse perform? Select all that apply 1. Administer naloxone. 2. Place client in side-lying position. 3. Stop oxytocin. 4. Increase the rate of IV fluids 5. Notify primary health care provider. 6. Administer oxygen at 8 L/min per face mask.

1. Incorrect: Naloxone is not indicated here. Naloxone reverses the effects of morphine. There is nothing in the stem indicating that the client received a narcotic. 2. Correct: The side-lying position will relieve pressure from the aorta thus getting more oxygen to the fetus. 3. Correct: Stop the oxytocin infusion. During uterine contraction, blood flow through the uterus slows reducing fetal oxygenation. These intense contractions may be the cause of the late decelerations. 4. Correct: Increasing the IV fluid expands the client's blood volume and improves placental perfusion. 5. Correct: The primary healthcare provider should be notified as continued late decelerations may mean the fetus needs to be delivered immediately via C-section. 6. Correct: Administering oxygen to increase the client's blood oxygen saturation will make more oxygen available to the fetus.

A medical-surgical LPN has been sent to a short-staffed pediatric unit. The charge nurse knows what client would be most appropriate for this LPN? 1. 3 month old child with nonorganic failure to thrive. 2. 14 year old with exacerbation of cystic fibrosis. 3. 5 year old newly admitted with epiglottitis. 4. 10 year old with type 1 diabetes mellitus.

1. Incorrect: This client is only 3 months old, which would require specialized skills to evaluate developmental needs. Additionally, nonorganic failure to thrive is a serious situation in which the infant is not getting appropriate nutrition. There could be economic factors, resulting in a lack of food or poor-quality breast milk. Parental beliefs or negligence could also contribute to the situation; therefore, an RN should be assigned to this infant. 2. Incorrect: Although this client is an adolescent, an exacerbation of cystic fibrosis would require careful and frequent respiratory assessments with possible chest physiotherapy. This client would be more appropriate for an RN. 3. Incorrect: A new admission is not appropriate for a nurse sent from the medical surgical unit to the pediatric unit, particularly an LPN, because of the need for initial and frequent assessments. Epiglottitis is a respiratory illness that also impacts the airway. This child should be assigned to an RN.

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 attempts to call them have 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 Glucagon IM and then 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 client returns to the med surg unit after having extra corporal lithotripsy. Which assessment finding by the nurse would be the best indicator that the treatment has been effective?

1. Pain only when urinating 2. Negative urine culture 3. Increased urinary output 4. Sediment in the foley catheter bag 4

The nurse is taking care of a client that has been on TPN for 5 days. Upon entering the room, the nurse observes that the TPN has been turned off. What is the nurse's priority assessment?

1. Patency of the IV site 2. Finger stick blood glucose level 3. Check prescription order 4. Air bubbles in the IV tubing 2

A client is admitted with a hip fracture after falling. Based on these lab values, what is the nurse's priority nursing intervention? Na+ 147 mEq/L (147 mmol/L) Specific gravity 1.030 Hct 55%

1. Provide foods high in iron 2. Increase fluid intake 3. Obtain a urine for culture 4. Measure intake and output 2

A nurse is assigned to care for a client with bipolar disorder in the manic phase. Which behavior by the client would require immediate intervention by the nurse?

1. Talking rapidly, jumping from one subject to another 2. Suggestive, sexual remarks to the staff 3. Aggressive physical activity 4. Telling other clients they own the hospital 3

The nurse is caring for a poorly controlled type 2 diabetic client. Lab results include a BUN of 22mg/dL (7.85 mmol/L) and a creatinine of 1.9 mg/dL (0.67 mmol/L). The nurse checks the client's blood sugar and it is 218mg/dL (12.09 mmol/L). Current medications include metformin and exenatide. What is the priority concern with this client taking metformin?

1. The metformin is not controlling his blood sugar. 2. Metformin can cause GI complaints. 3. Metformin can cause a decrease in appetite. 4. Metformin is contraindicated with an elevated creatinine level. 4

A client who comes to the emergency department (ED) reporting chest pain does not have the ability to pay for care. Which action should the nurse implement first?

1. Transfer the client by ambulance to a charity hospital. 2. Request the client sign a contract agreeing to pay the hospital bill. 3. Notify a family member to provide a deposit for care. 4. Connect client to a heart monitor. 4

A nurse educator is teaching first responders about disaster management, and provided the following scenario: A small community has experienced a severe tornado that hit a shopping mall and caused extreme damage and suspected mass casualties and injuries. First responders arrive on the scene. The nurse educator recognizes education has been successful when the first responders identify which action as 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

A small community has experienced a severe tornado that hit a shopping mall and caused extreme damage and suspected mass casualties and injuries. What should be done first?

The nurse is caring for a client that is 3 days post tonsillectomy and reports a 2 pound (0.91 kg) weight loss, lethargy, and frequent swallowing. What is the nurse's priority assessment?

1. Urinary Output 2. Daily weight 3. Heart rate 4. Breath sounds 3

A client was admitted to CCU with a diagnosis of acute coronary syndrome. Continuous cardiac monitoring has been implemented. Which assessment finding by the nurse is most significant?

1. Ventricular fibrillation 2. Ventricular tachycardia 3. 3rd degree AV block 4. Atrial fibrillation 1. Ventricular tachycardia with a ventricular rate greater than 100 per minute can be a precursor to ventricular fibrillation. This rhythm is the most life threatening and would be of greatest concern.

The nurse's assessment of a client post-op abdominoplasty reveals tachycardia, restlessness and shallow slow breaths. The client was medicated with morphine 2 mg for pain 1 hour ago. The primary healthcare provider prescribes arterial blood gases (ABG). Which ABG report is consistent with this clinical picture?

1. pH 7.30, PaCO2 40, HCO3 29 2. pH 7.33, PaCO2 48, HCO3 25 3. pH 7.47, PaCO2 35, HCO3 29 4. pH 7.50, PaCO2 33, HCO3 22 2

What interventions would be appropriate for the nurse to make for a child who is in Bryant's traction? Select all that apply 1. Perform neurovascular checks every 2 hours. 2. Maintain hip flexion at 90 degrees with buttocks raised 1 inch (2.54 cm) off the bed. 3. Reposition child infrequently so that traction is maintained. 4. Place child prone for one hour daily to prevent contractures. 5. Remove adhesive traction straps daily to prevent skin breakdown. 6. Use wrist restraints to keep child from turning over.

1.& 2. Correct: Both legs are extended in a vertical position in order to maintain hip flexion at 90 degrees. This helps to keep the femur in the hip socket. Because the legs are extended upward the circulation and nerves can be affected. The feet should be assessed for color, pulses, warmth, and sensation every 2-4 hours. 3. Incorrect: The child should be repositioned slightly every 1-2 hours to avoid skin breakdown. 4. Incorrect: The child cannot be placed prone while in Bryant's traction. 5. Incorrect: Traction should not be relieved, which is what would happen if straps are removed. 6. Incorrect: A jacket restraint is used to keep the child from turning over in the bed.

A home care nurse is completing an initial assessment on an elderly client living alone. What normal effects of aging would the nurse expect to find? Select all that apply 1. Loss of skin elasticity 2. Decline in sensory system 3. Decreased enjoyment of intimacy 4. Forgetfulness 5. Desire to remain at home

1., & 2. CORRECT. Normal body aging affects all adults, though certain factors can impact the speed of that process. Sensory organs or systems change very slowly and not drastically, over many decades. Some individuals may never need assistance with vision or hearing, while others will need glasses or hearing-aides very early in adulthood. Additionally, skin cells lose vitality and become less elastic from years of exposure to elements such as the weather, or perhaps a profession that exposes skin to chemicals and heat. There can also be genetic and cultural influences which impact the aging of skin. 3. INCORRECT. Lack of physical or emotional enjoyment with intimacy is not an automatic outcome of the aging process. Most seniors can enjoy an active sex life well into later years if there are no health issues that might cause discomfort. 4. INCORRECT. Forgetfulness is not an expected part of the aging process. Memory can be impacted by a client's physical health, medications, exercise, job, or even heredity. Actually, factors such as stress, isolation and even the living environment may have a greater impact on the brain than the aging process. 5. INCORRECT. There is no research to indicate elderly individuals prefer staying at home rather than participating in outside activities. Occasionally, health issues or difficulty with transportation may interfere with the ability to engage in social gatherings. However, a client who seems to prefer isolation should be evaluated for depression or health problems.

A pediatric nurse is providing anticipatory guidance to a group of parents who have children nearing the age of 1 year old. What milestones should the nurse teach the parents to expect to see in their 1 year old child? Select all that apply 1. Gets to a standing position without help. 2. Puts out arm or leg to help with dressing. 3. Able to say several single words. 4. Pulls toys while walking. 5. Builds a tower of 4 blocks.

1., & 2. Correct: A 1 year old should be able to get to a standing position without help. May stand alone. Can assist in getting dressed by putting out arm or leg. 3. Incorrect: Children at 18 months are able to say several single words. 4. Incorrect: Children at 18 months are able to pull toys while walking. 5. Incorrect: Children at 2 years of age can build a tower of 4 or more blocks.

The night nurse has reported to the day nurse that a client has not had a bowel movement in 2 consecutive days. What actions should the day nurse take? Exhibit Select all that apply 1. Write prescription to initiate "Bowel Protocol" per standing order. 2. Offer client 120 mL prune juice. 3. Give Milk of Magnesia (MOM) 30 mL po. 4. Administer bisacodyl suppository. 5. Provide sodium phosphate enema.

1., & 2. Correct: Look at the standing orders for Bowel Protocol. It states that if the client has not had a bowel movement in 2 consecutive days, the day shift nurse should write an order to initiate bowel protocol per standing order, and then offer 120 mL prune juice to the client. 3. Incorrect: The bowel protocol states to give MOM at 8 pm if there was no bowel movement on the day shift after giving prune juice. 4. Incorrect: The night nurse should give the suppository at 5 AM if there was no bowel movement prior to this time. 5. Incorrect: The day shift nurse on day 2 gives the enema at 11 AM if there has been no bowel movement.

The nurse is participating in a presentation regarding adolescent violence to middle and high school faculty and staff. What risk factors for violence should the nurse include? Select all that apply 1. Attention deficit disorder 2. Diminished economic opportunities 3. Authoritative parenting style 4. Active in school sports 5. High parental involvement

1., & 2. Correct: School learning problems such as attention deficit disorder, low IQ, and poor academic achievement can lead to poor self-esteem, increased stress and risk for becoming a victim or perpetrator of violence. Low socioeconomic status and low job opportunities contribute to a poor community with a high level of poor residents. This a community based risk factor. 3. Incorrect: Authoritarian childrearing parenting style is a family risk factor for becoming a victim or perpetrator of violence. Authoritarian parenting consists of a relationship that is controlling, power-assertive, and high in unidirectional communication. 4. Incorrect: Lack of involvement in conventional school and community activities is a social risk factor for becoming a victim or perpetrator of violence. 5. Incorrect: Low parental involvement in the child's life is a family risk factor risk for becoming a victim or perpetrator of violence.

What information should be included in the health promotion plan for parents regarding the promotion of adequate bowel elimination in their toddler? Select all that apply 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.

A nurse is monitoring a newly hired unlicensed assistive personnel (UAP) perform a bed bath on a client needing total care. Which action by the UAP would require further teaching? Select all that apply 1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus. 3. Makes certain bath water temperature is between 110-115°F (43-46°C). 4. Uses long, firm strokes to wash from wrist to shoulder of each arm. 5. Performs a back massage after completing the bath.

1., & 2. Correct: The nurse needs to intervene in these situations. Both side rails should not be lowered because the client could fall out of the bed. The UAP should lower the side rail closest to themselves and keep the opposite rail up. Wash eyes with water only since soap is very irritating to the eyes. 3. Incorrect: This would be a correct action by the UAP. The nurse does not need to intervene. Temperatures less than 110°F (43°C) can chill the client, and a temperature greater than 115°F (46°C) may be too hot and burn the client. 4. Incorrect: This is a correct action and does not require intervention by the nurse. Firm strokes from distal to proximal areas promote circulation by increasing venous blood return. 5. Incorrect: A back massage is appropriate after a bath and does not require nursing intervention. A back massage is a way of providing relaxation for the client.

Which signs/symptoms should the nurse assess for the presence of in a client diagnosed with valvular heart disease? Select all that apply 1. Orthopnea. 2. Paroxysmal nocturnal dyspnea. 3. Petechiae on the trunk. 4. Increasing CVP with decreasing BP. 5. Pericardial friction rub. 6. Widening pulse pressure.

1., & 2. Correct: These are signs seen with valvular heart disease. Orthopnea is a condition where the client must sit or stand to breathe comfortably. Paroxysmal nocturnal dyspnea occurs when the client is reclining. It is sudden respiratory distress. 3. Incorrect: This is a sign of endocarditis. 4. Incorrect: This is the hallmark sign for cardiac tamponade. 5. Incorrect: This is a sign of pericarditis. 6. Incorrect: This is a sign of increased intracranial pressure.

What should the nurse include in the teaching plan for a client receiving external beam radiation? 1. Small marks will be placed on the skin to mark the treatment area. 2. Lotion may be used around the treatment area to decrease dryness. 3. The radiation therapist can see, hear, and talk with you at all times during treatment. 4. Stay away from babies for 24 hours. 5. You will have to hold your breath during radiation treatment.

1., & 3. Correct: Small ink marks or small tattoos will be placed on the skin to mark the treatment area. Do not remove the marks. The radiation therapist can see, hear, and talk to the client at all times during treatment. Relieve anxiety by letting client know he/she is not alone. 2. Incorrect: Do not put lotion, powder or deodorant near or on treatment area. 4. Incorrect: Client is not radioactive and will not radiate others. The client can safely be around other people, babies, and children. 5. Incorrect: The client will need to stay very still so radiation goes to the exact same place each time, but can breathe as always and does not have to hold breath.

Which interventions should a nurse discuss with a client for primary prevention of skin cancer from exposure to ultraviolet light? Select all that apply 1. Use sunscreen when outdoors. 2. Stay in the shade when outdoors. 3. Wear wide brimmed hats when outdoors. 4. Examine skin every 3 months for changes. 5. Have an annual skin assessment by a dermatologist.

1., 2. & 3. Correct: Using sunscreen, staying in shaded areas, and wearing wide brimmed hats are effective interventions to prevent skin cancer. 4. Incorrect: Examine your whole body monthly for possible changes that may be precancerous or cancerous lesions. Early detection is considered secondary prevention. 5. Incorrect: Assessment by a dermatologist is not a primary prevention strategy. Early diagnosis is considered secondary prevention.

What should the nurse include in the teaching plan for a client receiving external beam radiation? Select all that apply 1. Small marks will be placed on the skin to mark the treatment area. 2. Lotion may be used around the treatment area to decrease dryness. 3. The radiation therapist can see, hear, and talk with you at all times during treatment. 4. Stay away from babies for 24 hours. 5. You will have to hold your breath during radiation treatment.

1., & 3. Correct: Small ink marks or small tattoos will be placed on the skin to mark the treatment area. Do not remove the marks. The radiation therapist can see, hear, and talk to the client at all times during treatment. Relieve anxiety by letting client know he/she is not alone. 2. Incorrect: The client should avoid the use of potential irritants (perfume, powders or cosmetics) on the skin in the treatment field. 4. Incorrect: The client receiving external beam radiation is not radioactive and will not radiate others. The client can safely be around other people, babies, and children. Clients who are undergoing brachytherapy or receiving radio pharmaceuticals require that you be aware that the client is emitting radioactivity. 5. Incorrect: The client will need to stay very still so radiation goes to the exact same place each time but can breathe as always. The client does not have to hold breath.

A client has been receiving 5-fluorouracil treatments for colon cancer and is admitted with weakness, fatigue, thrombocytopenia and low grade fever. Which actions would be appropriate for this client? Select all that apply 1. Dedicated supplies in room 2. Semi-private room 3. Liquid diet 4. Limit visitors 5. Nasogastric tube placement

1., & 4. Correct. This client is at risk for infection and bleeding. Keeping dedicated supplies in room will decrease the risk of infection. Limiting visitors will decrease risk of infection. 2. Incorrect. This client needs a private room because the client is immunocompromised. 3. Incorrect. Unless contraindicated, the client would be prescribed a high-calorie, high-protein diet. 5. Incorrect: To minimize the risk of bleeding, restrict the placement of nasogastric tubes, rectal tubes, and suctioning equipment.

The nurse enters the client's room and finds the client having a seizure on the floor. Which nursing interventions should the nurse implement? Select all that apply 1. Loosen tight shirt or jacket. 2. Move the client to the couch. 3. Place a pillow under the head. 4. Position the head tilted forward. 5. Insert a wash cloth between the teeth.

1., & 4. Correct: Client safety should be the priority action. The tight clothing should be loosened to reduce the potential of the clothing obstructing the airway. During a seizure, the head is tilted forward to allow the tongue to advance forward. This will assist in the drainage of saliva and mucus. 2. Incorrect: If the nurse tries to move the client during a seizure to the couch, there is the possibility that both the nurse and client could be injured. The client is safer on the floor than trying to move the client. 3. Incorrect: During a seizure, the head should not be placed on a pillow. The pillow may cause the client's airway to become occluded, and an increase of saliva and mucus in the mouth may not drain properly. 5. Incorrect: The nurse should not open the mouth of the client during a seizure. This action may result in injury to the client's teeth and/or jaws. The muscles in the jaws may spasm which will seal the mouth tight.

The charge nurse is observing a new nurse administer cortisporin otic to the left ear of a 2 year old child. What action by the new nurse would indicate that the charge nurse needs to intervene? Select all that apply 1. Position the client prone, with affected ear up. 2. Pull pinna down and back. 3. Administers medication at room temperature. 4. Allow child to sit up once medication is instilled. 5. Educate parents that the medication may burn when instilled.

1., & 4. Correct: The charge nurse needs to intervene if the new nurse does not position the client supine, with affected ear up. The child may lie in a parents lap to decrease anxiety and increase cooperation. The child should remain supine for 5 minutes after medication is instilled to assure medication remains in ear canal. Remaining supine for several minutes permits to fluid to be absorbed and not drain back out of the ear canal. 2. Incorrect: The charge nurse does not need to intervene if the new nurse pulls the pinna down and back. For children 3 years of age and younger, pull pinna down and back. For adults, pull pinna up and back for medication administration or otoscopic exam. 3. Incorrect: The charge nurse does not need to intervene if the new nurse administers the medication at room temperature. It should not be placed in the ear cold as it can cause nausea/vomiting and dizziness. 5. Incorrect: The charge nurse does not need to intervene if the new nurse teaches the parents that generally mild adverse reactions include ear irritation, local stinging or burning, and/or dizziness.

A client with cancer refuses treatment and asks about options for hospice home care. The client's daughter asks the case manager to talk the client into agreeing to cancer treatment. The nurse explains to the daughter that this violates which client right? Select all that apply 1. To self-determination 2. To decline participation in research studies and experimental treatments 3. To expect reasonable continuity of care 4. To make decisions about the plan of care 5. To advocacy

1., & 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. 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. 5. 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.

When disposing of waste in a client's room, the nurse would place which item(s) in a biohazard red bag? Select all that apply 1. Chest drainage unit 2. Doxorubicin IV bag and tubing 3. Staples removed from an abdominal incision 4. Tramadol 50 mg tablet prescribed but refused by client 5. Soiled dressing 6. Paper trash with identifying client information

1., & 5. CORRECT. Chest drainage units should be capped and placed in a large red biohazard bag for disposal. Dressings soiled with human waste, blood or body fluids should be disposed of in a red biohazard bag. 2. INCORRECT. Doxorubicin is an intravenous antineoplastic chemotherapy agent. IV bags and tubing used to administer chemotherapy medications should be disposed of intact and placed in a yellow or purple chemotherapy waste container with a lid. 3. INCORRECT. Client staples are considered a "sharp" and should be disposed of in a red biohazard sharps container. 4. INCORRECT. Tramadol is a non-hazardous waste medication, but it is also a Schedule IV narcotic. Narcotics should be disposed of in an irretrievable medicinal waste container or sharps container according to hospital policy. No matter the type of container used, for narcotics, it should be irretrievable. 6. INCORRECT. Paper trash containing client information should be disposed of in a manner that it is no longer readable, cannot be reconstructed and cannot be retrieved.

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

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

The nurse is sharing best practice for preventing pressure injuries in clients. What should the nurse include? Select all that apply 1. Use moisturizer daily on dry skin. 2. Massage reddened skin areas. 3. Prevent shearing by maintaining the head of bed at 45 degrees or higher. 4. Place rubber ring (donut) under client's sacral area. 5. Position client at 30 degree tilt when placed on side.

1., & 5. Correct: Moist skin is more pliable than dry skin, so keep dry skin moist by applying moisturizer daily. A good plan for positioning is the 30 degree rule. This plan ensures that the client is positioned and propped so that whatever part of the body is elevated is tilted back to no more than a 30 degree angle to the mattress rather than resting directly on a dependent body prominence. This rule applies to side lying and head of bed elevation positions. 2. Incorrect: Do not massage reddened skin areas. This can damage capillary beds and increase tissue necrosis. 3. Incorrect: Do not keep the head of bed elevated above 30 degrees to prevent shearing. If the client requires greater head elevation because of respiratory problems, they should be tilted up above 30 degrees with pillows behind the back to keep pressure off the sacral/coccyx area. 4. Incorrect: Do not place rubber ring (donut) under client's sacral area. This can cause pressure to the area and can damage capillary beds and increase tissue necrosis. There are products that redistribute tissue load, such as specialty bed mattresses and seat cushions.

The nurse is teaching a group of parents how to promote healthy teeth in their newborn. What should the nurse include? Select all that apply 1. Clean gums with a damp washcloth after feedings. 2. Use a firm-bristled toothbrush once teeth have erupted. 3. Beginning at birth use toothpaste the size of a pea. 4. Allow only milk bottles in bed. 5. Wean from bottle by 15 months.

1., & 5. Correct: Wiping milk or juice from the gums, decreases the amount of time that the gums are exposed to the high sugar content of these meals. Weaning from the bottle at age 12-15 months may help prevent dental caries. 2. Incorrect: Use a soft-bristled toothbrush once teeth have erupted. 3. Incorrect: Toothpaste is unnecessary in infancy. At age 2, begin brushing with a pea-sized amount (small smear) of fluoridated toothpaste. 4. Incorrect: Infants should not be allowed to take milk or juice bottles to bed, as the high sugar content of the fluid in contact with the teeth all night leads to dental caries.

How should the nurse interpret this blood gas report? pH - 7.33 PaO2 - 95% PaCO2 - 28 HCO3 - 18 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

1., & 6. Correct: This set of ABGs reflects partially compensated metabolic acidosis. The pH, bicarb, and carbon dioxide are all abnormal, so compensation is beginning. Since the pH is not normal yet, total compensation has not occurred. There is only partial compensation. 2. Incorrect: The pH remains low (acidic) so acidosis rather than alkalosis is occurring. 3. Incorrect: This set of ABGs reflects partially compensated metabolic acidosis. The pH, bicarb, and carbon dioxide are all abnormal, so compensation is beginning. Since the pH is not normal yet, total compensation has occurred. The pH and bicarb match indicating a metabolic problem initially. The lungs are attempting to compensate by blowing off CO2. 4. Incorrect: This set of ABGs reflects partially compensated metabolic acidosis. The original problem is not a lung problem, but a metabolic problem.

The homecare nurse is instructing the family of a client recently diagnosed with Parkinson's disease about potential neurologic changes. During the discussion, what signs should the nurse include? Select all that apply 1. Unsteady gait 2. Muscle rigidity 3. Hyperactive reflexes 4. Bradykinesia (slowed movements) 5. Expressive aphasia

1., 2 & 4. Correct: Parkinson's disease is a debilitating, progressive neurological disorder of unknown cause. The most classic symptoms include unsteady gait secondary to increasing muscle rigidity and bradykinesia, plus difficulty with purposeful movement. These symptoms worsen over time and are often accompanied by tremors in the extremities at rest. 3. Incorrect: Reflexes in clients with Parkinson's disease become progressively slowed, not hyperactive. Because this disorder affects the midbrain, and ultimately the connection of the basal ganglia, deep tendon reflexes decrease over the course of the disease. Hyperactive reflexes are associated with other neurologic disorders such as multiple sclerosis. 5. Incorrect: Expressive aphasia is associated with brain trauma or cerebral vascular accident (CVA) and prevents the client from verbalizing appropriate or desired terminology. In Parkinson's disease, the client's speech volume becomes too low and very monotone. Also, because of facial muscle rigidity, there is great difficulty articulating words enough to be clearly understood.

A nurse is completing a nursing history on a client admitted with peripheral vascular disease (PVD). Which data from the nursing history should the nurse identify as contributing to this diagnosis? Select all that apply 1. Family history of hyperlipidemia 2. Postmenopausal 3. BMI of 24 4. Swims three times a week 5. Leg pain when walking

1., 2 & 5. Correct: A family history of hyperlipidemia, hypertension, or PVD increases the risk of a client developing PVD as well. Men over age 50 and postmenopausal women are at increased risk. A decline in the natural hormone estrogen may be a factor in heart disease increase among post-menopausal women. Estrogen is believed to have a positive effect on the inner layer of artery wall, helping to keep blood vessels flexible. Developing PVD risk also increases if the client has hyperlipidemia, cerebrovascular disease, heart disease, diabetes, hypertension, and/or renal failure. Leg pain with activity such as walking is a sign of PVD increases risk. 3. Incorrect: Overweight clients are at increased risk for PVD. A BMI of 24 means the client is of normal weight for height. Body mass index (BMI) is a measure of body fat based on height and weight that applies to adult men and women. Underweight = <18.5; Normal weight = 18.5-24.9; Overweight = 25-29.9; Obesity = BMI of 30 or greater. 4. Incorrect: Swimming three times per week is good exercise for the client. Sedentary life style increases the risk for development of PVD.

The nurse is teaching a community education course regarding complementary and/or alternative therapies. Which therapies would the nurse include in the course as complementary and/or alternative therapies? Select all that apply 1. Acupuncture 2. Yoga 3. Tai chi 4. Reiki 5. Zumba

1., 2, 3, & 4. Correct: All are considered complementary and/or alternative therapies. Acupuncture involves stimulating specific points on the body. This is most often done by inserting thin needles through the skin, to cause a change in the physical functions of the body. Research has shown that acupuncture reduces nausea and vomiting after surgery and chemotherapy. It can also relieve pain. The practice of yoga makes the body strong and flexible, and improves the functioning of the respiratory, circulatory, digestive, and hormonal systems. Yoga brings about emotional stability and clarity of mind. Tai chi is an ancient Chinese discipline involving a continuous series of controlled usually slow movements designed to improve physical and mental well-being. Reiki is a healing technique based on the principle that the therapist can channel energy into the client by means of touch, to activate the natural healing processes of the body and restore physical and emotional well-being. 5. Incorrect: Zumba is a type of dance exercise and is not considered a form of alternative therapy.

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

3. Correct: We want to position for comfort with the knees flexed and on the side for airway.1. Incorrect: Avoided to prevent pooling and edema in pelvis2. Incorrect: Partial lying on stomach is going to be painful4. Incorrect: Stretching out straight puts pressure on the abdomen and should be avoided

The nurse is working with a group of elderly clients to promote better nutrition. Prior to developing the health promotion plan, the nurse assesses individual members of the group. Which assessment findings are expected as the nurse works with this group? Select all that apply 1. Some clients may have dental issues, making chewing difficult. 2. There may be a decreased appetite in clients. 3. Caloric and nutritional needs may vary somewhat depending on activity levels. 4. Access to fresh foods is adequate. 5. The desire and interest in cooking is increased.

1., 2. & 3. Correct: Many elderly people have dental issues that affect chewing and intake of nutritionally dense foods. Appetite may decrease due to changes in taste, medications, depression or isolation. Many elderly people are active; therefore, it is important to assess each one individually in regard to activity levels. 4. Incorrect: Many elderly clients may not have access to fresh foods due to infrequent grocery shopping, limited budgets, and a desire to not waste good food.5. Incorrect: Many elderly do not have a desire to cook for one or two. Pain and physical impairment may also decrease desire or interest in cooking.

A nurse is planning to educate diabetic clients on how to decrease their risk for developing renal failure. What educational points should the nurse include? Select all that apply 1. Avoid daily use of non-steroidal antiinflammatory medications. 2. Aggressive blood pressure management is necessary. 3. Aim to keep Glycosylated Hemoglobin (HgbA1c) less than 7%. 4. Have estimated glomerular filtration rate measured every five years. 5. Increase protein intake to 30% of total calories eaten per day.

1., 2. & 3. Correct: NSAIDs can damage the kidneys with chronic use. Risk factors for diabetic related renal complications include hypertension and hyperglycemia; therefore, management of blood pressure and blood glucose is necessary. The ADA treatment goal for HgbA1c is < 7%. 4. Incorrect: The estimated glomerular filtration rate (eGFR) should be assessed at least yearly if not more frequently. 5. Incorrect: A diabetic client's diet should consist of no more than 15-20% caloric intake of protein because protein makes the kidneys work harder.

Which signs and symptoms would indicate to the nurse that the client is having an anaphylactic response after receiving penicillin? 1. Reports a scratchy throat 2. Faint expiratory wheeze on auscultation. 3. Client statement, "I feel like something is wrong." 4. Bounding radial pulse rate of 100/min 5. BP 100/70

1., 2. & 3. Correct: Swelling of face, mouth, throat, and a scratchy throat are indicative of an inflammatory response that could obstruct the airway. Wheezes and stridor are indicators of breathing difficulties seen with anaphylactic reaction. A sense that something bad is happening should serve as a warning that something bad is really going on. Suspect anaphylactic response.4. Incorrect: The pulse rate would be increased, but the client would have a thready, weak pulse, not bounding. The pulse may also be irregular. 5. Incorrect: This blood pressure is not below 90 systolic which could indicate shock. Although on the low side, simply getting this BP reading does not tell you if perfusion is adequate. Once blood pressure decreases, other symptoms may appear such as dizziness, blurred vision and loss of bladder/bowel control.

Which assessment finding would the nurse expect in a client diagnosed with Paget's disease? Select all that apply 1. Severe back pain 2. Walking with a limp 3. Upper extremity grip weakness 4. A shuffled gait 5. Bow legged

1., 2. & 5. Correct: Paget's disease is a chronic skeletal bone disorder in which there is excessive bone resorption followed by the marrow being replaced by fibrous connective tissue. The new bone is larger, disorganized, and weak. These clients have severe pain, may walk with a limp, and may become bow legged. 3. Incorrect: Muscle weakness is not a symptom. 4. Incorrect: This is a manifestation of Parkinson's disease which is related to brain and nerve signals. It is not related to Paget's disease.

A client who has been trying to lose weight reports to the nurse that it is just easier to stop by the fast food restaurant on the way home from work than to go home and prepare a meal. Which interventions could help the client stay on track? Select all that apply 1. Suggest that the client eat yogurt and a piece of fruit upon returning home. 2. Suggest that the client order low fat options at the restaurants. 3. Encourage the client to pack a healthy snack to eat on the way home from work. 4. Inform the client that fast food restaurants do not have healthy food options. 5. Suggest that the client alter her route home from work in the evenings to avoid the fast food restaurants.

1., 2. & 3. Correct: The client is describing lack of convenience, a barrier to making better choices. The client can consume yogurt and fruit on the way home and still be making a good choice for dinner. Accessibility of healthier items will help the client stay on track. Availability of healthy foods will help the client stay on her food plan. 4. Incorrect: There are healthier choices currently at most fast food restaurants. Clients should be encouraged to choose from those.5. Incorrect: While this may help the client stay on track, it may make a healthy choice inaccessible. The client is more likely to make healthy choices when they are accessible, available, and affordable.

The nurse manager is planning a leadership development workshop for new charge nurses. Which components of the communication cycle should the manager include as necessary for effective verbal communication? Select all that apply 1. There is a sender for every message. 2. A clear message is formulated. 3. There is a receiver for every message. 4. The sender and receiver share the same life experiences. 5. There can be incongruence between the verbal and nonverbal message.

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

A 37 week pregnant woman presents to triage with reports of a headache and begins to have a seizure. What actions should the nurse take? Select all that apply 1. Place the client's head in the nurse's lap. 2. Administer oxygen. 3. Monitor tonic-clonic activity. 4. Place an oral airway into the client's mouth. 5. Administer diazepam.

1., 2. & 3. Correct: This client in triage experiencing a seizure should be gently lowered to the floor, with her head protected. Oxygen is needed to ensure supply of oxygen to mom and fetus. Seizure activity should be monitored for tonic and clonic phases of seizure, timing, and body part affected. 4. Incorrect: Never place an object in a client's mouth who is experiencing a seizure. 5. Incorrect: Magnesium sulfate is administered to control BP and decrease seizures. Magnesium sulfate leads to fewer maternal deaths and fewer future seizures when given for eclamptic seizures. Diazepam is contraindicated for use in pregnancy.

The client reports having trouble sleeping at night. "My mind is constantly working, and I can't fall asleep until 2:00 or 3:00 a.m."Which behaviors found in the assessment are likely to contribute to sleep difficulty? Select all that apply 1. Performs office work before going to bed. 2. Watches night-time drama shows on TV. 3. Drinks caffeine after dinner each evening. 4. Reads for pleasure before going to bed. 5. Exercises 45 minutes at 5 pm each evening.

1., 2. & 3. Correct: Working on job-related tasks before bedtime may increase anxiety and contribute to difficulty sleeping. Suspenseful night-time drama TV shows may be too stimulating prior to going to bed. Caffeine following dinner may interfere with sleep.4. Incorrect: Quiet reading is likely to ease the transition from wakefulness to sleep and may be an important intervention to promote sleep.5. Incorrect: Exercising early in the evening may be an effective intervention. If exercise is performed prior to going to bed, it may interfere with falling asleep.

The nurse is planning an educational seminar on ophthalmic health. Which risk factors for cataract formation should be included in the discussion? Select all that apply 1. Diabetes mellitus. 2. Cigarette smoking. 3. Family history of glaucoma. 4. Long-term use of corticosteroids. 5. Thin cornea.

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

The nurse has been teaching the parents of a child taking methylphenidate for the treatment of attention deficit hyperactivity disorder (ADHD). Which comments by the parents indicate adequate understanding of the important considerations for methylphenidate? 1. "I know that I need to monitor weight." 2. "I am supposed to call if my child has decreased attentiveness." 3. "This medication may cause increased drowsiness." 4. "I know that I need to monitor my childs height." 5. "If my child can't sleep, the dosage may need to be increased."

1., 2. & 4. Correct: Continued use of the medication may cause delays in growth and loss of appetite. Lack of appetite may cause weight loss. This drug may affect child's growth rate. The child's attentiveness should increase with this medication and if there is no improvement in attentiveness with this medication then notify the primary healthcare provider. 3. Incorrect: The medication is more likely to cause insomnia especially if administered late in the day. If this medication can cause insomnia. 5. Incorrect: If the client cannot sleep, it is likely that the afternoon dose will be decreased or omitted.

A 3-year-old child refuses to take a prescribed medication. Which statements by the mother, regarding the child's refusal, indicate to the nurse that parental education is needed? Select all that apply 1. "My child is trying to make me angry". 2. "I feel like such a bad mother when my child acts this way". 3. "I promise my child a reward for taking medicine". 4. "I am unfazed by my child's actions". 5. "My child doesn't have to take medicine if he doesn't want to".

1., 2. & 5. Correct: If the mother feels the child is trying to "make her angry" she may respond with inappropriate discipline. The nurse can help the mother understand that developing independence is one of the developmental tasks of a child this age, and that the movement toward independence reflects good, not bad, parenting. The child must take the prescribed medicine in order to get well. 3. Incorrect: Rewarding the client for taking medication is not contraindicated.4. Incorrect: Being "unfazed" by the child's actions does not reflect bad parenting.

A home health nurse is interpreting Mantoux skin test results of clients who received the test 48 hours ago. Which clients have a positive tuberculin skin test reaction? Select all that apply 1. HIV+ client with an induration of 6 millimeters. 2. Client who immigrated from Haiti 6 months ago who has an induration of 10 millimeters. 3. Client working at a nursing home with an induration of 8 millimeters. 4. 3 year old client with an induration of 12 millimeters. 5. Healthy client with no known TB exposure who has an induration of 5 millimeters.

1., 2. & 4. Correct: HIV infected clients are considered to have a (+) TB skin test with an induration of 5 millimeters or more. An induration of 10 millimeters or more is considered positive in recent immigrants (less than five years) from high-prevalence countries such as Haiti, and in children less than 4 years of age. 3. Incorrect: An induration of 10 millimeters or more is considered positive for residents and employees of high-risk congregate settings. 5. Incorrect: An induration of 15 millimeters or more is considered positive in any person with no known risk factors for TB.

Which interventions should be included in the nutritional teaching plan to accomplish the goal of a diet lower in fat? 1. Use 2% milk instead of whole milk. 2. Eat air-popped popcorn instead of potato chips. 3. Eat more red meat instead of fish. 4. Incorporate plant sources of protein. 5. Use olive oil instead of vegetable oil when frying.

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

Which interventions should be included in the nutritional teaching plan to accomplish the goal of a diet lower in fat? Select all that apply 1. Use 2% milk instead of whole milk. 2. Eat air-popped popcorn instead of potato chips. 3. Eat more red meat instead of fish. 4. Incorporate plant sources of protein. 5. Use olive oil instead of vegetable oil when frying.

What physical changes should the nurse discuss with a client who is entering menopause? Select all that apply 1. Loss of bone density 2. Loss of muscle mass 3. Improved skin elasticity 4. A reduction in waist size 5. Increased fat tissue

1., 2. & 5. Correct: Changes associated with menopause, with its dramatic decline in estrogen, include loss of muscle mass, increased fat tissue leading to thicker waist, dryness of the skin and vagina, hot flashes, sleep abnormalities, and mood changes. 3. Incorrect: A decrease in turgor and elasticity may occur as we grow older. Skin becomes dry and thin and collagen levels decrease after menopause. 4. Incorrect: There is increased abdominal fat. The waist size swells relative to hips after menopause.

A 3-year-old child refuses to take a prescribed medication. Which statements by the mother, regarding the child's refusal, indicate to the nurse that parental education is needed? 1. "My child is trying to make me angry". 2. "I feel like such a bad mother when my child acts this way". 3. "I promise my child a reward for taking medicine". 4. "I am unfazed by my child's actions". 5. "My child doesn't have to take medicine if he doesn't want to".

A client in labor is placed on an external fetal monitor. Which interventions should the nurse perform if a late fetal heart rate deceleration occurs? Select all that apply 1. Turn the client to the left side. 2. Administer oxygen. 3. Start an intravenous line. 4. Prep the mother for cesarian section. 5. Notify the primary healthcare provider.

1., 2. & 5. Correct: Late fetal heart rate decelerations are associated with fetal hypoxia and acidosis. Positioning the mother on her left side prevents compression of the vena cava. Oxygen administration increases maternal, then fetal blood level, thus treating current and preventing further development of hypoxia and acidosis. Failure to recognize fetal monitoring strip abnormalities and failure to report abnormalities to the primary healthcare provider are deviations from the standard of care. 3. Incorrect: Intravenous line would already be in place. This will not help the fetus 4. Incorrect: Prepping the client for caesarian section is premature.

The nurse is developing a teaching plan covering emergency responses to smallpox. This presentation will be used with newly hired hospital employees. What information is essential for the presentation? Select all that apply 1. People may be exposed to smallpox but not get the disease. 2. People may contract the disease by handling contaminated clothing or bedding. 3. Smallpox is fatal is about 50% of cases. 4. Smallpox victims are contagious for two weeks. 5. Smallpox victims are isolated from others.

1., 2. & 5. Correct: Not everyone who is exposed will develop the disease. Handling contaminated bedding or clothing is one way to contract the illness. If a person comes in contact with the wound discharge, infection may occur. Persons must be isolated for approximately 18 days after an exposure, and persons with smallpox should be isolated until the last scab falls off.3. Incorrect: Smallpox is fatal in 10 - 30% of victims.4. Incorrect: Smallpox is considered contagious until the last scab falls off. There is no specific time frame to determine this and is different for each individual.

A client is seen in an outpatient clinic for anxiety after losing the family home in a hurricane. What nursing interventions would be appropriate for the nurse to make? Select all that apply 1. Teach the client how to use progressive muscle relaxation. 2. Assist the client in correcting any distortion being experienced. 3. Suggest that the client might recover faster by moving away from the coastal area. 4. Refer the client to the family primary healthcare provider for a complete physical examination. 5. Allow the client time to talk about the loss.

1., 2. & 5. Correct: The correct answers are appropriate interactions for this client and will help the client with anxiety reduction. Allowing the client time to talk shows them that someone cares. Muscle relaxation helps relax the client. Helping the client see the situation accurately helps decrease a distorted view of the experience. When a person is feeling anxious or stressed, these strategies can help him or her cope: Practice yoga, listen to music, meditate, get a massage, or learn relaxation techniques. Stepping back from the problem helps clear your head. Eat well-balanced meals. Do not skip any meals. Do keep healthful, energy-boosting snacks on hand. Limit alcohol and caffeine, which can aggravate anxiety and trigger panic attacks. Get enough sleep. When stressed, your body needs additional sleep and rest. Exercise daily to help you feel good and maintain your health. Check out the fitness tips below. Take deep breaths. Inhale and exhale slowly. Talk to someone. Tell friends and family you're feeling overwhelmed, and let them know how they can help you. Talk to a physician or therapist for professional help. 3. Incorrect: This does not address the anxiety related to this crisis. Additionally, the nurse is trying to solve the client's problem through relocation, which may not be the client's desire. 4. Incorrect: This refers the client to someone else and does not address the problem. This may make the client feel as though their anxiety is not important.

In caring for a client exposed to radiation, the nurse knows that the type of damage due to radiation exposure depends on which factors? Select all that apply 1. Dose rate. 2. Organs exposed. 3. Type of tumor being treated. 4. Presence of metastatic disease. 5. Type of radiation.

1., 2. & 5. Correct: The extent of damage due to radiation exposure depends on the quantity of radiation delivered to the body, the dose rate, the organs exposed, the type of radiation, the duration of exposure, and the energy transfer from the radioactive wave or particle to the exposed tissue. 3. Incorrect: The type of tumor being treated is important to know, but this will not affect the type of damage the client receives from the radiation. 4. Incorrect: The client may be receiving radiation therapy for palliative treatment. Damage to the client due to the radiation exposure will not increase or decrease due to the metastatic disease.

A client's central venous pressure (CVP) reading has changed significantly from the last hourly reading. Which data would the nurse assess that reflect changes in the CVP reading? Select all that apply 1. Heart sounds 2. Skin turgor 3. Temperature 4. Nail bed color 5. EKG rhythm 6. Urinary output

1., 2. & 6. Correct: The CVP reading reflects the client's fluid volume status. If the CVP is elevated, indicating FVE, then the nurse is likely to hear S3 sounds when auscultating the heart sounds. The client's skin turgor and urine output would reflect the client's fluid volume status. 3. Incorrect: The CVP reading reflects the client's fluid volume status. The client's temperature would not reflect the client's fluid volume status. 4. Incorrect: The CVP reading reflects the client's fluid volume status. The nail bed color would not reflect the client's fluid volume status. 5. Incorrect: The CVP reading reflects the client's fluid volume status. The EKG rhythm would not reflect the client's fluid volume status.

The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (VTE). What interventions should the nurse initiate? Select all that apply 1. Measure the calf and thigh daily. 2. Apply sequential compression device to legs. 3. Position paralyzed leg with each distal joint higher than the proximal joint. 4. Place a trochanter roll at the hip. 5. Perform passive range of motion exercises once daily. 6. Monitor for pain by assessing Homan's sign.

1., 2., & 3. Correct: Assessment for VTEs is accomplished by measuring the calf and thigh daily, observing swelling, noting unusual warmth of the leg, and asking the client about pain in the calf. Prevention of VTEs include the use of sequential compression devices for bedridden clients. This device helps promote venous return. Positioning the paralyzed leg with each distal joint higher than the proximal joint will prevent dependent edema. 4. Incorrect: A trochanter roll does not prevent VTEs. They are used for the prevention of external hip rotation. 5. Incorrect: Passive range of motion exercises should be done several times a day to promote venous return and muscle tone. Once a day is not adequate. 6. Incorrect: Routinely checking the Homan's sign can actually cause a clot to dislodge. The nurse should not perform this procedure.

What should the nurse include about transmission of the chickenpox virus while teaching a group of parents about the importance of vaccination? Select all that apply 1. Direct contact 2. Indirect contact 3. Airborne 4. Droplet 5. Common vehicle

1., 2., & 3. Correct: Chickenpox is transmitted from person to person by directly touching the blisters, saliva or mucus of an infected person (Direct contact). Chickenpox can be spread indirectly by touching contaminated items freshly soiled, such as clothing, from an infected person (Indirect contact). The virus can also be transmitted through the air by coughing and sneezing (Airborne). Airbone transmission of infectious agents occurs either by: Airborne droplet nuclei (small particles of 5 mm or smaller in size); Dust particles containing infectious agents. Microoganisms carried in this manner remain suspended in the air for long periods of time and can be dispersed widely by air currents. Because of this, there is risk that all the air in a room may be contaminated. Some examples of microorganisms that are transmitted by the airborne route are: M. tuberculosis, rubeola, varicella, and hantaviruses. 4. Incorrect: Transmission occurs when droplets containing microorganisms generated during coughing, sneezing and talking are propelled through the air. However, these infected droplets may linger on surfaces for long periods of time, so these surfaces (within the range of the coughing/sneezing person) will need additional cleaning. 5. Incorrect: Applies to microorganisms that are transmitted by contaminated items such as food, water, medications, medical devices, and equipment.

What signs/symptoms would the nurse expect to assess in a client diagnosed with exocrine pancreatic cancer? Select all that apply 1. Dark tea colored urine 2. Clay colored stools 3. Jaundice 4. Coffee ground emesis 5. Lower abdominal pain

1., 2., & 3. Correct: Diseases of the head of the pancreas such as pancreatic cancer can lead to darkening of the urine, clay colored stools, and jaundice. All are the result of bile duct blockage. 4. Incorrect: Coffee ground emesis is a symptom of an ulcer that is bleeding. 5. Incorrect: Pain in the upper abdomen that radiates to your back is seen with pancreatic cancer. Lower abdominal pain can be associated with diseases such as diverticulitis.

What potential contributing factors for stress urinary incontinence should a nurse assess for in an elderly female client? Select all that apply 1. Lack of estrogen 2. Rising abdominal pressure 3. Multiparous vaginal births 4. Spinal cord injury 5. Dementia

1., 2., & 3. Correct: During pregnancy and childbirth, the sphincter and pelvic muscles stretch out and are weakened. Increased age, decreased estrogen, and a history of multiple vaginal births/pregnancies are contributing factors for stress incontinence. 4. Incorrect: Spinal cord injury results in urge incontinence because of damage to the nerves of the bladder. Urge incontinence means there is a sudden, involuntary contraction of the muscle wall. 5. Incorrect: With functional incontinence the person knows there is a need to urinate but cannot make it to the restroom. The dementia client cannot make the conscious decision or carry out the task of ambulating to the restroom.

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

1., 2., 4., 5., & 6. Correct: A clear liquid diet is made up of only clear fluids and foods that are clear fluids when they are at room temperature. These choices are considered to be clear liquids. 3. Incorrect. This is considered appropriate for a full liquid diet.

A nurse plans to educate a group of new parents about how to prevent burn injuries in children. What should the nurse include? Select all that apply 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.

A nurse from the maternity unit is pulled to the medical-surgical unit for the first four hours of the shift. Which clients would be appropriate for the charge nurse to assign to the nurse from the maternity unit? Select all that apply 1. Client with rheumatic fever 2. Client scheduled for an appendectomy 3. Client one day post cardiac catheterization 4. Client diagnosed with Methicillin-Resistant Staphylococcus Aureus 5. Client newly admitted with Guillian-Barre Syndrome

1., 2., & 3. Correct: Rheumatic fever is an inflammatory disease that can develop later as a complication of untreated or inadequately treated Group A beta hemolytic strep infections such as strep throat and scarlet fever. It is not contagious at this point, so the maternity nurse could be assigned to this client. The maternity nurse should have the knowledge and skill needed to provide preop care to a client scheduled for a routine appendectomy.This nurse routinely cares for preop surgical clients on the maternity unit. Since the client who had a cardiac catheterization is one day post procedure, the client is stable and could be appropriately assigned to the maternity nurse if needed. 4. Incorrect: This client is contagious and should not be delegated to the maternity nurse. The nurse will be going back to the maternity unit after four hours and will be a potential agent for spreading the infection. Client safety could be compromised. 5. Incorrect: Although the client with Guillian-Barre Syndrome is not contagious, this is a newly admitted client with a complex, possibly life threatening condition. The maternity nurse may not have the knowledge and assessment skills needed to care for this client. This would not be an appropriate assignment for this nurse.

A palliative care client is suffering from persistent diarrhea. What foods should the nurse suggest? Select all that apply 1. Applesauce 2. Rice 3. Bananas 4. Tea 5. Yogurt

1., 2., & 3. Correct: The BRAT diet is recommended for clients with persistent diarrhea. This diet consists of bananas, rice, applesauce, and toast. Rice and potatoes help to reduce diarrhea. Bananas will help replace potassium. Once the diarrhea subsides, the client can add easily digestible foods like eggs. 4. Incorrect: Avoid coffee and tea because caffeine containing beverages may have a laxative effect. Caffeine is a stimulant and will increase the peristalsis even more. 5. Incorrect: Dairy products may make the diarrhea worse. Avoid these until the diarrhea subsides.

The palliative care nurse is instructing the family of a client who is experiencing nausea and vomiting on methods of controlling these symptoms. What methods should the nurse include? Select all that apply 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. Chew 5-30 paw paw seeds

1., 2., & 3. Correct: These are all methods that can help control n/v 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: Paw paw seed is an herb that can be used for constipation. The question is not related to relieving constipation. It is related to nausea and vomiting prevention/control.

The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which client would be appropriate for the nurse to assign to the LPN/VN? Select all that apply 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. In diabetic ketoacidosis receiving IV insulin

1., 2., & 3. Correct: These are stable clients that can be assigned to the LPN. The LPN can provide medications for pain management. Since the postop client is not requiring frequent assessments and is considered stable at this point, the RN can assign the LPN to care for this client. The client having surgery in the AM is stable and will require predictable preop care the evening prior to surgery, so the LPN can care for this client as well. 4. Incorrect: This client has adrenal insufficiency. It occurs when at least 90 percent of the adrenal cortex has been destroyed. As a result, often both glucocorticoid (cortisol) and mineralocorticoid (aldosterone) hormones are lacking. This puts the client at risk for fluid volume deficit and shock. This would require higher level knowledge and skills of the RN and should not be delegated to the LPN. 5. Incorrect: The client in diabetic ketoacidosis is not considered a stable client. The administration of IV insulin is outside the scope of practice for the LPN. Caring for this client would require higher level assessment skills, knowledge, and nursing care that is within the RNs scope of practice. This client should not be assigned to the LPN.

What should a community health nurse include when planning a presentation on prevention and early detection of colon cancer? Select all that apply 1. Maintain a diet high in fruits, vegetables, and whole grains. 2. Exercise regularly. 3. Regular screening should begin at age 30. 4. Yearly fecal occult blood test beginning at age 50. 5. Flexible esophagogastroduodenoscopy every 5 years.

1., 2., & 4. Correct: A diet high in vegetables, fruits, and whole grains have been linked with a decreased risk of colorectal cancer, whereas, a diet high in red meats, processed meats, and frying can increase risk of colorectal cancer. There is a greater risk of developing colorectal cancer in individuals who live a sedentary life style. The fecal occult blood test detects blood in the stool through a chemical reaction. This test is done yearly. 3. Incorrect: If there is no identified risk factors (other than age), regular screening should begin at age 50. 5. Incorrect: A flexible esophagogastroduodenoscopy is not a recommended procedure for the early detection of cancer of the colon.

A hiker that was lost in the mountains for 3 days experienced exposure to below freezing temperatures. Upon arrival to the emergency department (ED), the nursing assessment reveals hard, mottled, bluish-white toes bilaterally, and the client reports being unable to feel the toes. Which actions should the nurse initially take? Select all that apply 1. Remove any wet or constricting clothing. 2. Initiate a controlled and rapid rewarming process with warm water. 3. Wrap each toe individually with sterile gauze. 4. Encourage the client to walk. 5. Apply a heating pad to the feet. 6. Massage the frozen digits.

1., 2., & 3. Correct: Wet clothing is removed to eliminate continued exposure to the cold and allow the warming process to begin. Swelling is common so anything, such as clothing or jewelry that could cause constriction to blood flow should be removed. A controlled and rapid re-warming process is accomplished using a continuous flow of warm water until flushing is noted in the affected areas. Antiseptics or antibiotics are often used, and each digit is wrapped individually with sterile gauze (not constricting) to minimize the risk of infection and assist in the warming process. The core should be re-warmed first to prevent "afterdrop" which is a further drop in core temperature caused by cold peripheral blood returning to the central circulation. 4. Incorrect: Movement of frostbitten areas can cause ice crystals to form in the tissue and cause further damage. In addition, lack of sensation places the client at risk for falls or other injury. 5. Incorrect: External heat such as heating pads, fireplaces, etc. should not be used because burns are more likely to result due to the presence of decreased sensation in the affected areas. 6. Incorrect: Initial rubbing or massage of the frostbitten digits is an absolute contraindication as it can cause further tissue damage. Gentle handling is required to prevent stimulation of the cold myocardium.

The nurse is talking with a parent regarding childhood immunizations. What vaccination is recommended for children to receive at 6 months? Select all that apply 1. Diphtheria 2. Hib 3. Influenza 4. Measles 5. Mumps 6. Rubella

1., 2., & 3. In both the US and Canada, the third diphtheria vaccination is recommended at 6 months. The third Hib vaccine is also recommended in both countries at 6 months. Both countries also recommend that everyone 6 months of age and older get a flu vaccine each year. 4. Incorrect: The first measles vaccination is recommended at 12 months in Canada and between 12-18 months in the US. 5. Incorrect: The first mumps vaccination is recommended at 12 months in Canada and between 12-18 months in the US. 6. Incorrect: The first rubella vaccination is recommended at 12 months in Canada and between 12-18 months in the US.

A client is admitted with atrial fibrillation and heart failure secondary to chronic hypertension. Current medications include: Digoxin, Captopril, Carvedilol, Furosemide, and Warfarin. Based on this profile, what lab work is essential for the nurse to monitor? 1. Digoxin level 2. Potassium level 3. PT/INR 4. aPTT 5. CPK-MB

1., 2., & 3. Look at the hints: Atrial fib and heart failure, so automatically what do we know about his cardiac output? Decreased. Chronic hypertension, what does that mean for afterload? Increased. Look at the meds: antihypertensive, diuretics, anticoagulants, and dig. And we know that digoxin increases the force of the contraction and decreases the heart rate. So what lab work is essential to monitor? Dig level, potassium level because of the loop diuretic, PT/INR because of the anticoagulant, 4. Incorrect: aPTT is used to evaluate what? Heparin. 5. Incorrect: Well, this goes up with myocardial infarction.

What interventions can an occupational health nurse discuss with a client in an effort to improve lateral epicondylitis (tennis elbow) pain? You answered this question Incorrectly 1. Avoid activities that make the pain worse. 2. An oral, nonsteroidal, anti-inflammatory drug may be prescribed. 3. Immediately start stretching and exercising the muscle and tendon. 4. If pain persists, a cortisone injection into the inflamed area may be recommended. 5. Apply ice for 45 minutes, six times a day.

1., 2., & 4. Correct: General activities that make the pain worse should be avoided or at least cut back. While continued activity in the presence of mild discomfort is not harmful, activities that cause severe pain will only prolong the necessary recovery time and should be avoided. Oral, nonsteroidal, anti-inflammatory drugs are very helpful in controlling the pain and inflammation of tennis elbow. The medicine is taken daily for at least four to six weeks when treating severe cases. For less severe cases, these medicines may be taken only when needed. Cortisone injections are considered when the other measures have not worked and the pain is severe. The cortisone is injected into the area of the inflamed tendons in order to decrease the inflammation. 3. Incorrect: Stretching and exercising of the involved muscle and tendon unit is one of the mainstays of treatment for this condition once pain and inflammation have subsided, but not during the acute phase. A gentle stretching program is started through a range of motion at the elbow and wrist. This is combined with a program of muscle strengthening. 5. Incorrect: It is recommended to apply ice to the area two to three times a day, for 20 to 30 minutes each time.

What signs and symptoms of ovarian cancer should a nurse include when educating women? Select all that apply 1. GI disturbances 2. Menstrual changes 3. Malnutrition 4. Increasing abdominal girth 5. Pain radiating down the legs

1., 2., & 4. Correct: Signs and symptoms of ovarian cancer include irregular menses, increasing premenstrual tension, menorrhagia with breast tenderness, early menopause, abdominal discomfort, dyspepsia, pelvic pressure and urinary frequency. Indigestion, flatulence, and fullness after a light meal, and increasing abdominal girth are significant symptoms. 3. Incorrect: Malnutrition is a complication of advanced metastatic cancer. 5. Incorrect: Pain will be in the abdomen and pelvis, and does not radiate down the legs.

What should the nurse include in a discharge plan for a client diagnosed with lymphoma who will be receiving outpatient treatment? Select all that apply 1. Avoid uncooked meats, seafood or eggs and unwashed fruits and vegetables. 2. Take bleeding precautions. 3. Do not take influenza or pneumonia vaccine during treatment. 4. Avoid individuals with infections. 5. Emphasize importance of frequent oral hygiene with an alcohol based mouthwash.

1., 2., & 4. Correct: The client with lymphoma is susceptible to infection and should eat foods low in bacteria. The client should avoid uncooked meats, seafood or eggs and unwashed fruits and vegetables as the bacteria count will be higher than desired. Instruct client and family about bleeding precautions and management of active bleeding due to thrombocytopenia. They should be advised to avoid activities that place them at risk for injury or bleeding (including excessive straining). This client is at risk for infection due to low white count, so the client should avoid individuals who are ill. 3. Incorrect: Encourage clients to maintain current immunizations for influenza and pneumonia. They are more susceptible to infection. Cancer and cancer treatment can weaken the immune system, which puts them at higher risk of serious problems if they get the flu or pneumonia. Only live vaccines (MMR, varicella, oral polio) are contraindicated in clients receiving chemotherapy. 5. Incorrect: This client is at risk for bleeding and infection due to low platelet and white cell counts. The client needs frequent oral care with a soft toothbrush and alcohol free mouthwash. Alcohol-based mouthwashes can dry out the gum and increase bleeding.

A nurse is caring for a client diagnosed with pneumonia. What nursing interventions should the nurse implement for the client's night sweats and fever. Select all that apply 1. Keep water by the bedside 2. Place a plastic cover over the pillow 3. Administer an antipyretic every 4 hours 4. Keep a change of linen in the room 5. Position the client in a semi-fowlers position

1., 2., & 4. Correct: The nurse should encourage the client to consume liquids to replace insensible water loss and sweating. The plastic cover will protect the pillow from contact with perspiration. A time management technique for caring for a client with frequent fever episodes is to keep a change of linen in the room. 3. Incorrect: Antipyretics should be administered to reduce a client's fever. Antipyretics are usually prescribed as needed, not every 4 hours. 5. Incorrect: Placing a client in different positions will not affect the client's fever. Positioning the client in a semi-fowlers position may be more appropriate for the client, but will not affect the client's temperature.

What actions should the nurse take when administering fentanyl? Select all that apply 1. Remove old fentanyl patch prior to applying new patch. 2. Cleanse area of old fentanyl patch. 3. Shave hair where fentanyl patch will be applied. 4. Place fentanyl patch over dry skin. 5. Apply adhesive dressing over the fentanyl patch. 6. Dispose of fentanyl patch in trash.

1., 2., & 4. Correct: These are correct actions. Apply patch to dry, hairless area of subcutaneous tissue, preferably the chest, abdomen, or upper back. The old patch should be removed prior to applying a new patch so that too much medication is not given. This is also why the old site should be cleaned. The patch should be placed on dry skin. Do not place over emaciated skin, irritated or broken skin, or edematous skin. 3. Incorrect: Do not shave area where patch will be applied and do not apply over dense hair areas. If there is hair on the skin, clip the hair as close to the skin as possible, but do not shave. 5. Incorrect: Do not apply adhesive dressing over patch. It can interfere with absorption. If the patch comes loose, you may tape the edges and remove and apply a new patch. 6. Incorrect: Dispose of fentanyl patch in sharps container. Fentanyl patches that have been worn 3 days still contain enough medication to cause serious harm to adults and children

The home care nurse is caring for an elderly client status post total hip replacement and a history of cirrhosis. Which statements by the client's spouse indicates that teaching regarding pain management has been successful? Select all that apply 1. "If the pain increases, I must let the nurse know immediately." 2. "I should have my spouse try the breathing exercises to help control pain." 3. "This narcotic causes very deep sleep, which is what my spouse needs." 4. "If constipation is a problem, increased fluids will help." 5. "My spouse can have one glass of wine to help promote pain relief."

1., 2., & 4. Correct: These are correct responses by the spouse. Increased pain may indicate something else is going on. Breathing exercises would be an excellent non-pharmacological intervention. Increasing fluid is an appropriate intervention for constipation. Narcotics place the client at risk for constipation.3. Incorrect: The nurse should know that goal of pain relief and administration of narcotics is to use the smallest dose possible to relieve the pain. Narcotics are not used to put clients into deep sleep. Also, clients with liver failure have less tolerance to narcotics because they cannot mobilize drugs like a normal person. Narcotics must be given cautiously to clients with liver disease and the elderly.5. Incorrect: Alcohol should not be taken when a client has cirrhosis. Alcohol is hepatotoxic to the client with liver disease.

What should the nurse include in the teaching plan for a client who has iron deficiency anemia? Select all that apply 1. Consume iron rich foods such as dried lentils, peas, and beans. 2. Notify primary healthcare provider of glossitis, anorexia, and paresthesia. 3. Iron is needed for white blood cell development. 4. Educate about ferrous sulfate supplement. 5. After drinking liquid iron, follow immediately by water.

1., 2., & 4. Correct: These are examples of iron rich foods. Foods high in iron will help with correcting iron deficiency anemia. Glossitis, anorexia, and paresthesias can result from iron deficiency anemia. Foods high in vitamin C such as citrus fruits, dark green leafy vegetables and strawberries help with absorption. 3. Incorrect: Iron is needed for red blood cell development and oxygen transport to the cells. Iron is not needed for white blood cell development. White blood cell development. White blood cells are produced in the bone marrow. 5. Incorrect: Clients should dilute liquid iron with water or juice, drink with a straw, and rinse mouth after swallowing. Iron will stain the teeth.

In which client should the nurse question a prescription for a contraction stress test? Select all that apply 1. Client at 26 weeks gestation. 2. Client with a history of 4 Cesarean section deliveries. 3. Client at 38 weeks with gestational diabetes. 4. Client at 37 weeks gestation. 5. Client with placenta previa.

1., 2., & 5. Correct: 26 weeks is too early to stimulate contractions. This could lead to a preterm delivery. Stimulating contractions in a client with previous cesarean deliveries is not recommended. This may lead to uterine rupture. Stimulating contractions in a client with placenta previa is not recommended. This may lead to hemorrhage. 3. Incorrect: There is no reason to suspect complications from a contraction stress test for this client. 4. Incorrect: There is no reason to suspect complications from a contraction stress test for this client.

Prior to shift report, the charge nurse is making assignments for the nurses on the shift. Which client can be assigned to the LPN? Select all that apply 1. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. 2. Client who is a diabetic experiencing diabetic neuropathy. 3. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. 4. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. 5. Client with ureterolithiasis who requires frequent PRN pain medication.

1., 2., & 5. Correct: A LPN should be able to care for a client with arthralgia who requires pain medication on a regular schedule and is receiving warm compresses. The client is apparently stable and does not require any advanced assessment skills or specialized care. Did the words diabetic neuropathy make you think that a LPN should not be assigned to this diabetic? Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. Did you recognize ureterolithiasis as "kidney stones"? Yes! So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. 3. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. Teaching is not in the role of the LPN and therefore, this client would need to be assigned to the RN, not the LPN, for the teaching needs of the client. 4. Incorrect: What seems to be going on with this client? The abdominal pain is worsening. This could indicate a worsening of this client's condition. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN.

A charge nurse is observing a new nurse for proper use of standard precautions for infection control. Which actions indicate that standard precautions are being followed? 1. Wearing clean gloves to convert an IV to a saline loc 2. Donning sterile gloves for a cesarean dressing change 3. Wearing a N95 respirator while caring for a child who has respiratory syncytial virus (RSV) 4. Putting on a gown to take care of a client who has toxoplasmosis 5. Performing hand hygiene after removing gloves

1., 2., & 5. Correct: Clean gloves are needed when there is a chance of coming into contact with blood or body fluids, which is likely to happen when converting an IV to a saline loc. Dressing changes in the hospital are a sterile procedure and require the use of sterile gloves. Hand hygiene should be performed before and after contact with a client immediately after touching blood, body fluid, non-intact skin, mucous membranes, or contaminated items. It should also be performed after removing gloves, before eating, and after using the restroom.3. Incorrect:The N95 respirator is used with airborne precautions and RSV requires droplet precautions. 4. Incorrect: Toxoplasmosis is transmitted through the feces of infected cats or through ingestion of raw or rare meats. A gown is not required in the care of this client because transmission occurs through ingestion of the parasites.

A charge nurse is observing a new nurse for proper use of standard precautions for infection control. Which actions indicate that standard precautions are being followed? Select all that apply 1. Wearing clean gloves to convert an IV to a saline loc 2. Donning sterile gloves for a cesarean dressing change 3. Wearing a N95 respirator while caring for a child who has respiratory syncytial virus (RSV) 4. Putting on a gown to take care of a client who has toxoplasmosis 5. Performing hand hygiene after removing gloves

Which statements by an older adult indicate that teaching about adequate nutrition and hydration have been effective? Select all that apply 1. "Taking a multivitamin every day will help me get enough calcium and vitamin C." 2. "Enrolling in Meals on Wheels will provide me with a nutritious meal every day." 3. "I am less likely to become constipated if I increase my fiber intake to 20 grams a day." 4. "Drinking 1 liter of water a day will keep me hydrated." 5. "I will strive to eat at least 5 servings of fruits and vegetables a day."

1., 2., & 5. Correct: Older adults need an increased dietary intake of calcium and vitamins D, C, and A because aging changes disrupt the ability to store, use, and absorb these substances. If the client cannot eat enough foods containing these nutrients, then a multivitamin can help. There are many programs available which can assist the elder in getting more nutritious foods, such as food stamps, meals on wheels, and food banks. Five servings of fruits and vegetables a day reduces the risk of heart disease and stroke. 3. Incorrect: Older adults should consume 35-50 grams of fiber each day. 4. Incorrect: Older adults sometimes limit their fluid intake, especially in the evening, because of decreased mobility, prescribed diuretics, and urinary incontinence. Teach older adults the importance of drinking 2 liters of water a day plus other fluids as desired.

A nurse is planning to conduct primary prevention classes in a local community. Which initiatives should the nurse include? Select all that apply 1. Parenting classes for first time parents 2. Healthy diet classes for school-age children 3. Breast self-examination classes 4. Cardiac rehabilitation classes 5. Community exercise classes to promote weight loss

1., 2., & 5. Correct: Primary prevention is aimed at reducing the incidence of mental or physical disorders within the population. Primary prevention targets individuals and the environment. Emphasis is on assisting individuals to increase their ability to cope effectively with stress and targeting and diminishing harmful forces (stressors) within the environment. Teaching parenting skills and child development to prospective new parents, teaching healthy eating to school-age children, and promoting weight loss through exercise classes are all examples of primary prevention.3. Incorrect: This is an example of secondary prevention (initiatives that work to identify and detect disease in its early stages).4. Incorrect: This is an example of tertiary prevention (designed to restore self-sufficiency and to limit complications and disabilities associated with a disease state, such as after an MI).

The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessments by the nurse suggest that the client is developing this complication? Select all that apply 1. Asterixis 2. Lethargy 3. Amnesia 4. Behavioral changes 5. Kussmaul respirations

1., 2., 3. & 4. Correct: Hepatic encephalopathy results in changes in neurologic and mental responsiveness due to the accumulation of ammonia. All of the correct options are either mental or neurologic changes. 5. Incorrect: Kussmaul respirations are not a characteristic of hepatic encephalopathy. They are seen in diabetic ketoacidosis (DKA).

A child weighing 75 lbs. (34.1 kg) is admitted to the unit with a diagnosis of bacterial meningitis. The child has been started on an IV of D5 NS at 100 mL per hour and IV antibiotic therapy has been initiated. Which assessment finding would need to be reported immediately to the healthcare provider? Select all that apply 1. Urinary output of 28 mL/hr. 2. Change in the level of consciousness. 3. Temperature of 101.2 degrees F (38.4 degrees C). 4. Increase of 5 mm Hg in systolic BP from baseline. 5. Sodium level of 130 mEq/L (130 mmol/L).

1., 2., & 5. Correct: The urinary output should be at least 1 mL/kg/hr for a child. This child, who weighs 34 .1 kg should have an output of at least 34 mL/hr. A change in the level of consciousness in this client with meningitis could indicate a worsening of the condition, resulting in neurologic changes, or could indicate the development of FVE and worsening cerebral edema. Careful management of fluid and electrolyte balance is always a very important aspect in the care of clients with meningitis. The sodium level is too low (hyponatremia). This can be due to fluid retention or other causes and be very serious, if not corrected. 3. Incorrect: An elevated temperature is common in children with bacterial meningitis. A temperature of 101.2 degrees is not considered excessive and would not be something that would have to be reported immediately. 4. Incorrect: Children with meningitis are often dehydrated upon admission. An increase in 5 mm Hg in the systolic pressure could be from rehydration and does not warrant immediate notification to the primary healthcare provider. However, the increase in pressure would need to be monitored to make sure that the pressure does not continue to rise, indicating a FVE, which could worsen cerebral edema.

The nurse is observing a new nurse inserting a nasogastric (NG) tube. Which action by the student nurse needs to be corrected by the nurse? Select all that apply 1. Measures from the tip of the nose to the xiphoid process of the client. 2. Lubricates the NG tube with petroleum gel. 3. Aspirates the NG tube to test gastric contents with a pH stip. 4. Marks the tubing at measurement mark with tape and secures to nose. 5. Places tube end into a glass of water to assess for bubbling.

1., 2., & 5. Correct: These actions by the new nurse are not done properly. The measurement for tube placement should be nose to ear and then xiphoid process. Lubricate the tube with a water solution, not a petroleum gel. Never place the tube in water because if the tube is in the trachea, the client can aspirate the water into the lungs. 3. Incorrect: This is the proper technique for checking placement of the NG tube. The pH should be less than 5 if in the stomach. 4. Incorrect: Yes, the tubing should be marked with a piece of tape and secured to the nose with tape or a commercial device if available.

A nurse is caring for a client with a suspected myocardial infarction (MI). What lab work or diagnostics should the nurse anticipate the primary healthcare provider prescribing to specifically confirm the diagnosis? Select all that apply 1. ECG 2. Troponin Level 3. PTT 4. Metabolic Panel 5. CPK-MB 6. CPK-BB

1., 2., & 5. Correct: Yes, when a client is suspected of having an MI, the client needs an ECG, Troponin, and CPK-MB levels. Remember Troponin is our favorite, because Troponin will confirm an MI even when the client delays seeking care. CPK-MB is right because CPK-MB is cardiac specific. 3.Incorrect: No, PTT looks at clotting factors and does not tell you if the client is having an MI. 4 Incorrect: No, but what if you just don't know about this answer? Look at it; a metabolic panel will tell you about metabolism and that is not what I am concerned with here. 6.Incorrect: No, CPK-BB is used to assess for brain damage, not cardiac damage.

The nurse is to administer a client's first dose of lithium. Prior to giving the medication, the nurse should verify that what tests have been completed? Select all that apply 1. Blood urea nitrogen (BUN) 2. Thyroid stimulating hormone (TSH) 3. Electroencephalogram (EEG) 4. Alanine Aminotransferase (ALT) 5. Electrocardiogram (ECG)

1., 2., & 5. Correct:. Lithium is an anti-mania medication used to treat bipolar disorder or other manic issues. However, this drug may adversely affect other body systems, which is why it is vital to verify the client has no undiagnosed renal, thyroid or cardiac problems. Blood urea nitrogen (BUN) reveals the function of the kidneys while thyroid stimulating hormone (TSH) indicates how well the thyroid is working. An electrocardiogram (ECG) will show arrhythmias or rhythm problems with the heart. The nurse needs to verify these tests were completed and the results were given to the primary healthcare provider. 3. Incorrect: An electroencephalogram (EEG) is a study of brain wave activity achieved by placing dozens of external electrodes on the skull. While Lithium may affect an individual's thought patterns and emotional stability, actual brain functions are not impacted. 4. Incorrect: Alanine aminotransferase (ALT) is an enzyme produced by the liver for the purpose of helping breakdown proteins for metabolism. This blood test would indicate the status of the liver, which is not a major concern while taking lithium.

The nurse recognizes which manifestation as a sign/symptom of Hodgkin's lymphoma? Select all that apply 1. Drenching night sweats 2. Small, red, itchy bumps 3. Painful lymph nodes in the neck 4. Weight loss of 2 kg in 1 week 5. Flushed skin 6. Enlarged spleen

1., 2., & 6. Correct. With this disease, the body switches back and forth from fever and chills to excessive sweating. The sweating is the worst at nighttime; and many clients report waking up in the middle of the night to clothing and bedding that is completely drenched. As the lymphoma cells grow, they secrete a chemical that causes a generalized itchiness and irritation of the skin throughout the body. The spleen is part of the lymph system and works as a drainage network that defends the body against infection. Since Hodgkin's lymphoma affects the lymphatic system, the spleen is also affected. 3. Incorrect. The most common symptom of Hodgkin lymphoma is one or more enlarged lymph nodes. The enlarged lymph node may be in the neck, upper chest, armpit, abdomen or groin. The swollen lymph node is usually painless. 4. Incorrect. This is not a significant weight loss. A large decrease in weight is common in many types of cancers and is particularly noticeable in lymphoma cases. 5. Incorrect. Lymphoma lowers the body's red blood cell count, leading to anemia and even greater fatigue. Skin will be pale.

A community health nurse, participating in a health fair, is educating a community group about risk factors for developing varicose veins. What risk factors should the nurse include? Select all that apply 1. Sitting for prolonged periods 2. Obesity 3. Female 4. Leg exercises 5. Wearing high-heeled shoes

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

A client who has diabetes calls the nurse hot-line reporting shakiness, nervousness, and palpitations. Which questions would yield information that would help the nurse decide that this is a hypoglycemic episode? Select all that apply 1. What have you eaten today and at what times? 2. Are you using insulin as a treatment of diabetes, and if so, what kind? 3. Do you feel hungry? 4. Do you have access to a glucose monitor to check your current glucose level? 5. Does your skin feel hot and dry?

1., 2., 3. & 4. Correct. This question will give the nurse information about how much time has elapsed since the last meal and will indicate the amount of protein and carbohydrates consumed at the last meal. Even a minor delay in meal times may result in hypoglycemia. Insulin type will give the nurse information about duration of action and peak time. Hunger is a symptom of hypoglycemia.If the client has a glucose monitor, an accurate reading would give the nurse valuable information about how much food the client should consume now.5. Incorrect. Hot and dry skin is not an indicator of hypoglycemia and would not help the nurse determine if the client is experiencing a hypoglycemic episode. Cool, clammy skin is a symptom of hypoglycemia.

A nurse is developing a proposal to implement a pet therapy program at a nursing home. What information should the nurse include in the proposal to support this program? Select all that apply 1. Evidence has shown that animals can directly influence a person's mental and physical well-being. 2. Bringing a pet into a nursing home for the elderly has been shown to enhance social interaction. 3. Petting an animal can be helpful in lowering a client's blood pressure. 4. Some researchers believe that animals actually may retard the aging process among those who live alone. 5. Nursing home clients are more submissive after petting an animal.

1., 2., 3. & 4. Correct: All of these statements are correct in reference to pet therapy programs. Petting a dog or cat has been shown to lower blood pressure. Studies indicate a 7 mm Hg drop in systolic and an 8 mm Hg decrease in diastolic BP when volunteers talked to or would pet their dogs as opposed to reading aloud or resting quietly. 5. The clients are not more submissive or passive after participating in pet therapy. Evidence does show increased mental and physical well being with pet therapy.

The nurse is teaching the family of a homebound client about ways to increase the client's safety while bathing independently. Which strategies should the nurse include? Select all that apply 1. Install grab bars in the tub or shower. 2. Install hand bars on sides of tub. 3. Use tub/shower seat for bathing. 4. Provide a long handled bath scrubbie for bathing. 5. Schedule bathing routines three times per week.

1., 2., 3. & 4. Correct: Grab bars will assist the client in getting into or out of the tub or shower, thus reducing the chance for falls. Hand bars are very helpful as one enters or exits the tub. The increased stability offered by these devices reduces risk of falls. Using a shower seat will allow the client to remain independent in terms of entering or exiting the tub or shower. The use of handled scrubbies or sponges allows the client to reach lower extremities or back with greater ease.5. Incorrect: The bathing routine may need to be more often than three times per week depending on the client. The bathing schedule does not relate to a client's independence.

The homecare nurse is instructing a client with chronic obstructive pulmonary disease (COPD) about the importance of a nutritious diet to avoid weight loss. The nurse knows that teaching has been effective when the client selects which foods for a breakfast menu? Select all that apply 1. Scrambled eggs 2. Cheese omelet 3. Sliced banana 4. Orange juice 5. Whole milk 6. Dry toast

1., 2., 3. & 4. Correct: Maintaining weight and nutrition is vital to the health of clients with (COPD). Extreme fatigue along with excessive mucus production decreases the client's ability to eat complete, well-balanced meals, leading to weight loss or malnourishment. Therefore, the nurse would instruct the client to eat small, frequent meals high in protein and fiber. Good sources of protein include eggs, cheese, fish and poultry, beans and even nuts. Fresh fruit such as bananas along with non-carbonated beverages such as orange juice are excellent breakfast food choices. 5. Incorrect: Although milk and dairy products like yogurt could be considered part of a healthy breakfast, it is recommended that COPD clients use 1% or 2 % milk products to avoid increasing mucus production. This client should select the orange juice from the choices provided. 6. Incorrect: Dry toast provides little nutrient value, and may actually increase coughing because of its brittle nature. Coughing quickly leads to exhaustion rather than eating. This client would benefit more from a more palatable choice such as muffin or French toast.

The nurse, caring for a client who has chronic renal failure, suspects that the client is experiencing anxiety. Which statements by the client would validate the nurse's suspicion? Select all that apply 1. "I do not think I can continue working." 2. "My husband has taken over the house cleaning and cooking." 3. "I fear I am dying." 4. "I have an "uneasy" feeling most of the time." 5. "Most of the time I feel very 'down and blue'."

1., 2., 3. & 4. Correct: The inability to maintain employment is of concern to most clients who have been used to working. With a chronic illness, the client is unlikely to be able to return to work. Anxiety related to role strain is common. The client may not be able to perform the duties that she once did, thus causing others to have to assume their roles. Death is a possible outcome if transplant does not occur. Fear may be a later diagnosis as the client's condition deteriorates. Clients with anxiety often report feeling uneasy or on edge.5. Incorrect: These comments are more indicative of a depressed mood than anxiety. Depression may also occur in the client who has chronic renal failure.

The home health nurse is assessing the home environment for threats to the safety of the toddler who lives in the home. Which observations should be included in this assessment? Select all that apply 1. Do stairs have guard gates? 2. Are safety covers on electrical outlet plugs? 3. Is the swimming pool inaccessible to the toddler? 4. Are cleaning supplies located out of the toddler's reach? 5. Are stairs brightly lit?

1., 2., 3. & 4. Correct: Toddlers may fall if left unsupervised around stairs. Make sure that gates are in place and that they are used. Toddlers are at risk for exploring the outlets by putting metal objects into the outlets or putting their fingers in them. They should be covered unless in use. Toddlers can drown in small amounts of water and they may try to explore swimming pools if they are accessible. Pools should have fences or locking stairs and the child should never be left unsupervised around the pool. Toddlers are curious and may get into cabinets containing harmful substances. 5. Incorrect: This assessment would be important for the visually impaired or elderly, but not specifically for toddlers. The guard gates should be in place so that the toddler does not have access to the stairs.

The nurse is working on interventions for a young family whose child has severe allergies and asthma symptoms. Which interventions would be important to include in the plan? Select all that apply 1. Wash stuffed animals/toys frequently in hot water. 2. Make sure that bathrooms and high humidity areas are properly vented. 3. Limit carpet in the bedrooms. 4. Use humidifiers regularly. 5. Vacuum floors and upholstered furniture regularly.

1., 2., 3. & 5. Correct: The frequent washing in hot water removes dust mites. Adequate venting lessens the likelihood of fungal/mold spores. Carpet harbors dust and other allergens. The floors and upholstered furniture may harbor dust, pollen from clothing, and other irritants. 4. Incorrect: Humid air may contribute to mold or fungal spores in the house. Less humidity is appropriate.

A home health nurse is planning home safety education for a client and spouse. Which actions should be included to promote fire safety in the home setting? Select all that apply 1. A fire extinguisher should be kept on each level of the home. 2. Keep matches and lighters away from children by storing them in a locked cabinet. 3. Install carbon monoxide smoke alarms, and test them monthly. 4. You may leave Christmas lights lit all night as long as the tree is artificial. 5. Have a planned route of exit and a place where all family members will meet.

1., 2., 3. & 5. Correct: A fire extinguisher should be placed on each level of the home, near an exit, but out of reach of children. Keeping matches and lighters away from children by storing them in a locked cabinet can prevent fire-related deaths. Carbon monoxide smoke alarms will alarm for smoke as well as carbon monoxide, which is an odorless gas than can kill quickly. Alarms should be tested every month and repaired or replaced immediately if malfunction occurs. A plan facilitates exit from the building, and a place to meet helps identify that all family is out of the building. 4. Incorrect: Lit Christmas lights should be turned off when no one is home and when people go to bed for the night. It does not matter whether the tree is real or artificial.

A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate? Select all that apply 1. Elevate HOB 30 degrees 2. Pad side rails 3. Provide sponge bath if temperature greater than 101°F (38.3°C) 4. Initiate airborne isolation precautions 5. Darken room

1., 2., 3. & 5. Correct: An acute onset of fever, headache, stiff neck, n/v, and mental status changes are consistent with bacterial meningitis. Elevate the head of the bed to promote comfort and decrease intracranial pressure. The client is at an increased risk for seizures, and the nurse should implement seizure precautions which include padding the side rails. A sponge bath is an independent nursing intervention appropriate for a fever greater than 101°F (38.3°C). Darkening the room is also a comfort measure as this client will have photophobia. 4. Incorrect: Droplet precautions should be initiated for the first 24 hours of antimicrobial therapy.

The nurse is educating a group of sexually active teenagers about Chlamydia. What should the nurse teach these clients to prevent them from acquiring or transmitting this disease ? Select all that apply 1. Use a latex condom when having sex to protect against Chlamydia. 2. Seek the advice of a primary healthcare provider if there is vaginal discharge or burning on urination. 3. Suggest that the teens be screened for Chlamydia. 4. Reassure the teens that if they have no symptoms, they have no disease. 5. Take prescribed medication if diagnosed with Chlamydia, and repeat screening in three months.

1., 2., 3. & 5. Correct: Consistent use of latex condoms protects against STIs. Although chlamydia may have no symptoms, burning and discharge should be reported for further evaluation. It is recommended that all sexually active young women less than 25 years of age be screened for chlamydia on an annual basis. Medication should be taken as prescribed, and rescreening should occur in 3 months to make sure that there is no more disease present.4. Incorrect: Chlamydia does not always produce visible symptoms, and, if left untreated, can lead to pelvic inflammatory disease (PID). False security may lead to unsafe sex practices.

The nurse has been trained to work in a decontamination station for hazardous exposure victims. What should the nurse tell the victim about the process? 1. First you will remove clothing and dispose of it in hazardous material containment area. 2. You will be placed in a warm shower for decontamination. 3. You will spend a minute or so using soap over the entire body before rinsing. 4. You will spend approximately 15 minutes in the shower. 5. You will apply soap from head to toe and then rinse for a few minutes.

1., 2., 3. & 5. Correct: If the victim can remove his/her own clothing, then instructions should be given to do so and dispose of in hazardous material container. The person will wash for several minutes, beginning with a minute or so of full body rinsing with water to remove any visible contaminants, followed by soap and finally the rinse. The length of time for washing and rinsing will vary with institution and known contaminants. Using soap with good surfactant qualities is important. Generally, the victim is instructed to rinse with tepid water, apply soap from head to toe, and then rinse again with copious amounts of water.4. Incorrect: Most procedures require about 5 to 6 minutes for the decontamination process. Times may vary depending on policy, contaminants, and the level of ability of the victim.

A client has been instructed not to take non-steroidal anti-inflammatory drugs (NSAIDs) post lumbar laminectomy with spinal fusion. The nurse knows that education was successul when the client identifies which medications should be avoided? Select all that apply 1. Celecoxib 2. Ibuprofen 3. Naproxen 4. Acetaminophen 5. Indomethacin

1., 2., 3. & 5. Correct: NSAIDs, such as celecoxib, ibuprofen, naproxen, and indomethacin prevent platelet aggregation. This can result in a tendency for bleeding that interferes with healing after a laminectomy with spinal fusion surgery. 4. Incorrect: Acetaminophen is a peripheral-acting analgesic and not a non-steroidal anti-inflammatory drug.

When providing care for a client with a chest drainage unit (CDU) set at 20 cm. of suction, which nursing actions are correct? Select all that apply 1. Maintain chest drainage system below the client's chest during transport. 2. Apply tape to the tubing connection sites. 3. Add sterile water to suction control chamber to achieve 20 cm. 4. Assess respiratory effort every shift. 5. Ensure that tubing is not kinked or looped.

1., 2., 3. & 5. Correct: Never raise the drainage system above the level of the client's chest. All connection sites should be tightly secured. If the water level drops below the prescribed suction, more saline must be added. Tubing must not be kinked or looped. 4. Incorrect: Respiratory effort for a client with a CDU must be assessed more often than every shift. This assessment should be done at least every 2 hours.

The son of an elderly diabetic client reports that his mother is frequently having low blood sugar. What should the nurse teach this family member about symptoms of hypoglycemia in the elderly? Select all that apply 1. Elders may not be aware that blood sugar is dropping due to decreased release of epinephrine in response to the lowered blood sugar. 2. Suggest that the client and family check with primary healthcare provider to ensure that the medication prescribed has low incidence of hypoglycemic episodes. 3. Symptoms of hypoglycemia may be averted if the client maintains routines and regular meal schedules. 4. Stress the importance of proper foot care and regular eye exams. 5. Check blood glucose levels if client becomes unsteady, has difficulty concentrating, or is tremulous.

1., 2., 3. & 5. Correct: Older clients are at risk for hypoglycemia unawareness. Blood sugar levels should be checked frequently. Some oral medications are more likely to cause hypoglycemia episodes. If the client has frequent episodes, perhaps a medication change is warranted. The elderly must maintain regular meal schedules and adequate food intake. This may present challenges for the elder who lives alone. If an elder develops unsteady gait, loss of concentration, and/or lightheadedness, the blood glucose levels should be checked. These symptoms are typical in a hypoglycemic episode.4. Incorrect: Proper foot care and regular eye exams should be done to avoid complications caused by hyperglycemia, not hypoglycem

A school nurse is planning a session on the effects of cannabis use for a high school health class. Which information does the nurse need to include? Select all that apply 1. Cannabis ingestion can cause tachycardia. 2. Inhaled cannabis produces a greater amount of tar than tobacco. 3. Cannabis smoke contains more carcinogens than tobacco smoke. 4. Cannabis ingestion reduces the risk for heart disease 5. Orthostatic hypotension can be caused by cannabis ingestion.

1., 2., 3. & 5. Correct: Tetrahydrocannabinol (THC) is the chemical compound in cannabis. THC enters the blood stream quickly and is transported to the brain and other organs. Within minutes, the heart rate may increase by 20-50 bpm and last for up to 3 hours. Cannabis ingestion may cause tachycardia and orthostatic hypotension. Cannabis smoke contains more carcinogens and tar than tobacco. Lowering of blood pressure during use is common and can lead to orthostatic hypotension. 4. Incorrect: Research has indicated that the ingestion of cannabis increases the risk for heart disease.

The nurse is working on a health promotion plan for a young family whose child has severe allergies and asthma symptoms. Which interventions would be important to include in the health promotion plan? Select all that apply 1. Wash stuffed animals/toys frequently in hot water. 2. Make sure that bathrooms and high humidity areas are properly vented. 3. Limit carpet in the bedrooms. 4. Use humidifiers regularly. 5. Vacuum floors and upholstered furniture regularly.

An elderly client is being discharged home on warfarin following treatment for a deep vein thrombosis. While reviewing discharge instructions, the client asks the nurse if the newly ordered medication will interfere with herbal supplements taken at home. After reviewing all meds taken at home, the nurse knows the client will need to discontinue which supplements? Select all that apply 1. saw palmetto 2. St. John's wort 3. garlic tablets 4. echinacea 5. ginkgo biloba

1., 2., 3. & 5. Correct: The greatest concern with herbal supplements is interaction with prescribed medications. In this case, specific herbs may increase the effects of warfarin, leading to hemorrhaging. Saw palmetto is often used by men with benign prostatic hypertrophy to decrease frequency and increase urinary flow; however, saw palmetto does interact with blood thinners and increase bleeding times. Garlic tablets are reported to boost immunity while decreasing the risk of atherosclerosis or cancer. But garlic also enhances the action of anti-coagulants, resulting in excessive bleeding. Ginkgo biloba is often recommended to improve memory, particularly for clients with early onset dementia or Alzheimer's disease. This supplement should not be taken with either NSAIDS or blood thinners because of the increased risk of bleeding. St. John's wort has been used in cases of mild depression, anxiety, and even to treat symptoms of PMS. Occasionally this supplement may be used in cases of chronic pain such as fibromyalgia or chronic fatigue syndrome, with basic side effects that include dry mouth, dizziness, or increased blood pressure. St. John wort can inhibit the effect of warfarin. 4. Incorrect: Echinacea is reported to enhance the immune system, prevent cold symptoms and decrease healing time in wounds. This herbal supplement has very few known side effects or interactions, although it is not recommended for pregnant or lactating women. It does not interfere with the action of warfarin.

A nurse is planning discharge education for a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which instructions should the nurse include when teaching this client? Select all that apply 1. Limit fluid intake. 2. Report muscle cramping. 3. Measure intake and output. 4. Perform mouth care once a day. 5. Report weight gain of 2 pounds (0.9 kg) over 24 hours.

1., 2., 3. & 5. Correct: The nurse should advise the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) to limit fluid intake. In SIADH, excessive amounts of water are reabsorbed by the kidneys, creating potentially disastrous dilutional hyponatremia. Water must be restricted to prevent water intoxication. The nurse should advise the client diagnosed SIADH to report muscle cramping. Muscle cramping should be reported immediately to the primary healthcare provider because this sign could indicate hyponatremia, which can lead to seizures or coma. The nurse should advise the client diagnosed with SIADH to measure intake and output. Intake and output should be monitored carefully to assess the amount of fluid restriction needed. Weight gain of 2 pounds (0.9 kg) or more should be reported to the primary healthcare provider because this is an indication of fluid retention and increases the client's risk for fluid volume excess. 4. Incorrect: The nurse should teach the client to rinse the mouth frequently to keep mucous membranes moist during fluid restriction, not just once a day.

While suctioning a client's endotracheal (ET) tube, the nurse notes that the client's heart rate has gone from 78 to 44. The nurse stops suctioning the ET tube. What is the nurse's best action? 1. Deflate the ET tube cuff. 2. Have the client cough several times in a row. 3. Oxygenate the client with 100% oxygen. 4. Notify the primary healthcare provider.

3. Correct: The drop in pulse rate indicates acute hypoxia, which can be caused by suctioning. The nurse should stop suctioning and oxygenate with 100% oxygen.

The client has pustules on the arm from intravenous drug abuse. The microbiology laboratory informs the nurse that the client's cultures are growing methicillin-resistant Staphylococcus aureus (MRSA). Which action would the nurse take? Select all that apply 1. Cover the pustules to prevent drainage. 2. Implement contact precautions immediately. 3. Instruct the client on the importance of hand hygiene. 4. Inform the client to wear a mask when ambulating in the hall. 5. Instruct visitors to wash hands before entering the client's room.

1., 2., 3. & 5. Correct: The pustules should be covered with a dressing, because MRSA is transmitted via contact! It is important that the nurse implement these interventions in order to prevent the spread of infection. The number one way to prevent the spread of infection is handwashing. That includes the client, staff, and visitors. If the client refuses to follow instructions, then isolation precautions are warranted. 4. Incorrect: The client is placed on contact precautions not droplet precautions. The client would not need to wear a mask since the infection is not transmitted via the respiratory system.

A client is preparing to be discharged after a total hip replacement. Which client statement would indicate teaching has been successful regarding prevention of hip prosthesis dislocation? Select all that apply 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: These are appropriate actions to prevent hip prosthesis dislocation. Until the hip prosthesis stabilizes it is necessary to follow these instructions for proper positioning to avoid dislocation. 4. Incorrect: The knees should be kept apart to prevent dislocation.

The parents of a toddler tell the nurse that their child will not drink milk. What alternatives should the nurse recommend? Select all that apply 1. Frozen yogurt 2. Pudding 3. Hot cocoa in milk 4. Cheddar cheese 5. Watermelon

1., 2., 3., & 4. Correct: A 1/2-cup serving of fat-free frozen yogurt offers more than 100 milligrams of calcium. Pudding contains approximately 28% of the daily food allowance of calcium. An 8-oz. mug of homemade hot chocolate contains 285 mg of calcium. Cheddar cheese has 204 mg of calcium per serving. 5. Incorrect: 1 cup of watermelon supplies only 11 mg of calcium.

Which independent nursing actions should the nurse initiate for a client admitted with heart failure? Select all that apply 1. Monitor for distended neck veins 2. Measure abdominal girth 3. Evaluate urine output from diuretic therapy 4. Educate client regarding signs and symptoms of heart failure 5. Administer medications as prescribed

1., 2., 3., & 4. Correct: An independent nursing intervention is one that an RN can prescribe, perform, or delegate based on their skills/knowledge. A collaborative intervention is one that is carried out in collaboration with other health team members (physical therapist, healthcare provider). Dependent nursing intervention is one prescribed by a healthcare provider but carried out by the nurse. These actions do not require an order by a healthcare provider nor collaboration with another. They are independent nursing functions.5. Incorrect: Administering prescribed medications is a dependent nursing intervention and cannot be initiated without an order being in place. This is the only option that is dependent on the primary healthcare provider's actions first before the nurse can initiate it.

A client has been admitted to the telemetry unit with a diagnosis of a cerebral vascular accident. What should the nurse assess to determine the client's risk for aspiration? Select all that apply 1. Ability to swallow 2. Gag reflex 3. Level of consciousness 4. Cough reflex 5. Ability to follow commands

1., 2., 3., & 4. Correct: Assessing the ability of a client to swallow is something the nurse can and should do. A small amount of water should be given to the client as the nurse observes for coughing or gurgling. If the nurse suspects a client is having difficulty safely swallowing, further assessment by a speech and language therapist is recommended. To test for a gag reflex use a tongue depressor. Ask the client to open the mouth and look at their throat with a penlight. If the uvula and pharynx rise as the client says "aaahh" then the gag reflex is intact. If it does not rise, touch the back of the throat at the soft palate and watch for the rise in the pharynx in a gag response, If intact,the client should not be at risk for aspiration with eating. A client with a decrease level of consciousness is always at risk for dysphagia and aspiration. A cough reflex is assessed by administering a small sip of water and observing for a cough. if the client coughs, feeding should be withheld until further testing can be performed. 5. Incorrect: Assessing ability to follow commands does not identify a problem with swallowing. It does not provide a great deal of information about cognitive function. The other tests provide more information specific to aspiration

What should be included in the discharge teaching plan for a client who has lymphedema post right mastectomy? Select all that apply 1. Use a thimble when sewing. 2. Wear a heavy duty oven mitt for removing hot objects from the oven. 3. Long sleeves should be worn to prevent insect bites. 4. Shave underarms with an electric razor. 5. Avoid wearing jewelry.

1., 2., 3., & 4. Correct: Because lymphedema is a lifelong threat, teach the client hand and arm precautions to minimize the risk of injury, infection, and impaired circulation. All of these options are correct options to minimize these risks. Even a minor injury such as a pin prick or sunburn can cause painful swelling after lymph node removal. 5. Incorrect: The client may wear jewelry that does not inhibit lymph drainage. They should avoid jewelry that constricts the affected arm.

What developmental milestone does the nurse expect to see in an 18 month old toddler? Select all that apply 1. Says and shakes head "no". 2. Points to one body part. 3. Drinks from a cup. 4. Points to show someone what they want. 5. Kicks a ball. 6. Walks up and down stairs holding on.

1., 2., 3., & 4. Correct: By the age of 18 months, the nurse would expect the baby to say and shake the head "no", point to a body part, drink from a cup, and point to what they want. 5. Incorrect: The nurse should expect to see the baby watch the path of something as it falls. It is a little to early to expect the 18 month old to do this. 6. Incorrect: The 2 year old can accomplish walking up and down stairs while holding on. The 18 month old is not physically ready to do this.

What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation? Select all that apply 1. Document current functional status assessment 2. Notify the primary healthcare provider of transfer completion. 3. Transfer essential medical record to the receiving facility. 4. Phone report to the receiving nurse. 5. Send a day's worth of medications with the client to the receiving facility.

1., 2., 3., & 4. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. It is the nurse's responsibility to communicate the client's condition and care plan to the receiving facility nurse in order to support continuity of care. 5. Incorrect: Medications are not transferred with the client to a new facility. A list of current medications is sent to the facility.

Which nursing interventions should the nurse initiate for a client post-thoracotomy with two chest tubes in place connected to a chest drainage unit (CDU)? 1. Elevate head of bed 45 degrees. 2. Educate on use of incentive spirometry. 3. Support chest incision with pillow when client coughs. 4. Document amount and color of drainage. 5. Notify the primary healthcare provider if tidaling is noted in the water-seal chamber.

1., 2., 3., & 4. Correct: Elevate HOB to promote breathing. Educate on incentive spirometry to promote lung expansion. Supporting chest incision decreases pain and can help client produce a productive cough and can improve deep breathing efforts. Assessing for excessive bleeding is important. Keep sterile water at bedside in case the tubing becomes disconnected. 5. Incorrect: Tidaling—fluctuations in the water-seal chamber with respiratory effort—is normal. The water level increases during spontaneous inspiration and decreases with expiration.

A nurse is planning an educational session on safety for parents of young children. What safety points should the nurse include? Select all that apply 1. Teach children the basics of swimming. 2. Plan an escape route in the event of fire. 3. Make sure that sand surrounds the playground equipment. 4. Gates should be placed at the top and bottom of stairs when toddlers are present. 5. Vitamins should be referred to as candy so that children will take them. 6. A child at age 7 may sit in the front seat of a car.

1., 2., 3., & 4. Correct: Everyone should know the basics of swimming (floating, moving through the water) and cardiopulmonary resuscitation (CPR). Create and practice a family fire escape plan and involve kids in the planning. Make sure everyone knows at least two ways out of every room and identify a central meeting place outside. Falls on playgrounds are common and can cause serious injury. Wood chips or sand, not dirt or grass should be under playground equipment. Having a gate at the top and bottom of stairs can prevent falls. 5. Incorrect: Do not tell children that medication, even vitamins, is candy. Children may take medicine because they think it really is candy when they see medication not intended for them. 6. Incorrect: Children should not sit in the front seat of a car until 8-12 years of age or they are 4ft. 9in. (145 cm) in height.

The nurse is preparing to administer 0900 medications. Which medications should the nurse include? Exhibit Select all that apply 1. Heparin 2. Escitalopram 3. Conjugated estrogens 4. Omeprazole 5. Lopressor 6. Magnesium gluconate

1., 2., 3., & 4. Correct: Heparin was due at 0800 and is now overdue, so the nurse needs to administer this medication now. The other three medications are scheduled for 0900. 5. Incorrect: Lopressor needs to be held based on the prescription to hold the medication for a systolic BP below 90. This clients current BP is 88 systolic. 6. Incorrect: The latest magnesium lab value is within normal limits. Based on the prescription, this medication should be held.

What signs and symptoms would a nurse assess for in a client who is receiving hospice care and is close to death? Select all that apply 1. Cool extremities 2. Mottling 3. Cheyne-Stokes respirations 4. Loss of appetite 5. Increased blood pressure

1., 2., 3., & 4. Correct: In the hours before death, blood will be shunted to the vital organs and not the periphery. This will make the extremities cool to the touch and mottled in appearance. Both cool extremities and mottling are due to reduced blood flow. Cheyne-Stokes respirations is a respiratory pattern that consists of loud deep inhalations followed by a pause of apnea. Loss of appetite will occur as energy needs decline. The use of moistened clothes around the mouth and lip balm may help with keeping lips moist and comfortable. 6. Incorrect: Blood pressure will not increase as death nears. The pumping action of the heart declines when death is occurring which leads to a decrease in cardiac output and blood pressure.

What action should the nurse take after mistakenly administering the wrong medication? Select all that apply 1. Notify the nursing supervisor. 2. Inform the primary healthcare provider. 3. Complete an incident (variance) report. 4. Document client assessment and response to medication. 5. Document medication error and incident (variance) report in nurse's notes.

1., 2., 3., & 4. Correct: Nurses must immediately report all client care issues, concerns or problems to the supervising nurse, the primary healthcare provider and/or the performance improvement or risk management department. A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). Documentation of what occurred, and the client's assessment is required in the nurse's notes. 5. Incorrect: Do not document that an error was made or that an incident (variance) report was completed. Document what medication was given, the client's assessment, the notification of the nursing supervisor, and primary healthcare provider, and any prescriptions received.

The nurse is reviewing some clients' prescriptions. Which prescription should the nurse question and have corrected? Select all that apply 1. Furosemide 40 mg PO q.d. 2. Lisinopril 20.0 mg PO daily 3. Start MgSO4 at 3g/hr IV 4. Risperidone .5mg PO daily 5. Dexlansoprazole 30 mg PO daily

1., 2., 3., & 4. Correct: Nurses must use and recognize appropriate terminology and abbreviations to avoid potential client harm. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. So what is wrong with option #1? Well, do you see the q.d.? This is on the "Do Not Use" list of abbreviations because the period after the "Q" can be mistaken for "I", which would be interpreted as qid (four times a day) instead of the intended once daily dosage. Now, in Option #2, we see a dangerous prescription. There is a trailing zero after the prescribed dose. This could be devastating to the client if the decimal point is missed and the client receives 200 mg instead of the intended 20 mg of lisinopril. For Option #3, you may have recognized MgSO4 as being magnesium sulfate. However, it is on the "Do Not Use" list of abbreviations because it can be confused with morphine sulfate (MSO4). Administering 3 g/hr IV of morphine would be extremely dangerous. In option #4, we see that the leading zero is missing from the prescription. If the decimal point is missed in this situation, the client could receive 5 mg instead of the intended dose of 0.5 mg of risperidone. 5. Incorrect: This prescription is written correctly.

A nurse working in a clinic is planning to assess a client for any sensory deficits. What assessments should the nurse include? Select all that apply 1. Ask the client about any recent changes in vision. 2. Observe the client's conversation with others. 3. Assess two-point discrimination. 4. Perform the Rinne test. 5. Test near vision with the Snellen chart.

1., 2., 3., & 4. Correct: Physical assessment determines whether the senses are impaired. During the physical examination, the nurse assesses vision and hearing and the olfactory, gustatory, tactile, and kinesthetic senses. The exam should reveal the client's specific visual and hearing abilities, perception of heat, cold, light touch, pain in the limbs, and awareness of the position of body parts. Start with a history and ask about recent changes in vision. Observing client conversation with others can indicate hearing or communication problems. Two-point discrimination will assess tactile sense. The Rinne test assesses hearing. 5. Incorrect. Near vision is assessed by using the Rosenbaum eye chart. It consists of paragraphs of text or characters in different sizes on a 3.5 x 6.5 inch card. Be sure the client has a literacy appropriate for the text used.

A nurse, planning an educational seminar on chronic kidney disease, would invite clients with which medical conditions? Select all that apply 1. Polycystic kidney disease 2. Diabetes 3. Hypertension 4. Glomerulonephritis 5. Acute urinary tract infections (UTI)

1., 2., 3., & 4. Correct: Polycystic kidney disease is a genetic condition that causes damage to the kidneys. Clients with diabetes and hypertension make up more than 67% of clients diagnosed with chronic kidney disease. Glomerulonephritis damages the kidneys and can lead to permanent damage. 5. Incorrect: Acute UTIs do not generally lead to chronic kidney disease.

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? Select all that apply 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 en face position when holding the infant, pointing out common features, smiling and gazing at the infant, touching infant, progressing from fingertips to holding, speaking 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.

The nurse is discussing frostbite prevention with a group of teenagers who participate in cold weather activities. What risk factors for developing frostbite will the nurse include? Select all that apply 1. Alcohol use 2. Dehydration 3. Diabetes 4. Exhaustion 5. Low level alt

1., 2., 3., & 4. Correct: Risk factors for developing frostbite include alcohol and drug abuse, dehydration, medical conditions such as diabetes or any condition that results in poor blood flow to the extremities, fatigue and exhaustion. 5. Incorrect: Being at a high altitude reduces the oxygen supply to extremities and places the person at increased risk for developing frostbite.

The nurse is preparing to educate a client diagnosed with essential hypertension on how to decrease the risk of developing complications. What topics should the nurse include? 1. Following the DASH dietary plan. 2. Use of blood pressure monitoring device. 3. Diaphragmatic breathing exercises. 4. Brisk walking for 30 minutes 3-4 times/week. 5. Reduce sodium intake to less than 2700 mg/day.

1., 2., 3., & 4. Correct: The DASH Eating Plan is recommended for clients who have hypertension. It is high in vegetables, fruits, low-fat dairy products, whole grains, poultry, fish, beans, and nuts and is low in sweets, sugar-sweetened beverages, and red meats. Home blood pressure monitoring can help the client keep closer tabs on their blood pressure, show if medication is working, and even alert the client and primary healthcare provider to potential complications. However, home blood pressure monitoring isn't a substitute for follow-up visits. Reducing stress as much as possible helps to decrease blood pressure. Healthy coping techniques, such as muscle relaxation, deep breathing or meditation are good options. Getting regular physical activity and plenty of sleep can help, too. Regular physical activity can lower blood pressure, manage stress, reduce the risk of several health problems and keep weight under control. 5. Incorrect: A limit of 1500 mg of sodium per day is preferred on the low sodium DASH diet. On the standard DASH diet 2,300 mg of sodium are allowed each day.

A client who was diagnosed with amyotropic lateral sclerosis (ALS) has been immobile for 2 weeks. Which of the nursing interventions would the nurse implement? Select all that apply 1. Explore diversional activities. 2. Perform range of motion exercises. 3. Maintain the feet in dorsiflexion position. 4. Assess pressure points for skin changes. 5. Encourage a fluid intake of 1500 mL/24 hours.

1., 2., 3., & 4. Correct: The client's immobility may lead to apathy and isolation. The nurse should explore diversional activities which can reduce the frustration and depression of being immobile. Immobility will result in muscle weakness and decreased venous return. The client is encouraged to perform active range of motion exercises. Also passive range of motion exercises should be performed if the client cannot perform the active exercises themselves. Due to the client's decreased movement of the ankles, the client's feet should be positioned in the dorsiflexion position to prevent plantar flexion contractures. A bed board should be positioned to the foot of the bed. Active and passive range of motion exercises to the ankle and foot will promote proper joint movement. An immobile client's skin is affected by extrinsic, intrinsic, and shear forces. A decrease in the client's perfusion and peripheral circulation are intrinsic factors. The immobile client is experiencing the extrinsic factor of increased skin temperature at the skin pressure points. Moving the immobile client may result in a shearing force on the skin. 5. Incorrect: The effects of immobility on the urinary system may include urinary retention, renal calculi, and urinary tract infections. Also the immobile client may experience constipation if the fluid intake decreases. The fluid intake for a healthy adult is recommended at 2200 - 2700 mL per 24 hours.

The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. The nurse has just completed a 12 hour shift. What options would be appropriate for the nurse to take? Select all that apply 1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action. 5. Simply accept the assignment since overtime is mandatory.

1., 2., 3., & 4. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. Splitting the overtime shift is an acceptable option that the nurse could suggest in order to solve the staffing problem and decrease the amount of time the nurse will be working. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. This documentation should go to your manager. Refuse the assignment, being prepared for disciplinary action. If your reasons for refusal were client safety, nurse safety, or an imperative personal commitment, document this carefully including the process you used to inform the facility (nurse manager) of your concerns. Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. 5. Incorrect. The nurse can also accept the assignment; however, that nurse should document professional concern for client safety and the process you used to inform the facility (manager) of your concerns. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court

What strategies for smoking prevention could the school nurse recommend to the community task force? Select all that apply 1. Have a "Pledge Campaign" asking students not to use tobacco. 2. Include effects of smoking in health classes. 3. Enlist help from celebrities who are against smoking. 4. Conduct a "Don't Smoke" poster contest aimed at seventh graders. 5. Start a smoking cessation class for students who currently smoke.

1., 2., 3., & 4. Correct: These are all activities that the nurse could recommend. All are primary prevention strategies that may educate and influence students to abstain from smoking. 5. Incorrect: This is a worthy activity; however, it is for students who are already smoking and wish to stop. This is not primary but tertiary prevention.

What signs of cannula displacement should the nurse monitor for at an arterial line insertion site? Select all that apply 1. Swelling 2. Fluid leakage 3. Blanching 4. Poor arterial waveform 5. Pyrexia 6. Purulent drainage

1., 2., 3., & 4. Correct: These are signs of cannula displacement. Observe for signs of cannula displacement into the tissues which will be swelling, bleeding, lack of a normal arterial waveform, fluid leakage, blanching, and pain or discomfort. 5. Incorrect. This is a sign of infection rather than cannula displacement. Signs of infection include pain, redness, purulent drainage, and fever. 6. Incorrect. This is a sign of infection rather than cannula displacement.Signs of infection include pain, redness, purulent drainage, and fever.

The client diagnosed with active tuberculosis has been prescribed isoniazid 300 mg by mouth every day. What should the nurse teach this client? Select all that apply 1. "Notify your healthcare provider if your urine turns dark." 2. "Your healthcare provider has prescribed B6 along with the isoniazid to prevent neuritis." 3. "You should avoid eating aged cheeses and smoked fish." 4. "Eat foods such as tuna twice a week." 5. "Rise slowly from lying to sitting, or sitting to standing."

1., 2., 3., & 5 Correct: Signs of hepatotoxicity from this medication include dark urine, jaundice, and clay-colored stool. Isoniazide- induced pyridoxine (Vitamin B6) depletion causes neurotoxic effects. Vitamin B6 supplementation of 10-50 mg usually accompanies isoniazid use. Aged cheeses and smoked fish are high in tyramine which may cause palpitations, flushing, and blood pressure elevation while taking isoniazid. Avoid these foods during treatment. Isoniazid should be taken on an empty stomach, one hour before or two hours after food. Some clients experience orthostatic hypotension while taking isoniazid, so caution against rapid positional changes. 4. Incorrect: Histamine containing foods such as tuna and yeast extracts may cause exaggerated drug response (H/A, hypotension, palpitations sweating, itching, flushing, diarrhea).

A client who has recurrent episodes of allergic rhinitis asks the nurse what could be done to decrease symptoms. What instruction should the nurse provide to this client? Select all that apply 1. Remove pets from interior of home. 2. Treat a stuffy nose with warm salt water. 3. Remove carpeting. 4. Stay inside when pollen count is at its lowest. 5. Wash bed linens in hot water.

1., 2., 3., & 5. Correct: Controlling pet dander and other pet allergens is one way to reduce allergic rhinitis. Keep pets outside. Cleaning nasal passages with saline solution (warm salt water) will relieve stuffy nose. Control dust and dust mites by dusting regularly, removing carpeting and washing bed linens in hot water. 4. Incorrect: Stay inside with closed doors and windows during high-pollen season.

A client who is at high risk for developing a stroke has been advised to follow a Mediterranean type diet by the primary healthcare provider. Which food choices, if selected by the client, would indicate to the nurse that the client understands this diet. Select all that apply 1. Grilled eggplant 2. Purple grape juice 3. Bacon 4. Cashews 5. Skim milk 6. Salmon

1., 2., 4., 5., & 6. Correct: It is reasonable to counsel clients to follow a Mediterranean-type diet over a low-fat diet. The Mediterranean type diet emphasizes vegetables, fruits, and whole grains and includes low fat dairy products, poultry, fish, legumes, and nuts. It limits intake of sweets and red meats. 3. Incorrect: Substitute fish and poultry for red meat. When eaten, make sure it's lean and keep portions small (about the size of a deck of cards). Also avoid sausage, bacon and other high-fat meats.

A client is admitted to the Labor & Delivery Unit with severe preeclampsia. Which nursing intervention does the nurse include in the plan of care for this client? Select all that apply 1. Monitor for headache. 2. Place client in left recumbent position. 3. Insert indwelling urinary catheter. 4. Administer propranolol for BP > 100 diastolic. 5. Initiate external fetal heart monitoring.

1., 2., 3., & 5. Correct: Headache is a sign of increasing BP and increasing ICP. The left recumbent position moves the fetus off the mom's aorta and will help decrease the BP. This client needs to have UOP closely monitored because of the fluid volume excess (FVE), so an indwelling urinary catheter is needed. The fetus needs to be monitored for complications, and the fetal heart rate (FHR) should be 120-160/minute so close monitoring is required. 4. Incorrect: Propranolol, a beta blocker, is not given during pregnancy as it decreases HR and the amount of blood pumped by the heart. This can cause fetal bradycardia, decreased cardiac output, and potential for fetal demise.

What risk factors should the nurse include when teaching a group of clients about osteoarthritis? 1. Sports injury to joint 2. Genetic predisposition 3. Obesity 4. Male sex 5. Repetitive joint stress

1., 2., 3., & 5. Correct: Injuries, such as those that occur when playing sports or from an accident, can increase the risk of osteoarthritis. Some people inherit a tendency to develop osteoarthritis. Carrying extra body weight contributes to osteoarthritis. If a person's job or a sport places repetitive stress on a joint, that joint might eventually develop osteoarthritis. 4. Incorrect: Women are more likely to develop osteoarthritis, though it isn't clear why.

What discharge education should a nurse provide to a client post hip replacement with a metal joint? 1. Weight bearing limits. 2. Use of a high seated chair. 3. Sexual intercourse in dependent position for up to six months. 4. Avoid taking showers. 5. Use of long handled tongs to assist with dressing.

1., 2., 3., & 5. Correct: Weight bearing limits on the involved extremity varies according to the healthcare providers preference but are commonly prescribed. The client needs to avoid flexion. This includes sitting in low chairs and getting into a bath tub; elevated toilet seats and raised seats are necessary. Sexual intercourse should be carried out with the client in a dependent position (flat on the back) for 3-6 months to avoid excessive adduction and flexion of the new hip. To avoid flexion when dressing, adaptive devices and utensils may be used to help with bathing, dressing and personal hygiene. 4. Incorrect: Showers are preferable as getting into a tub would cause flexion of the new hip. This could cause the hip to dislocate.

What discharge education should a nurse provide to a client post hip replacement with a metal joint? Select all that apply 1. Weight bearing limits. 2. Use of a high seated chair. 3. Sexual intercourse in dependent position for up to six months. 4. Avoid taking showers. 5. Use of long handled tongs to assist with dressing.

A client is admitted with a diagnosis of disorganized schizophrenia. What characteristic should the nurse anticipate being manifested? Select all that apply 1. Evidence of loose associations 2. Use of neologisms and clang associations 3. Unpredictable or inappropriate emotional responses 4. Presence of stupor or presence of waxy flexibility 5. Suspiciousness and delusions of persecution 6. Flat or inappropriate affect

1., 2., 3., & 6. Correct: Disorganized schizophrenia is characterized by social withdrawal and disorganization in speech, behavior, and emotional expression. One of the characteristics that you may see in a client with disorganized schizophrenia includes evidence of loose associations in which the client rapidly shifts topics when speaking without any logical connection between the thoughts. Clients with disorganized schizophrenia may also use neologisms which are made up words that only have meaning to them, or they may have clang associations where they use words that typically rhyme but have no connection in meaning. Unpredictable or inappropriate emotional responses are common in clients with disorganized schizophrenia. They have a lack of impulse control and exhibit behaviors that are bizarre or lack purpose. Even activities of daily living can be difficult or impossible for the client to complete. These clients often exhibit flat or inappropriate affect. Their facial expressions, voice tone, and mannerisms may show little or no emotion or have responses that are inappropriate to the situation. 4. Incorrect: Presence of stupor or presence of waxy flexibility are characteristics of catatonic schizophrenia. There can be a total lack of psychomotor activity or you may see the client assume a position that is maintained until moved by another person. Once moved, the client then maintains that set position. 5. Incorrect: Suspiciousness and delusions of persecution are classic signs of paranoid schizophrenia.

A nurse is teaching a client the advantages of having a PICC line inserted rather than a peripheral IV. What information should the nurse include? Select all that apply 1. TPN may be infused using a PICC line. 2. Use of a PICC can allow for early client discharge. 3. PICC lines do not have to be replaced as often as a peripheral IV line. 4. PICC lines have the same risk of infection as a peripheral IV line. 5. PICC lines do not need to be flushed as frequently. 6. PICC placement decreases the need for skin puncture when blood sampling is needed.

1., 2., 3., & 6. Correct: Peripheral IV lines must be changed every 72-96 hours. PICC lines may remain in place for extended periods of time. A PICC can be cared for at home by home care nurses, family members, or in outpatient clinics. TPN cannot be administered via a peripheral line since it is hypertonic. PICC lines offer a lower chance for infection than a peripheral line. As long as the PICC is functioning and there is no evidence of infection, the PICC line can remain in place until it is no longer needed. 4. Incorrect: PICC lines are long lasting, so the risk of infection from changing sites is eliminated. Additionally, sterile technique is used for insertion, with sterile dressing changes. Precautions should still be taken to prevent complications. 5. Incorrect: Both peripheral and central lines need to be flushed to maintain patency.

Which health promotion instructions should the nurse provide to a client diagnosed with cirrhosis? 1. Use a shower chair when performing hygiene. 2. Limit alcohol intake. 3. Stop any activity that causes dizziness. 4. Calculate daily sodium intake. 5. Proper hand hygiene.

1., 3., 4., & 5. Correct: Using a shower chair while showering and performing hygiene will help to save energy. Stop any activity that causes chest pain, a marked increase in shortness of breath, dizziness, or extreme fatigue or weakness. High sodium promotes fluid volume excess. The client should maintain a low sodium intake. Proper hand hygiene prevents infection. 2. Incorrect: The client must stop drinking alcohol to halt the progression of cirrhosis.

A client states, "I have not had a drink for 24 hours and I am beginning to feel anxious". What additional signs/symptoms would indicate to the nurse that the client is in the early phase of alcohol withdrawal? Select all that apply 1. Agitation 2. Insomnia 3. Course tremors 4. Visual hallucinations 5. Confabulation 6. Tachycardia

1., 2., 3., & 6. Correct: The earliest signs of alcohol withdrawal are anxiety, agitation, insomnia, and tremors. Tachycardia of 120-140 /min persists throughout withdrawal. 4. Incorrect: The onset of hallucinations indicates alcohol withdrawal delirium, a potentially fatal complication of alcohol withdrawal that occurs when the withdrawal process has not been medically managed. It begins the 2nd or third day after the client's last drink and lasts 48-72 hours. 5. Incorrect: Confabulation is a symptom of alcohol amnestic disorder or Korsakoff syndrome. Thiamine deficiency is thought to cause this syndrome.

The nurse is discussing television, video games, and internet usage with a group of parents who have 8 to 10 year old children. What should the nurse include? 1. Keep TVs, iPads, and other screens out of kids' bedrooms. 2. Turn off all screens during meals. 3. Allow screen time only after chores and homework are complete. 4. Have a screen free day once a week. 5. Limit screen time to 2 hours daily. 6. Use screen time as a reward for good behavior.

1., 2., 3., 4 & 5. Correct: It is wise to keep TV, internet and other digital media out of children's rooms. When these devices are in children's bedrooms, it's much more difficult to monitor what's going on. Turn off digital devices during meals. This allows parents to be involved in the lives of their children. Those intimate life details are required for successful parenting. So, parents should observe, listen, ask, and parent. Declare a "screen free day" once a week where nobody watches TV, uses the computer or plays video games. This allows for more family activities like bike rides and hikes. The American Academy of Pediatrics suggests limiting entertainment screen time -- including TV, video games and computer use -- to two hours a day for kids ages 6 - 10 years of age. 6. Incorrect: Screen time should not be used as a reward. Parents should set guidelines on when the child can have screen time; for example, after homework or when chores are complete.

The nurse is discussing television, video games, and internet usage with a group of parents who have 8 to 10 year old children. What should the nurse include? Select all that apply 1. Keep TVs, iPads, and other screens out of kids' bedrooms. 2. Turn off all screens during meals. 3. Allow screen time only after chores and homework are complete. 4. Have a screen free day once a week. 5. Limit screen time to 2 hours daily. 6. Use screen time as a reward for good behavior.

A 19 year old client preparing to enter college asks the clinic nurse about immunizations. What immunizations should the nurse suggest the client discuss with the primary health care provider? Select all that apply 1. Meningococcal conjugate vaccine 2. Tdap vaccine 3. HPV vaccine 4. Seasonal flu vaccine 5. Hepatitis B 6. Polio

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

The nurse providing palliative care to a client would include which outcomes in the teaching plan? Select all that apply 1. Maintaining the client's quality of life 2. Minimizing family caregiver stress 3. Managing the client's pain 4. Managing the client's and family's emotional needs 5. Attending to the client's spiritual needs 6. Ensuring the client understands that disease focused treatments will cease

1., 2., 3., 4. & 5. Correct: Palliative care includes supporting the client's and family's quality of life. Palliative care includes managing pain and symptoms. Palliative care includes managing the client's and family's emotional needs and attending to their spiritual needs. 6. Incorrect: Palliative care includes treatment of discomfort, symptoms, and stress of serious illness. Disease focused treatments will not cease.

Which signs/symptoms does the nurse expect to note when caring for a client with a suspected cystitis? Select all that apply 1. Incontinence 2. Urgency 3. Frequency 4. Hematuria 5. Nocturia 6. Flank pain

1., 2., 3., 4. & 5. Correct: Signs and symptoms of cystitis include burning on urination, nocturia, incontinence, suprapubic or pelvic pain, hematuria, and back pain. 6. Incorrect: Flank pain is seen when the urinary tract infection progresses to the kidneys.

An occupational health nurse works in a factory where loud equipment is used in production of the factory's product. What should the nurse emphasize to factory management persons to reduce the risk of hearing impairment? Select all that apply 1. Supply workers with earplugs when exposed to noise. 2. Replace high noise machinery with low noise machinery. 3. Limit amount of time a person spends at a noise source. 4. Operate noisy machines during shifts when fewer people are exposed. 5. Supply personal noise monitoring to identify employees at risk from hazardous level of noise. 6. Have all employees make an appointment for a hearing test.

1., 2., 3., 4., & 5. Correct: All of these are primary prevention methods of controlling hearing loss in employees exposed to hazardous noise levels. Earplugs, or earmuffs, are considered an acceptable but less desirable option to control exposures to noise and are generally used during the time necessary to implement engineering and administrative controls to protect worker's hearing. Engineering controls include choosing low noise tools and machinery, maintaining and lubricating machinery and equipment, placing a barrier between the noise source and employed, and enclosing or isolating the noise source. Administrative controls are changes in the workplace that reduce or eliminate the worker's exposure to noise. This includes operating noisy machines during shifts when fewer people are exposed, limiting the amount of time a person spends at a noise source, and using monitoring equipment to monitor hazardous noise level. 6. Incorrect: Some employees may need a hearing test but this will not reduce the risk of hearing impairment. This is secondary prevention, which focuses on screening and early diagnosis of disease.

What food should the nurse include when teaching an older adult about increasing vitamin B12 intake? Select all that apply 1. Calf liver 2. Feta cheese 3. Fresh spinach 4. Shrimp 5. Tuna 6. Tofu

1., 2., 4., & 5. Correct: A serving of just one ounce of beef liver contains well over the amount of B12 that the average person needs for the day. Feta cheese contains a good amount of vitamin B12 as well as several other important nutrients such as calcium and vitamin B2. Shrimp contain about 80 percent of the daily value needed of vitamin B12. Tuna either canned or grilled has a lot of vitamin B12. In fact, just one three ounce serving offers an entire day's worth of vitamin B12. 3. Incorrect: Fresh spinach does not have any vitamin B12. 6. Incorrect: Tofu is low-carb, dairy-free, gluten-free, cholesterol-free, and vegan, so it is popular with people who have specialized diets. However, vitamin B12 is not in tofu.

The case manager is arranging a planning meeting for the care of a client diagnosed with chronic obstructive pulmonary disease (COPD). Who should be included in the meeting? Select all that apply 1. Client 2. Nurse 3. Pulmonologist 4. Social worker 5. Pharmacist 6. Occupational therapist

1., 2., 3., 4., & 5. Correct: Care coordination is the deliberate organization of and communication about client care activities between two or more members of the healthcare team, including the client. Nursing is involved with the client 24 hours a day. So, the nurse has knowledge of the client that others may not have. The pulmonologist is the specialist who deals with chronic pulmonary issues and will guide medical care with the team. The social worker may be able to assist the client with financial information and any home care arrangements. The pharmacist will be able to discuss medication regimen that the client is receiving and make suggestions regarding other medications or medication interactions. 6. Incorrect: In this case, the occupational therapist is not needed. Occupational therapists help clients with activities of daily living and modifications to the home environments. Nothing in the stem indicates that this service is needed.

A nurse is planning a health fair in a Hispanic community composed of primarily young adults. What would be essential for the nurse to provide to this community at the health fair? 1. Blood pressure screening 2. Glucose monitoring 3. Influenza vaccination 4. BMI calculation 5. Test urine for protein. 6. Pneumococcal vaccination

1., 2., 3., 4., & 5. Correct: In order to answer this question correctly, the test taker needs to understand what is considered young adulthood (ages 18 to 40 yrs). Middle adulthood is from ages 40 to 65 yrs and late adulthood is greater than 65+ yrs. You also need to know what Hispanics are at risk for. Hispanics have a higher incidence of death from heart disease and stroke. Blood pressure monitoring is essential to detect and control hypertension. Diabetes is prevalent in the Hispanic community. Early diagnosis is critical to manage and control for the risk of complications. Flu vaccination is recommended for all ethnic groups. Obesity is very high among Hispanic Americans at >70%. Chronic renal failure is a high risk for Hispanic Americans particularly since diabetes is prevalent. Early testing for protein in urine is recommended. 6. Incorrect: Pneumococcal vaccination is recommended for older adults (greater than age 65).

A nurse is planning a health fair in a Hispanic community composed of primarily young adults. What would be essential for the nurse to provide to this community at the health fair? Select all that apply 1. Blood pressure screening 2. Glucose monitoring 3. Influenza vaccination 4. BMI calculation 5. Test urine for protein. 6. Pneumococcal vaccination

Which vaccines would a nurse participating at a health fair encourage a 65 year-old adult to receive? Select all that apply 1. Influenza 2. Herpes Zoster 3. Diphtheria 4. Pertussis 5. Pneumococcal vaccine 6. Measles, mumps, and rubella (MMR)

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

Safety and Infection Control The homecare nurse is providing family teaching on safety issues for a client diagnosed with Parkinson's disease. What adaptations should the nurse instruct the family to initiate? Select all that apply 1. Install grab bars on tub walls. 2. Place nightlights in hallways. 3. Add bran and fiber to daily diet. 4. Remove scatter rugs or loose cords. 5. Keep bedroom dark, cool and quiet. 6. Put tennis balls on legs of walker.

1., 2., 3., 4., & 5. Correct: Parkinson's disease causes deterioration of the basal ganglia, ultimately impacting motor control and function. As muscles become stiff and rigid, mobility slows, resulting in poor coordination and loss of balance. Safety is a chief concern in all ADLs, requiring modifications in activity, nutrition, and the client's environment. Because Parkinson's disease affects mobility, modification such as grab bars and night lights are essential. Clients develop constipation because of decreased peristalsis, so adding bran and fiber can address impending bowel issues. Scatter, or throw, rugs along with loose extension cords on the floor create a fall risk because the client is unable to pick up feet during ambulation. The shuffling gait that develops increases the risk for falls. These clients also have problems with insomnia along with poor REM sleep, leading to daytime drowsiness. Making the bedroom conducive to sleep may help alleviate symptoms for a period of time. A dark, cool room with no distractions is the most appropriate sleep environment. 6. Incorrect: The proper method of utilizing a walker is to step into the walker, pause and then move it forward before stepping again. Even though clients with Parkinson's disease have a shuffling gait and stooped posture, sliding a walker with tennis balls on the walker legs presents a serious safety issue. The client would not have the ability to control the speed or hold the walker steady while stepping into it.

A child is brought into the emergency department (ED) after accidently ingesting 3 grams of acetylsalicylic acid. Initial assessment reveals lethargy, excessive sweating, hyperventilation, and hyperthermia. What interventions should the nurse initiate? Select all that apply 1. Provide tepid water sponge bath. 2. Start an IV for fluid resuscitation. 3. Insert a nasogastric tube. 4. Pad side rails. 5. Obtain blood gases. 6. Administer ipecac syrup orally.

1., 2., 3., 4., & 5. Correct: This client has hyperthermia. Methods to decrease temperature include external cool down, such as with a tepid water sponge bath. Dehydration occurs early in aspirin poisoning due to vomiting and hyperventilation. IV fluid is needed to offset the dehydration. Gastric lavage and activated charcoal are needed to deactivate the aspirin. The child is at risk for seizures so pad the side rails for safety. Care is based on blood gas results. Metabolic acidosis is the imbalance of the most concern. 6. Incorrect: Although ipecac syrup was used commonly in the past to make a client vomit, it is rarely recommended today. It would not be suggested in aspirin poisoning due to the chance that the client might develop altered mental status or convulsions.

A nurse manager has several issues regarding staff maintaining proper infection control while caring for clients. What actions should the manager take regarding this issue? Select all that apply 1. Place colorful posters regarding infection control in conspicuous places on unit. 2. Monitor staff providing client care for the use of appropriate infection control. 3. Give staff a written test on proper infection control. 4. Have all staff read agency policy and procedures regarding infection control. 5. Dock pay of staff who do not maintain proper infection control. 6. Provide mandatory in-service sessions on infection control for every shift.

1., 2., 3., 4., & 6. Correct. Each of these actions can be taken by the nurse manager. The staff needs further education, reminders, and follow-up observation. Posters are great reminders of concepts. All nurses need to supervise those under their direction. Testing can be done as pretest or post test along with in service education. Staff development or in service sessions are required by Joint Commission on Accreditation of Healthcare Organizations (JCHO) on infection control. 5. Incorrect. This is not the best solution, because most people want to do what is right. Education should be tried first, then documentation of the infractions. You must support, supervise and educate!

The nurse is discussing appropriate toys for preschoolers with a group of parents. What toys should the nurse include? Select all that apply 1. Six piece jigsaw puzzles 2. Puppets 3. Paint brush and paint set 4. Dress up clothes 5. Jump rope 6. Sewing cards

1., 2., 3., 4., & 6. Correct: Large piece puzzles, puppets, paint and brush set, clothes for dress up and sewing cards are appropriate for the preschooler. 5. Incorrect: Jump rope is an example of the increased development of gross motor skills of the school-age child.

A client who is 36 weeks gestation has been admitted to the labor and delivery area for evaluation due to worsening signs of pregnancy induced hypertension (PIH). The BP upon arrival is 168/96. While being monitored, she reports a sudden onset of severe abdominal pain. Further nursing assessment reveals vaginal bleeding, abdominal rigidity, and a fetal heart rate of 90/min on the fetal monitor. What nursing actions would be appropriate for this client? Select all that apply 1. Continuously monitor the client's vital signs. 2. Keep the mother informed of the fetus' condition. 3. Careful monitoring of the fetal heart rate electronically. 4. Accurate measurement of I & O. 5. Prepare for emergency vaginal delivery. 6. Monitor for restlessness and decreased level of consciousness (LOC).

1., 2., 3., 4., and 6. Correct: The nurse recognizes that the client is demonstrating signs of placental abruption (abruptio placentae), most likely due to the presence of PIH. Due to the risk of shock, the maternal vital signs are checked immediately and continuously monitored. The mother will be aware of the emergent nature of her situation. She will need to be informed of what is occurring and kept informed of the status of the fetus. Accurate measurement of I&O, in addition to assessing the amount of vaginal blood loss, will be crucial in determining fluid volume status. Restlessness and decreasing level of consciousness would indicate poor cerebral perfusion as a result of decreased vascular volume and decreased cardiac output. Fluid and blood replacement would be indicated. 5. Incorrect: T

A nurse is planning to provide information to a group of adults considering smoking cessation. What information should the nurse include? Select all that apply 1. Nicotine is the drug in tobacco products that produces dependence. 2. Withdrawal symptoms may include irritability, difficulty concentrating, and increased appetite. 3. Stopping smoking reduces the risk of coronary heart disease. 4. All smokers need to have a prescription for bupropion SR in order to quit. 5. Refer to smoking quit-lines that offer free support, advice, and counseling from experienced coaches.

1., 2., 3., 5. Correct: These are correct statements. Nicotine is the drug in tobacco products that produces dependence. Other withdrawal symptoms include anxiety and cravings for a cigarette. There are many health benefits to smoking cessation including reducing the risk of coronary heart disease, stroke, peripheral vascular disease, COPD and reduced risk for infertility in women. Clients should be referred to educational programs and support groups. 4. Incorrect: The majority of cigarette smokers quit without using this prescription; however, treatments can help the smoker quit, so they should discuss possible medications with their primary healthcare provider. Other medications such as the nicotine patch or varenicline (chantix) may also be used to assist with smoking cessation.

Which signs/symptoms does the nurse expect to see in a client diagnosed with Bell's Palsy? Select all that apply 1. Drooping of one side of the face. 2. Inability to wrinkle forehead. 3. Excessive tearing. 4. Decreased sensitivity to sound. 5. Inability to taste. 6. Numbness of affected side of fac

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

A client is being evaluated for possible Rheumatoid Arthritis (RA). Which lab data and assessment findings by the nurse would be indicative of RA? Select all that apply 1. Joint pain, swelling, and warmth. 2. Decreased movement in joints. 3. Presence of Rheumatoid factor on lab analysis. 4. Presence of Dupuytren's contractures. 5. Elevated erythrocyte sedimentation rate (ESR). 6. Presence of Cyclic Citrullinated Peptide Antibody.

1., 2., 3., 5., & 6. Correct: Classic features of RA include joint pain, swelling, and tenderness worsened by movement and stress placed on joint. Morning stiffness that often lasts for one hour or more and limited movement in joints are common manifestations as well. The Rheumatoid Factor is present in 80% of adults who have rheumatoid arthritis. The ESR blood test is elevated with RA and is used to determine if an abnormal level of inflammation exists in the body. The cyclic citrullinated peptide antibody, if present, helps to confirm the diagnosis of RA and may indicate the risk of having severe symptoms. Levels that are at a moderate to high level may indicate that the client is at increased risk for damage to the joints. 4. Incorrect: Dupuytren's contractures are a type of hand deformity where a layer of tissue under the skin in the palms of the hands is affected. Hard knots form in the palm areas and eventually create a thick cord that can pull one or more of the fingers into a bent position. However, this is not associated with RA.

The nurse is talking with parents of school-aged children about promoting healthy eating in their children. What information should the nurse provide? Select all that apply 1. Skipping breakfast will decrease energy level and could lower school grades. 2. Freeze fruit before placing in lunch box to keep it tasting fresh. 3. Limit snacks to when the child is hungry, rather than bored. 4. Enforce rule that child must eat food even if they do not like it. 5. The parent should eat a variety of foods as an example to children. 6. Prepare homemade healthy version of favorite take out meals.

1., 2., 3., 5., & 6. Correct: Don't let the child skip breakfast. The child will have less energy to play well later in the day. Skipping breakfast can also lower grades in school as concentration decreases. Freeze fruits before putting them in the lunch box. This will keep the lunch items cool and the fruit fresh tasty. Canned pineapple, bananas, and grapes freeze well. Children need to learn to eat only when they are hungry. Children often eat out of boredom. Discourage nonstop grazing by planning activities to occupy the child. Lead by example. Children eventually adopt the eating patterns of their parents. If they see the parents eat vegetables, they will eventually try them. Prepare homemade healthy versions of take out favorites. 4. Incorrect: Forcing children to eat foods they do not like will only deepen their dislike for them. Give them the healthy foods they do enjoy and eventually they will explore more options.

The nurse is monitoring the infection risk in a client that is to begin chemotherapy. Which activity should alert the nurse that the client is at a higher risk for infection? Select all that apply 1. Enjoys getting manicures and pedicures every two weeks. 2. Loves to go with the children to the local water park. 3. Relaxes in hot tubs when traveling. 4. Selects steamed vegetables as part of routine dietary intake. 5. Prefers to go barefooted when at home. 6. Keeps cats in the home and cleans the litter boxes once a week.

1., 2., 3., 5., & 6. Correct: Infection is one of the most common life-threatening complications associated with cancer and chemotherapy. You know that both the cancer and chemotherapy weakens the immune system. Therefore, clients on chemotherapy should be familiar with activities that should be avoided due to the risk of infection with the immunosuppressed state. There are several things that are known to increase the risk of infection in these clients. Did you pick up on these? Well, let's look at a few of these. Clients on chemo should not get manicures or pedicures at salons or spas and should avoid having false nails or nail tips applied. There is too great a risk of contamination at the public salons, so clients are encourage to use their own personal and well-cleaned tools for nail care at home. Another source of bacterial contamination is public water parks. Although these parks take measures to reduce the risk of infection to the general public, the risk is too great for a client on chemo. Swimming can result in accidental ingestion of water which increases the risk of cryptosporidium or other waterborne pathogens. Same thing applies to hot tubs. So why is going barefoot at home such a big deal? Well, this increases the risk of cuts, scrapes, or other injury that would increase the portal for infectious agents to enter. In addition, the exposure to potential infectious agents is greater. The oncologist may direct the client in the best way to deal with this client having cats in the home and cleaning the litter box due to the risk of exposure to bacteria and parasites. If allowed to clean the litter box, latex or rubber gloves, along with a mask over the nose and mouth is generally recommended to reduce the risk of infection. In addition, the client should be instructed to thoroughly wash the hands with soap and water after cleaning the litter box or after touching the cats. 4. Incorrect: Although the intake of fresh fruits and vegetables has been controversial, most agree that if washed properly, even fresh fruits and vegetables can be consumed. However, the oncologist should be the one to approve the dietary intake of these. Here, we have vegetables that have not only been washed, but steamed as well. These should be safe for consumption for clients on chemo

The nurse suspects a client admitted with myasthenia gravis is going into a cholinergic crisis. Which signs and symptoms would validate the nurse's suspicions? 1. Abdominal cramping 2. Lethargy 3. Salivation 4. Hypertension 5. Lacrimation 6. Miosis

1., 2., 3., 5., & 6. Correct: The signs of cholinergic crisis include Diarrhea and abdominal cramping, Urination increased, Miosis (pinpoint pupils), Bradycardia, Emesis (nausea and vomiting), Lacrimation, Lethargy, Salivation. Remember this: DUMBELLS as a mnemonic to help you recall these signs and symptoms. 4. Incorrect: Hypertension is not a sign of cholinergic crisis. Muscles get weaker so BP would go down.

A client who has been taking phenytoin for several years arrives to the clinic for follow-up care. During the nurse's history and physical of the client, which findings indicate a possible side effect to the phenytoin? Select all that apply 1. Skin rash 2. Reports fatigue 3. Dyspnea on exertion 4. Pale conjunctiva 5. Heart rate 60/min

1., 2., 3.,& 4. Correct: An adverse effect of phenytoin is aplastic anemia. Phenytoin is an anticonvulsant. Aplastic anemia is a blood disorder where not enough new blood cells are produced in the bone marrow. The blood cells include red blood cells, white blood cells and platelets. The most common symptom of decreased RBC's is fatigue and dyspnea upon exertion because RBC's are responsible for oxygen transport throughout the body. A common sign/symptom of aplastic anemia is also skin rashes. Collectively, these are signs/symptoms of aplastic anemia caused by this medication. 5. Incorrect: This is a normal heart rate, and there is no concern for vital signs within normal limits.

A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions of at risk clients. What steps should the QA manager include? Select all that apply 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Ask staff what fall precautions are taken 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. Correct: The QA manager can do chart reviews to see if staff are documenting fall precaution for a client. Direct observation of unit staff will let the QA manager know if staff are performing proper precautions while caring for clients. The first step is to identify what clients are at risk for falls and then see if the staff have identified these clients to be at risk as well. Monitoring should be at unpredictable intervals, so staff do not comply when it is time for an evaluation. 3. Incorrect: Ask the staff what they do to provide fall precautions for at risk clients does not ensure that they follow through. It will tell you if they know what should be done. The QA manager needs objective data and asking the staff is subjective data.

The nurse is caring for a client who has hypercholesterolemia. When evaluating the effects of atorvastatin, the nurse should monitor the results of which laboratory tests? 1. AST 2. Alkaline phophatase 3. Complete blood count 4. Serum cholesterol levels 5. Serum triglyceride levels

1., 2., 4. & 5. Correct: AST is a liver function test. Liver function tests including AST should be monitored before, at 12 weeks after initiation of therapy or after dose elevation, and then every 6 months. If AST levels increase to 3 times normal, atorvastatin should be reduced or discontinued. Atorvastatin may increase alkaline phosphatase and bilirubin levels. Atorvastatin is a lipid-lowering agent/HMG-CoA reductase inhibitor. The expected outcome of treatment with atorvastatin is lower serum cholesterol and triglycerides.3. Incorrect: The CBC results would not be used to evaluate the effectiveness of treatment with atorvastatin. The CBC is used to evaluate your overall health and can be used to measure components and features of your blood such as RBC'c, WBC's, Hgb, Hct and platelets.

A client is admitted to the hospital due to alcohol toxicity. Which interventions should the nurse initiate? Select all that apply 1. Pad side rails 2. Attach client to pulse oximeter 3. Monitor closely for hyperthermia 4. Place in recovery position 5. Monitor fluids and electrolytes

1., 2., 4. & 5. Correct: Alcohol toxicity can lead to behavior changes and alcohol-induced central nervous system depression which can lead to respiratory and circulatory failure. The client can also experience unconsciousness, or coma leading to possible death. The client can also experience hypokalemia, hypomagnesemia and hypoglycemia. Client is at risk for seizures so pad the side rails. Client is at risk for hypoventilation and may stop breathing. Pulse oximeter will measure oxygen levels. The recovery position decreases the risk for aspiration. Alcohol has a diuretic effect, so I&O should be monitored. 3. Incorrect: Due to the fluid shift, this client is at a higher risk for hypothermia. The client with alcohol toxicity is not at risk for hyperthermia.

A nurse is educating a group of community citizens about risk factors for developing peripheral neuropathy. Which risk factors should the nurse include? Select all that apply 1. Uncontrolled diabetes 2. Alcohol abuse 3. Vitamin A deficiency 4. Rheumatoid arthritis 5. Varicella-zoster virus

1., 2., 4. & 5. Correct: All are risk factors for peripheral neuropathy. 3. Incorrect: Vitamin A deficiency can result from inadequate intake, fat malabsorption, or liver disorders. Deficiency impairs immunity and hematopoiesis and causes rashes and typical ocular effects (e.g., xerophthalmia, night blindness). Vitamin B deficiency can cause peripheral neuropathy.

A client diagnosed with rheumatoid arthritis has been prescribed dexamethasone orally as part of initial treatment therapy. What side effects should the nurse teach the client are expected? Select all that apply 1. Fatigue 2. Insomnia 3. Hypoglycemia 4. Truncal obesity 5. Increased appetite 6. Low blood pressure

1., 2., 4. & 5. Correct: Dexamethasone (Decadron) is a corticosteroid used short term to treat severe inflammation occurring in rheumatoid arthritis (RA). Expected side effects are associated with the body's response to excessive steroids in the system. Even short term use of corticosteroids will produce fatigue, secondary to insomnia, truncal obesity accompanied by thin extremities, and an increased appetite resulting in weight gain. Despite the short and intermittent use of corticosteroids for this auto-immune disease, some side effects remain permanently. 3. Incorrect: Excessive steroids in the body cause blood glucose levels to increase, resulting in hyperglycemia. Clients taking corticosteroids will need regular finger stick glucose monitoring while taking these medications for rheumatoid arthritis. 6. Incorrect: The body's response to increased corticosteroids in the system is an elevated blood pressure, often accompanied by headaches or nausea. Clients taking steroids will need to have blood pressure checked frequently.

A client reports crushing chest pain 3 hours prior to arrival in the emergency department. Initial assessment by the nurse reveals a BP of 90/50, a weak, thready pulse at 108/min, cool, clammy skin, and confusion. Which interventions should the nurse perform? Select all that apply 1. Initiate cardiac monitoring. 2. Monitor intake and output hourly. 3. Position client in recumbant position. 4. Limit physical activity. 5. Administer dopamine at 5 micrograms/kg/min.

1., 2., 4. & 5. Correct: This client exhibits signs of cardiogenic shock, a complication of myocardial infarction. Hypotension accompanied by clinical signs of increased peripheral resistance (weak, thready pulse and cool, clammy skin) and inadequate organ perfusion (altered mental status and decreased urinary output) are found in this client. Initiate cardiac monitoring, watching for dysrhythmias, monitor I&O hourly to make sure kidneys are perfused. Limit activity to decrease oxygen demand. Dopamine is administered to increase BP and cardiac output. 3. Incorrect: Position upright to promote optimal ventilation by reducing venous return and lessen pulmonary edema.

A nurse works in the operating room (OR) as a circulator. Which actions should the nurse perform to help prevent surgical-site infections? Select all that apply 1. Keep the OR doors closed during a surgical case. 2. Minimize traffic in the OR. 3. Ensure the room has negative air flow. 4. Monitor the sterile field at all times. 5. Immediately discard any object that becomes contaminated.

1., 2., 4. & 5. Correct: Positive pressure can be used in rooms adjacent to a negative pressure room. The purpose of positive pressure is to ensure that airborne pathogens do not contaminate the patient or supplies in that room. Positive pressure could be used in an operating room to protect the patient and sterile medical and surgical supplies. Positively pressured rooms are typically considered the cleanest rooms in the hospital. Keeping the doors open impedes the air exchange system in the OR. The air exchange system is designed to decrease airborne contaminants in the OR. Limiting the traffic in the room decreases the amount of bacterial shedding, minimizes harmful air turbulence, and prevents accidental contamination of the sterile field. Contaminated objects break sterile field.3. Incorrect: Negative air flow has not been proven to prevent surgical-site infections. Negative air flow refers to an airborne infection isolation room. A negative pressure room in a hospital is used to contain airborne contaminants within the room. Harmful airborne pathogens including bacteria, viruses, fungi, yeasts, molds, pollens, gases, VOC's (volatile organic compounds), small particles and chemicals are part of a larger list of airborne pathogens you can find in a hospital. A negative pressure isolation room is commonly used for clients with airborne infections. For example, a client with active tuberculosis, a disease caused by the bacteria Mycobacterium tuberculosis, will be placed in a negatively pressurized room because the tuberculosis bacterium is spread in the air from one person to another. When the client with active tuberculosis sneezes or coughs, other people may become infected when they inhale. However, by using a negative pressure room you can better contain the bacterium within the room.

The nurse has been teaching the client about warfarin for prevention of pulmonary emboli. Which comments by the client indicate understanding of the medication? Select all that apply 1. "I must get my blood levels checked regularly." 2. "I shouldn't change my diet to include a lot of foods containing vitamin K without supervision." 3. "I should eat lots of foods containing vitamin K." 4. "I should report this medication to any primary healthcare provider that I see." 5. "I should not change the dosage without talking with my primary healthcare provider."

1., 2., 4. & 5. Correct: The client should comply with regular follow up visits for checks of INR level. INR is the international normalization ratio and is used for clients taking anticoagulants (blood thinning medications). The client should eat a normal healthy diet, but should not increase foods containing high amounts of vitamin K. The client should report using warfarin to any primary healthcare provider, as treatment may be changed due to this medication. The client should not manipulate the dosage unless instructed by the primary healthcare provider. An identification card or bracelet may also be recommended in case of emergencies. Clients should inform dentists and other healthcare providers especially before a medical procedure. The anticoagulant effect must be closely monitored.3. Incorrect: Vitamin K reverses the anticoagulant effects of warfarin, so instruct the client to avoid foods high in vitamin K (examples are green leafy vegetables, brussels sprouts, prunes, cucumbers and cabbage).

Which signs and symptoms experienced by the client correlate with chronic renal failure diagnosis? Select all that apply 1. Fatigue 2. Anorexia 3. Dark skin pigmentation 4. Swollen extremities 5. Hyperkalemia

1., 2., 4. & 5. Correct: The client will have fatigue from anemia and anorexia from toxins. Fluid volume excess leads to swollen extremities. Hyperkalemia can be caused by reduced renal excretion or excessive intake. 3. Incorrect: The client may have an uremic frost not dark skin pigmentation.

Which teaching points should the nurse include when preparing the school-age child for heart surgery? 1. Discuss postoperative discomfort and interventions. 2. Show unfamiliar equipment. 3. Explain that an endotracheal tube will be needed. 4. Let the child hear the sounds of an ECG monitor. 5. Answer questions about surgery using words at the child's level of understanding.

1., 2., 4. & 5. Correct: Yes, let the child talk about their feelings, fears and discomforts. Explain in simple terms what the child will see and experience the day of surgery. Let the child visit the surgical area to see and touch equipment. All of these interventions will help decrease anxiety during the pre and postoperative periods and reduces fear of the unknown. 3. Incorrect. Do not use big words or give too much detail of events of which the child will not be aware.

Which teaching points should the nurse include when preparing the school-age child for heart surgery? Select all that apply 1. Discuss postoperative discomfort and interventions. 2. Show unfamiliar equipment. 3. Explain that an endotracheal tube will be needed. 4. Let the child hear the sounds of an ECG monitor. 5. Answer questions about surgery using words at the child's level of understanding.

What discharge teaching should the nurse include to the parent of an adolescent who has a mild concussion? 1. Concussion symptoms may last anywhere from hours and days to weeks and months. 2. Return to the emergency department for worsening headache. 3. Monitor for increased intracranial pressure. 4. Avoid physical activities until released from care. 5. Awaken the client every two hours.

1., 2., 4., & 5. Correct. This injury will result in symptoms that may last anywhere from hours and days to potentially weeks and months. Contact the primary healthcare provider or the Emergency Department if the client has repeated vomiting, severe or worsening headache, severe or worsening dizziness, or any worsening symptom that alarms client or family. Avoid physical activities (sports, gym, and exercise) and reduce cognitive demands (reading, texting, computer use, video games, etc). The brain is responsible for managing physical and cognitive functions of the body; therefore, it is important to decrease any activity that increases symptoms. Awaken every two hours to check level of consciousness. 3. Incorrect. A lay person would not know the signs/symptoms of increased ICP.

Which signs/symptoms would lead a nurse to suspect Fifth disease in a child brought into a pediatric clinic? Select all that apply 1. Erythema on the cheeks. 2. Joint pain. 3. Temperature 102°F (38.88°C). 4. Swollen knees. 5. Pruritic rash on soles of feet.

1., 2., 4., & 5. Correct: These are common signs/symptoms of Fifth disease. 3. Incorrect: Low grade fever is seen with this disease.

Which assessment finding on a client four hours post right femoral percutaneous transluminal coronary angioplasty (PTCA) would require immediate intervention by the nurse? Select all that apply 1. Client reports chest discomfort. 2. Legs elevated 15 degrees. 3. Pressure dressing over puncture site intact/dry. 4. Client reports slight tingling to right foot. 5. Left pedal pulse 2+/4+, Right pedal pulse 1+/4+

1., 2., 4., & 5. Correct: All episodes of chest pain post PTCA should be reported to the primary healthcare provider as the artery may be occluding. After PTCA, the client will need to keep the affected extremity straight for several hours. In some cases, the primary healthcare provider may use a device that seals the small hole in the artery; that may allow the client to move around more quickly. Any neurovascular changes that are abnormal will require intervention. If the client starts reporting tingling or numbness to the right foot and a decrease in the grade force of the right pedal pulse is noted by the nurse, then the primary healthcare provider will need to be notified. 3. Incorrect: Having an intact and dry pressure dressing is a good thing. A pressure dressing will help prevent arterial bleeding. The dressing is intact and there is no bleeding. This is a good thing.

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? Select all that apply 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. 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 and may need suctioning if unable to clear secretions from the oropharynx. The client at the end stages of liver disease will be hypoxemic, so oxygen therapy is provided. 3. Incorrect: The unresponsive client will not need a walker.

A school nurse is planning to teach kindergarten students about oral health. Which points should the nurse include? Select all that apply 1. Do not drink soft drinks between meals. 2. Eat raw vegetables to help keep teeth clean. 3. Brush teeth twice a day with toothpaste that does not have fluoride. 4. Use a pea size amount of toothpaste. 5. Floss teeth daily.

1., 2., 4., & 5. Correct: Avoid sweet foods and drinks between meals. Take them in moderation at meals. Eat coarse, fibrous foods, cleansing foods, such as fresh fruits and raw vegetables. If unable to brush after a meal, vigorously rinse mouth with water. Teeth should be flossed daily. 3. Incorrect: Brush the teeth thoroughly with toothpaste that has fluoride.

The nurse is caring for a client post heart transplant who is being discharged on cyclosporine and azathioprine. Which precautions would be important for the nurse to teach the client? Select all that apply 1. Avoid crowds. 2. Do not obtain live vaccinations. 3. Drink at least 3 liters of fluids per day and watch the urine for sediment. 4. Use a soft-bristled brush to clean your teeth. 5. Advise to use contraceptive measures during treatment.

1., 2., 4., & 5. Correct: Both cyclosporine and azathioprine are immunosuppressants. Clients should be taught to protect themselves from sources of infection. Vaccinations are not given to immunocompromised clients. Avoidance of crowds will decrease the client's chance of contact with infections, especially those spread by droplets. As a general rule, significantly immunosuppressed clients should not receive live vaccines. Cyclosporine may cause growth of extra tissue in your gums so use a dentist regularly. These drugs are teratogenic. Clients should avoid pregnancy while on these medications.3. Incorrect: Drinking 3 liters of fluids per day will not prevent renal impairment.

A child has been diagnosed with varicella in the clinic. What should the nurse tell the parents about home treatment of the child? 1. Apply calamine lotion to affected areas several times a day. 2. Provide cool baths with baking soda. 3. Administer aspirin for fever. 4. Do not allow visitors who have never had varicella. 5. Keep fingernails trimmed short.

1., 2., 4., & 5. Correct: Calamine lotion and cool baths with baking soda will relieve itching. Anyone not vaccinated for chickenpox or who has never had chickenpox should not be exposed. Pregnant women and anyone with a weakened immune system (persons with HIV/AIDS, cancer, had a transplant, receiving chemotherapy, immunosuppressive medications, or long-term use of steroids) should avoid exposure. Keeping fingernails trimmed short may help prevent skin infections caused by scratching blisters. 3. Incorrect: Do not use aspirin or aspirin-containing products to relieve fever from chickenpox. The use of aspirin in children with chickenpox has been associated with Reye's syndrome, a severe disease that affects the liver and brain and can cause death. Instead, use non-aspirin medications, such as acetaminophen, to relieve fever from chickenpox. The American Academy of Pediatrics recommends avoiding treatment with ibuprofen if possible because it has been associated with life-threatening bacterial skin infections.

The nurse is discussing obesity prevention with a group of parents who have 3 and 4 year old children. What should the nurse include? Select all that apply 1. Ensure at least 11 hour of sleep. 2. Do not put a TV in the child's bedroom. 3. Select a day care center that provides physical activity opportunities every 4 hours. 4. Limit 100% fruit juice to 6 ounces (180 mL) per day. 5. Walk after the evening meal while the child rides a bike or skates.

1., 2., 4., & 5. Correct: Children between the ages of 2 and 5 should get between 11-12 hours of sleep each night. Keeping TVs out of bedrooms, creates an environment that promotes naps and nighttime sleep. Establishing sleep routines are all important to promoting healthy sleep habits. Fruit juice should be limited to 4-6 ounces (120-180 mL) per day, as excess consumption can lead to excess weight gain. Preschoolers should be encouraged to drink water. Role modeling behaviors such as exercise and doing it with the child encourages activity and decreases sedentary time. 3. Incorrect: The Institute of Medicine (IOM) stresses the importance of giving young children plenty of opportunity to be active during the day. Several states now require day care centers to provide the opportunity for at least two hours of physical activity during an eight-hour day. Selecting a day care that limits TV time and encourages play will promote a healthy lifestyle.

A school nurse is concerned that a teenager may have bulimia. What assessment findings would substantiate this belief? Select all that apply 1. Discolored teeth 2. Calluses on knuckles 3. Underweight 4. Dehydration 5. Hoarseness

1., 2., 4., & 5. Correct: Discolored teeth occur from exposure to stomach acid when throwing up. The teeth may look yellow, ragged, or translucent. Calluses or scars on the knuckles or hands from sticking fingers down the throat to induce vomiting. Dehydration can occur from excessive vomiting and laxative or diuretic abuse. Hoarseness and chronic sore throat can occur due to stomach acid getting in the throat when vomiting. 3. Incorrect: The client is not underweight, but has a changing weight. Most are within normal weight range but may become slightly underweight or slightly overweight.

An alcoholic client has agreed to take disulfiram 250 mg PO daily. The nurse recognizes that education has been successful when the client makes which statements? Select all that apply 1. "If I decide to stop taking disulfiram, I should not ingest any alcohol for at least 2 weeks or I will have a reaction." 2. "I must read labels carefully so that I know that alcohol is not an ingredient." 3. "I am allowed to eat chili made with beer since the alcohol evaporates from the chili with prolonged cooking." 4. "This medication is not a cure. I still need to attend therapy sessions." 5. "I should avoid eating a lot of chocolate while on this medication."

1., 2., 4., & 5. Correct: Disulfiram works by reacting with alcohol to produce negative side effect which may last up to two weeks after discontinuation of the drug.The client should not consume any alcohol including hidden alcohol such as mouthwash and cough syrups. Disulfiram is not a cure for alcoholism. It is used in combination with supportive care and psychotherapy. Disulfiram can increase the side effects of caffeine, so avoid chocolate and other caffeine containing substances.3. Incorrect: Not even a small amount of alcohol can be ingested. This includes sauces and foods made with alcohol vinegar and vanilla extract. Meat holds on to alcohol, so chili with beer in the sauce should not be consumed. Additionally, do not use after shave, cough mixtures, or rubbing alcohol.

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

1., 2., 4., & 5. Correct: High fiber foods include raw fruits, legumes, vegetables, whole breads, and cereals. Avocados have 10.5 grams of fiber per cup. Acorn squash has 9 grams of fiber per cup. Lima beans 13.2 grams of fiber per cup. Raspberries have 8 grams of fiber per cup. 3. Incorrect: Raw fruits have more fiber than cooked or processed fruits. A raw apple would provide more fiber than applesauce. 6. Incorrect: Milk and foods made from milk: such as yogurt, pudding, ice cream, cheeses, cottage cheese and sour cream are low fiber.

The nurse is teaching a group of clients how to decrease the risk of developing osteoarthritis (OA). What should the nurse include? Select all that apply 1. Control blood sugar. 2. Use largest, strongest joints for lifting. 3. Do intense aerobic exercise, daily. 4. Maintain a healthy weight. 5. Wear joint padding with playing sports.

1., 2., 4., & 5. Correct: High glucose levels speed the formation of certain molecules that make cartilage stiffer and more sensitive to mechanical stress. The client should use the largest and strongest joints and muscles. Use both arms when lifting or carrying an object. By using the largest and strongest joints, less stress occurs on single joints or weaker areas of the body. Excess weight is one of the biggest risk factors for osteoarthritis. Although injuries aren't always avoidable, it pays to protect joints. If playing sports, wear protective gear, such as joint padding for soccer or hockey. And make sure any baseball field uses break-away bases. 3. Incorrect: Physical activity is one of the best ways to keep joints healthy. As little as 30 minutes of moderately intense exercise five times a week helps joints stay limber and strengthens the muscles that support and stabilize the hips and knees. However, it does not have to be daily or intense.

Which client would be appropriate for the RN to assign to the LPN? Select all that apply 1. Client with cast to right leg requiring pain medication. 2. Client with chronic emphysema experiencing mild shortness of breath. 3. Client one day post kidney transplant. 4. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. 5. Client prescribed antibiotics for cystitis.

1., 2., 4., & 5. Correct: The client who has a cast and requires pain medication is a stable and predictable client. This client needs ongoing monitoring which is within the scope of practice for the LPN. The client with chronic emphysema has expected shortness of breath. This client is stable and predictable. The client post PEG placement is stable. The LPN can monitor the wound and provide care to the PEG insertion site. The client with cystitis is stable and has a predictable outcome. It is within the LPNs scope of practice to administer antibiotics. 3. Incorrect: This client does not have a predictable outcome. There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. This client will also need a lot of education regarding anti-rejection medications.

During the admission examination of a client diagnosed with acute pyelonephritis, what signs or symptoms would the nurse expect to find? Select all that apply 1. Dysuria 2. Costovertebral angle tenderness 3. Weight loss 4. Chills 5. Urinary frequency

1., 2., 4., & 5. Correct: The client with acute pyelonephritis, will often exhibit these signs/symptoms due to the kidney infection. 3. Incorrect: Weight loss is not a symptom of acute pyelonephritis. The client will more likely experience weight gain due to the decreased functioning of the kidneys.

A nurse is caring for a client diagnosed with the ebola virus who is experiencing vomiting and diarrhea. What personal protective equipment should be worn by the nurse while providing care to this client? Select all that apply 1. Single use impermeable gown 2. Powered Air Purifying Respirator (PAPR) or N95 respirator 3. One pair of sterile gloves 4. Single use boot covers 5. Single use apron

1., 2., 4., & 5. Correct: The nurse should wear a single use (disposable) impermeable gown OR a single use impermeable coverall. Either a PAPR or a disposable, NIOSH-certified N95 respirator should be worn to reduce the risk of contamination in the case of an emergency situation where a potentially aerosol-generating procedure would be performed. The PAPR reduces the risk of self-contamination while providing client care, but the N95 respirator is less bulky. If the N95 respirator is selected for use, nurses should be extremely careful to make sure that they do not accidentally touch their faces under the face shield during client care. Disposable boot covers should be worn and should extend to at least mid-calf. Some agencies may add the single use shoe covers over the boot covers to reduce the risk of contaminating the underlying shoes. If clients with Ebola are vomiting or have diarrhea, a single use (disposable) apron should be worn over the gown to cover the torso to mid-calf. This will provide additional protection to reduce the risk of contaminating the gown (or coveralls) by the infectious body fluids and also provides a way to rapidly remove a soiled outer layer if contamination occurs on the apron. 3. Incorrect: Sterile gloves are not required, but two pairs, instead of one pair, of gloves should be worn so that a contaminated outer glove can be safely removed when providing client care or safely removed without self-contamination when removing the PPE. These gloves should at the very least have extended cuffs.

A client who has been receiving care for cirrhosis arrives to the clinic for follow-up care. Which new signs and symptoms noted by the nurse would indicate that the client has developed hepatic encephalopathy? Select all that apply 1. A musty breath odor 2. Poor concentration 3. Fatigue 4. Slow movements 5. Asterixis

1., 2., 4., & 5. Correct: These are signs and symptoms of hepatic encephalopathy, a severe complication of hepatitis and cirrhosis: A musty or sweet breath odor, poor concentration, fatigue, slow movement, asterixis (an abnormal tremor consisting of involuntary jerking movements, especially in the hands). These occur due to increasing ammonia levels in the blood. However, fatigue would not be a correct symptom to look for since the client will have fatigue already due to the cirrhosis. 3. Incorrect: Fatigue would not be a new symptom because it is a symptom of cirrhosis. The client will already have fatigue due to the cirrhosis, so fatigue would not indicate that the client is going into encephalopathy.

After determining that a client diagnosed with a stroke has adequate swallowing ability, the nurse develops interventions to safely provide oral feedings to the client. What interventions should the nurse include in this plan of care? Select all that apply 1. Provide mouth care prior to feeding. 2. Flex head forward for eating. 3. Have dietary puree foods. 4. Use crushed ice as a stimulant for swallowing. 5. Offer thickened liquids to drink. 6. Position client in semi fowler's position after feeding.

1., 2., 4., & 5. Correct: These interventions will stimulate sensory awareness, salivation, swallowing, and decrease the risk of aspiration. 3. Incorrect: Pureed foods are not usually the best choice because they are often bland and too smooth making it difficult to swallow. 6. Incorrect: The client should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for feeding and for 30 minutes afterward.

What signs and symptoms will the nurse look for when caring for an infant with severe dehydration? Select all that apply 1. Dark, yellow urine 2. Lethargic 3. Bulging fontanels 4. Tachypnea 5. Decreased urine output

1., 2., 4., & 5. Correct: These would be signs and symptoms of dehydration in an infant. Amber or dark urine is an indication of dehydration. Urine should be a clear, pale yellow. Fussiness and irritability are seen in infants when they do not feel well. As dehydration worsens, lethargy and unresponsiveness can develop. Tachypnea or rapid respiration along with tachycardia and low blood pressure are present with severe dehydration. With severe dehydration, there will be decreased urine ouput. The body is trying to conserve volume. 3. Incorrect: The fontanels will be sunken rather than bulging. Bulging fontanels indicate brain swelling or fluid build up in the brain. Sunken fontanels are related to dehydration.

What nursing interventions should a nurse initiate for a client diagnosed with pyelonephritis? Select all that apply 1. Monitor urine for dark, cloudy, foul smelling urine. 2. Place client on intake and output monitoring. 3. Decrease fluid intake to 1 liter/day. 4. Advise client wear protective clothes outside while taking levofloxacin. 5. Monitor for hypotension, tachycardia, fever.

1., 2., 4., & 5. Correct: With pyelonephritis urine will be dark, cloudy and foul smelling due to the bacteria. Anytime a client has a renal problem, that client should be placed on I&O. Levofloxacin could make the client sunburn more easily. Avoid sunlight or tanning beds. Wear protective clothing and use sunscreen (SPF 30 or higher) when outdoors. Monitor for septic shock, a complication of pyelonephritis. S/S include hypotension, tachycardia, and fever. 3. Incorrect: Fluid intake should be increased to 2-3 liters/day unless contraindicated.

A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance? Select all that apply 1. Provide "just in time" posters outlining the critical importance and steps in pain assessment. 2. Conduct brief in-services for each shift. 3. Write nurses up when pain level scale is not utilized. 4. Ensure that a complete and clear performance standard exists. 5. Assess nurses' reasons for not using pain level scale.

1., 2., 4., 5. Correct: If nurses have been provided the knowledge and performed the skill before, but the opportunity to perform is presented infrequently, a different type of education is required. This may take the form of "just in time" tools such as posters or guidelines outlining the critical steps in performing the skill. Brief in-services, videos, or DVDs available on the unit may also be effective in providing on the spot refreshers. Ensuring that performance standards exist, are clear and complete, and that they are readily available to staff is essential. Of course, nurses must have read the standards and understand them. The first step in correcting a performance gap is to understand what the difference is between the behavior being exhibited and what the expectations are. Always assess why staff are doing or not doing what is needed for clients. There may be a lack of knowledge or there may be a sense of non-importance. Perhaps a process is not working properly. So assessment is first. 3. Incorrect. This is not the most effective way of improving performance as it is considered punitive. If the above listed strategies are not effective, formal reporting of the behavior may be necessary.

What symptoms of meningeal irritation would the nurse anticipate when performing an assessment on a newly admitted client with a diagnosis of bacterial meningitis? Select all that apply 1. Positive Kernig's sign 2. Positive Brudzinski's sign 3. Presence of Babinski's reflex 4. Photophobia 5. Severe headache 6. Nuchal rigidity

1., 2., 4., 5., & 6 Correct: Brudzinski's sign is the involuntary lifting of the legs when the neck is passively flexed (head is lifted off the examining surface). Kernig's sign is positive when the thigh is bent at the hip and knee at 90 degree angles and attempts to extend the knee are painful, resulting in resistance. Both of these signs are thought to indicate meningeal irritation. These seem to be caused when the motor roots become irritated as they pass through inflamed meninges, and the roots are brought under tension. Photophobia (sensitivity to bright light), severe, unrelenting headache, and nuchal rigidity (stiff neck) are all believed to be due to irritation of the meninges. 3. Incorrect: Babinski reflex is a normal reflex in infants up to age 2, but is a pathological reaction in adults. It is often indicative of severe damage to the central nervous system but is not indicative of meningeal irritation.

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

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

1., 2., 4., 5., & 6. Correct: Music therapy may produce relaxation by quieting the mind and promoting a restful state. Aromatherapy with chamomile may also help overcome anxiety, anger, tension, stress, and insomnia in dying clients. When the lights go down and the room darkens, this signals to the brain that it's time for rest. Keeping conversations quiet will help to decrease stimuli. Simple techniques such as repositioning pillows or bed clothes and gentle massage (if tolerated) can also provide relief from pain. 3. Incorrect: Restraints will only agitate the client more. Remember, use restraints as a last resort.

The nurse is planning to teach a group of senior citizens about modifiable risk factors for developing a stroke. Which factors should the nurse include? 1. Diabetes mellitus 2. Hypertension 3. Hispanic ethnicity 4. Atrial fibrillation 5. Sleep apnea 6. Smoking

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

The nurse is planning to teach a group of senior citizens about modifiable risk factors for developing a stroke. Which factors should the nurse include? Select all that apply 1. Diabetes mellitus 2. Hypertension 3. Hispanic ethnicity 4. Atrial fibrillation 5. Sleep apnea 6. Smoking

What develpomental milestone does the nurse expect to see in a 4 year old child? Select all that apply 1. Can say first and last name. 2. Draws a person with 2 to 4 body parts. 3. Copies a triangle. 4. Can tell what is real and what is make believe. 5. Sings a song from memory. 6. Talks about likes and interests.

1., 2., 5., & 6. Correct: By the age of 4 years, the nurse would expect the child to know both their first and last name, be able to draw a person with 2-4 body parts, sing a song from memory such as the "Itsy Bitsy Spider" or the "Wheels on the Bus", and talk about what they like and are interested in. 3. Incorrect: When checking the developmental milestones of a 5 year old, the nurse should expect to see the child to be able to copy a triangle. 4. Incorrect: The 5 year old can distinguish between reality and make believe. The 4 year old often cannot tell the difference.

What developmental milestone does the nurse expect to see in a 2 year old toddler? Select all that apply 1. Builds towers of 4 or more blocks. 2. Says sentences with 2 to 4 words. 3. Does puzzles with 3 or 4 pieces. 4. Takes turns in games. 5. Walks up and down stairs holding on. 6. Stands on tiptoe.

1., 2., 5., & 6. Correct: When checking the developmental milestones of a 2 year old, the nurse should expect to see the toddler build a tower of at least 4 blocks, say short sentences of 2-4 words, walk up and down stairs while holding on, and stand on tiptoe. 3. Incorrect: The toddler should be able to complete a 3-4 piece puzzle by age 3. This would not be of concern if a 2 year old is unable to complete this task. 4. Incorrect: The toddler should be able to take turns during a game by age 3. This would not be of concern if a 2 year old does not take turns. A two year old plays mainly beside other children.

A petite female client presents to the clinic with symptoms of back pain and states, "I think I am getting shorter." Which information would be appropriate for the nurse to provide? Select all that apply 1. Spend time in the sunlight. 2. Wear low heeled, nonslip sole shoes. 3. Walk at least 30 minutes most days. 4. Include yogurt and cheese in diet. 5. Take regularly scheduled prescribed corticosteroids.

1., 2.,3. & 4. Correct: The client with osteoporosis is usually female, and small framed. Back pain from collapsed vertebrae and shortening are symptoms. Exposure to light converts vitamin D stores in the skin. Low-heeled, nonslip soled shoes are a safety issue to prevent loss of balance and falls. Weight bearing exercises like walking will promote bone density. Yogurt and cheese are high in calcium. 5 Incorrect: This individual should not be taking corticosteroids as these drugs will promote the loss of calcium from the bones.

Which clients should the nurse recommend receive the human papillomavirus (HPV) vaccine? Select all that apply 1. Twelve year old male. 2. Nine year old female. 3. Twenty-five year old bisexual male. 4. Twenty-two year old female with compromised immune system. 5. Twenty-six year old male who has not received the HPV vaccine.

1., 3, & 4. Correct: The HPV vaccine is recommended for preteen boys and girls at age 11 or 12 so they are protected before ever being exposed to the virus. Young women can get HPV vaccine through age 26, and young men can get vaccinated through age 21. The HPV vaccine is recommended for any man who has sex with men through age 26 and for men with compromised immune systems through age 26 if they did not get HPV vaccine when they were younger. The HPV vaccine is recommended for men and women with compromised immune systems through age 26. 2. Incorrect: The HPV vaccine is recommended for preteen boys and girls at age 11 or 12 so they are protected before ever being exposed to the virus. Young women can get HPV vaccine through age 26, and young men can get vaccinated through age 21. 5. Incorrect: Catch up vaccines are recommended for males through age 21 and for females through age 26 if they did not get vaccinated when they were younger.

A nurse is caring for a client who has been prescribed prednisone. What education should the nurse provide to the client? Select all that apply 1. Avoid crossing legs. 2. Eat a low calcium diet. 3. Take prednisone with food. 4. Taper prednisone dose prior to completion. 5. Instruct the client to use arm rests when rising from a chair.

1., 3, 4, & 5. Correct: A potential side effect of prednisone is thromboembolism. An intervention to decrease thromboembolism is to avoid crossing legs. When the client crosses their legs, the client is decreasing the blood flow in the lower extremities. To decrease irritation of the lining of your stomach prednisone should always be taken with a meal. The food covers the surface of the stomach which can reduce irritation so eat before taking the prednisone. Client's on an extended prescription of prednisone will precipitate possible dangerous side effects, if the prescription is abruptly discontinued. The adrenal glands will have to adjust to the abrupt reduction of the prednisone. Gradually reducing the dosage of prednisone before discontinuing the drug allows the normal production of cortisol to reoccur. Osteoporosis is a possible side effect of extended prescription of prednisone. The client should be instructed to use arm rests when rising from a chair to prevent falling. The client could also experience falling due to postural hypotension. 2. Incorrect: A musculoskeletal side effect of prednisone is osteoporosis. Osteoporosis is a decrease in bone mass and density. To promote bone growth the client is encouraged to consume a diet high in calcium.

A pediatric nurse is teaching a group of new parents about what to expect regarding their infants eyes and vision. What points should the nurse include? Select all that apply 1. At 4 weeks of age, the infant should be able to gaze at objects. 2. Infants should have tears by the age of 1 month. 3. Visual acuity is about 20/300 at 4 months of age. 4. During the first 2 months of life, infant's eyes may appear to be crossed. 5. Depth perception begins around the 5th month of age.

1., 3, 4, & 5. These statements are correct. At birth the baby's vision is limited best to 8-10 inches from their face. The eyes are not well coordinated and may appear crossed. 2. Incorrect: Infants do not have tears until about 3 months of age.

Which assessment findings would the nurse expect when assessing a client for dementia? Select all that apply 1. Slow progressive deterioration of cognitive functioning 2. Decreased level of consciousness 3. Personality changes 4. Difficulty paying attention 5. Suicidal thoughts and sadness

1., 3. & 4. Correct: Dementia is characterized by a slow onset of symptoms over months to years. Dementia progresses to noticeable changes in personality. Dementia progresses to noticeable changes in attention span. 2. Incorrect: Dementia is progressive deterioration of cognitive functioning with no change in consciousness. 5. Incorrect: Sadness and suicidal thoughts are signs of depression.

A nurse is planning a teaching session for a group of clients diagnosed with irritable bowel syndrome. What points should the nurse include to help the clients control symptom flare-ups? 1. If you are constipated, try to make sure you have breakfast. 2. Avoid low fat foods. 3. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. 4. Drinks containing caffeine are likely to contribute to symptoms. 5. Foods such as broccoli and cabbage are good sources of fiber.

1., 3. & 4. Correct: If you are constipated, try to make sure you eat breakfast, as this is the meal that is most likely to stimulate the colon and give you a bowel movement. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. (If you suspect more than one, cut out one at a time so you know which one causes you problems.) If there's no change, go back to eating it. The foods most likely to cause problems are: Insoluble (cereal) fiber; Coffee/caffeine; Chocolate; Nuts 2. Incorrect: Avoid meals that over-stimulate the gut, like large meals or high fat foods. 5. Incorrect: Broccoli and cabbage are common gas-producing foods that can cause abdominal distention and flatulence

A nurse is planning a teaching session for a group of clients diagnosed with irritable bowel syndrome. What points should the nurse include to help the clients control symptom flare-ups? Select all that apply 1. If you are constipated, try to make sure you have breakfast. 2. Avoid low fat foods. 3. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. 4. Drinks containing caffeine are likely to contribute to symptoms. 5. Foods such as broccoli and cabbage are good sources of fiber.

A client with diabetes mellitus has a newly prescribed insulin pump. Which statements made by the client indicate understanding of an insulin pump? Select all that apply 1. "I will attach the pump to my waistband or wear it in the pocket of my pants." 2. "I can eat whatever I want as long as I cover the calories with sufficient insulin." 3. "I may take my insulin pump off when I exercise." 4. "I need to check my blood glucose level several times a day." 5. "I have to change the catheter at the end of the pump every week."

1., 3. & 4. Correct: Insulin pumps are externally worn on clothing or in a pocket. Pumps can be easily disconnected for limited periods such as for showering, exercise, and sexual activity. Clients must assess their blood glucose level several times daily. 2. Incorrect: Clients are prescribed a specific caloric intake and insulin regimen, and maintaining as much consistency as possible in the amount of calories and carbohydrates is essential. 5. Incorrect: The needle or catheter attached at the end is changed at least every three days.

The nurse is caring for a client hospitalized with dissociative amnesia. Which nursing interventions are appropriate for this client? Select all that apply 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: This is not a nursing function. Hypnosis is not in the nurse's scope of practice.

A client requires external radiation therapy. The nurse knows external radiation may cause which problems? Select all that apply 1. Pancytopenia 2. Leukocytosis 3. Erythema 4. Fever 5. Fatigue

1., 3. & 5. Correct: Effects of radiation therapy include, but are not limited to pancytopenia (marked decrease in the number of RBCs, WBCs and platelets), erythema (redness of the skin), and fatigue.2. Incorrect: Leukocytosis is an increase in WBCs. External radiation causes pancytopenia which is a decrease in the number of blood cells including WBCs. 4. Incorrect: Fever is not typically seen with external radiation.

A nurse enters the operating room (OR) with artificial fingernails in place. What should the charge nurse explain to the nurse? Select all that apply 1. Pathogenic bacteria can be found on the fingertips of those who wear artificial fingernails. 2. Artificial fingernails are allowed to be worn in the OR. 3. Fungal growth can occur under the artificial fingernail, thus increasing the risk of surgical site infection to the client. 4. A more vigorous scrub is required if artificial fingernails are worn. 5. Long fingernails and artificial fingernails increase microbial load on the hands.

1., 3. & 5. Correct: The variety and amount of pathogenic bacteria cultured from the fingertips of those wearing artificial fingernails is greater than from those with natural nails, both before and after handwashing. Fungal growth occurs frequently under artificial fingernails because moisture gets trapped between the natural fingernail and artificial fingernail, providing a medium for growth. Natural nails should be less than 1/4 inch (6.35 mm) long.2. Incorrect: Artificial fingernails are not allowed in the OR. They are known to harbor gram-negative microorganisms and fungus. 4. Incorrect: A vigorous scrub of the fingernails does not decrease the moisture under the nails. Chipped nail polish, or if worn longer than 4 days, should be removed due to increased likelihood of harboring bacteria.

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 be assigned to the medical surgical nurse? Select all that apply 1. Total abdominal hysterectomy (TAH). 2. Client post C-section to be discharged home. 3. Breast Reduction. 4. Vaginal delivery of fetal demise. 5. 28 week gestation of bed rest. 6. Bladder suspension with anterior and posterior repair.

1., 3. and 6. Correct: When a nurse is pulled to another unit, always assign them like a brand new nurse. A client with a TAH, Breast reduction or bladder suspension require basic post-operative care. These are within the scope of knowledge of a brand new nurse with medical-surgical knowledge. 2. Incorrect: This client is going to require specific discharge teachings related to her care, medication and care of the newborn. Specialized training is necessary here. 4. Incorrect: The nurse caring for this client needs to have skills related to postpartum care as well as psychological care of this type of loss. A pulled nurse from the medical-surgical floor will not be prepared to assist this client with all her needs. 5. Incorrect: This client is on bedrest for a reason and is hospitalized for a reason. Skilled assessment to identify change in status or denote impending complications is essential. This is not appropriate for the pulled medical-surgical nurse.

When caring for a client on bedrest, which interventions should the nurse implement to decrease the risk of deep vein thrombosis? Select all that apply 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. Pillows under the knees help with pressure on the lower back. However, if 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.

A 35 year old client, concerned about weight, asks a clinic nurse, "What is my BMI?" The client weighs 135 pounds and is 5 feet 2 inches tall. Determine the client's BMI to the nearest tenth?

BMI = 24.7 Formula: BMI = (703 x weight in pounds) ÷ (height in inches)2 BMI = (703 x 135) ÷ (62)2 -62x62=3,844 BMI = (94,905) ÷ (3,844) BMI = 24.689 BMI = 24.7

What should the nurse check when assessing a client's balance? Select all that apply 1. Walking on tiptoes 2. Babinski reflex 3. Romberg test 4. Muscle strength of legs 5. Dorsalis pedis pulses

1., 3., & 4. Correct: Asking the client to walk on the tips of the toes assesses foot strength and balance. Muscle strength is needed to maintain balance and a Romberg's test asks the client to stand erect with arms at their side and feet together. The nurse notes any sway or unsteadiness. Then the client does the same thing with their eyes closed for 20 seconds again noting imbalance and sway. A positive Romberg is seen with swaying and moving feet apart to prevent a fall. It indicates a problem with balance. 2. Incorrect: Babinski sign is an important neurologic examination based upon what the big toe does when the sole of the foot is stimulated. If the big toe goes up, that may mean trouble with the central nervous system. This is not part of assessment for balance 5. Incorrect: Assessing the dorsalis pedis pulse is done as part of a circulatory check not while assessing balance.

The nurse is planning to teach a group of young women who want to become pregnant. What information should be included as recommendations to increase the chances of having a healthy baby? Select all that apply 1. Take 400 micrograms of folic acid every day. 2. Limit alcohol to 1 glass per day. 3. Avoid smoking. 4. Take the flu vaccine during flu season. 5. Start prenatal care by 3 months of pregnancy

1., 3., & 4. Correct: Folic acid is a B vitamin. If a woman has enough folic acid in her body at least a month before and during pregnancy, it can help prevent neural tube defects. Smoking can lead to premature birth, cleft lip or cleft palate, and infant death. The flu shot given during pregnancy has been shown to protect mom and baby (up to 6 months old) from flu. 2. Incorrect: When a woman drinks alcohol, so does her unborn baby. This can cause the baby to be born with fetal alcohol spectrum disorder.5. Incorrect: A woman should be certain to see her healthcare provider when planning pregnancy and start prenatal care as soon as she thinks she is pregnant.

A 9 month old client is admitted to the hospital with a diagnosis of pertussis. Which interventions should the nurse initiate? Select all that apply 1. Initiate droplet precaution. 2. Place client under mist tent with low humidity. 3. Administer erythromycin 10 mg/kg/dose 4 times daily for 7 days. 4. Use client dedicated and disposable equipment. 5. Keep NPO.

1., 3., & 4. Correct: Pertussis is a very contagious disease that spreads from person to person by coughing or sneezing or when spending a lot of time near one another where you share breathing space. The nurse should place the child on droplet precautions in addition to standard precautions. For infants older than 1 month of age, macrolides drugs such as erythromycin are the drugs of choice. With droplet precautions you should use client dedicated or disposable equipment to prevent the spread of infection. If this is not possible, you must clean and disinfect shared/reusable equipment between use. This includes IV pumps, cell phones, pagers, other electronics, supplies, equipment. Clean prior to removing from the room. 2. Incorrect: A mist tent with high humidity may be used. The purpose is to improve a child's respiratory status by liquefying pulmonary secretions. 5. Incorrect: This child needs fluids, either by mouth or IV to keep from getting dehydrated, and to liquify secretions.

he nurse is caring for a client diagnosed with dementia. Which task can the nurse assign to the unlicensed assistive personnel (UAP)? Select all that apply 1. Assist the client with toileting. 2. Inform family that the client needs a Computed Tomography (CT) scan. 3. Accompany the client while walking in the hall. 4. Reorient the client frequently. 5. Apply restraint belt for client safety.

1., 3., & 4. Correct: The UAP can provide assistance with routine activities of daily living, which includes toileting. The UAP can also walk with a client in the hallway. There is no mention that the client is having difficulty with ambulation, so there is no reason why the UAP cannot walk with the client. Orienting the client frequently can be done by all staff encountering the client. 2. Incorrect: Informing the client or family of procedures is not within the scope of practice for the UAP. 5. Incorrect: Restraints need to be put on properly, insuring that they are not applied too tightly. This is not within the scope of practice for the UAP.

A nurse is planning care for a laboring client who is about to be started on oxytocin. What interventions should the nurse include in this plan of care? Select all that apply 1. Piggy back oxytocin into main IV fluid. 2. Monitor for early decelerations. 3. Discontinue if contractions last longer than 90 seconds. 4. Maintain one on one care. 5. Check fetal heart tones hourly.

1., 3., & 4. Correct: The oxytocin is piggy backed into the main IV fluid, so when the nurse discontinues the medication, the main IV fluid is quickly resumed. Contractions should be at a rate of 1 every 2-3 minutes with each lasting no more than 90 seconds. Hyperstimulation of the uterus can occur and result in fetal distress. One on one care is needed since complications such as fetal distress and uterine rupture can occur. 2. Incorrect: External continuous fetal monitoring should begin prior to oxytocin administration. A reactive fetal heart rate tracing should be obtained over 30 minutes. 5. Incorrect: Continuous fetal monitoring is must be maintained during oxytocin administration to fetus is not experiencing distress in utero with contractions.

Which nursing intervention should the nurse include when planning care for a client with Parkinson's disease? Select all that apply 1. Encourage high fiber diet with increased fluid intake. 2. Schedule activities early in the morning. 3. Help client perform stretching and strengthening exercises. 4. Teach client to sit upright at 90 degree angle when eating. 5. Maintain a high protein diet while taking levodopa.

1., 3., & 4. Correct: These are appropriate interventions for a client with Parkinson's disease. Constipation is a common problem in clients with Parkinson's disease. Increasing dietary fiber and fluid intake is useful in managing this problem. These clients have impaired mobility, so stretching and strengthening exercises are necessary to keep muscles working as long as possible. Loss of control of the mouth and throat muscles causes difficulty swallowing. Sitting upright at 90 degrees makes chewing and swallowing easier by using your posture to assist with the process. 2. Incorrect: Appointments and activities are best scheduled for late morning so that the client will not be rushed in performing self-care. 5. Incorrect: For clients on levodopa, explain that they shouldn't take this drug with high-protein meals as this can reduce its absorption and availability. Caution them to avoid foods and supplements high in pyridoxine (vitamin B6), which can inhibit the drug's action.

What action by the unlicensed assistive personnel (UAP) would require the nurse to intervene? Select all that apply 1. Returning clean unused linens for a client to the linen supply closet. 2. Tying the linen bag securely and tightly at the top. 3. Filling the linen bag with as much soiled linen as possible. 4. Shaking linens after removing from the bed to check for personal items. 5. Washing hands after removing linens from the bed.

1., 3., & 4: Correct: Once linen leaves the supply closet, it should not be returned. It should be sent to be laundered. Filling the linin bag too much can cause linen to spill out onto the floor. This can lead to contamination and the spread of infection. Never shake linen as it can spread pathogens. 2. Incorrect: Tying the linen bag closed will secure the linens and decrease transmission risk.

After a cholecystectomy, a client experiences palpitations, weakness and diarrhea following meals. Which teachings would be appropriate for the nurse to provide the client? Select all that apply 1. Avoid drinking liquids with meals. 2. Increase high sugar foods as they are well tolerated. 3. Take adequate vitamins, iron and calcium. 4. Lie down on right side after meals. 5. Eat at least six small meals per day.

1., 3., & 5 Correct: Dumping syndrome is associated with meals having a hyperosmolar composition. To decrease hyperosmolar components, you decrease the carbs and electrolytes. You should avoid fluids with meals because they increase the size of the food bolus. Vitamins, iron, and calcium may become depleted after stomach surgery and due to dumping syndrome so taking these will help to maintain good health. Small frequent meals decrease the extremes of the hyperosmolar content and keep a steady blood sugar level. 2. Incorrect: High sugar foods and carbs speed through the GI tract. Fats and proteins digest slower and stay in the stomach longer. 4. Incorrect: Lying down on the left side slows emptying of the stomach. Lying on the right side will speed up emptying and make the symptoms worse. Sit upright for 30-60 minutes after eating.

The nurse is caring for a client who has an active herpes simplex 1 lesion on the lip. What measures should be implemented by the nurse? Select all that apply 1. Tell the client to avoid touching the lesion. 2. Scrub the lesion gently with soap and water prior to meals. 3. Apply a thin layer of acyclovir to the lesion 5 times a day. 4. Wear sterile gloves when applying medication to lesion. 5. Ask client to discard lip balm until lesion is resolved.

1., 3., & 5. Correct. The number one way of spreading herpes simplex if through oral secretions and sores on the skin. So, the nurse needs to tell the client to avoid touching the lesion. Acyclovir is an antiviral medication that slows the growth and spread of the herpes simplex virus so that the body can fight off the infection. Only enough cream should be applied to cover the sore. Since touching the lesion or secretions from the lesion can spread the virus, lip balm, lip stick, and make up should be discarded until the lesion has healed. 2. Incorrect: Scrubbing the lesion even gently would transfer the virus along the nerves and lips. 4. Incorrect: Sterile gloves are not needed. Clean gloves should be used.

Which health promotion instructions should the nurse provide to a client diagnosed with cirrhosis? Select all that apply 1. Use a shower chair when performing hygiene. 2. Limit alcohol intake. 3. Stop any activity that causes dizziness. 4. Calculate daily sodium intake. 5. Proper hand hygiene.

A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the nurse? Select all that apply 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. The first entry provides the age, provides the diagnosis, room number, and plan for care. this gives a "snap shot" of the admission. Option 3 is documentation of informed consent for surgery. It states that the consent is signed, the surgery to be performed, and very importantly, that the client is consenting to surgery after the surgeon discussed the procedure. Option 5 appropriately documents a transfer. It presents where the client was transferred, how they were transported, and the condition upon their transfer. 2. Incorrect. "Appears" is subjective. Pain should be assessed in an objective manner, such as by using a pain scale. The nurse should not use subjective documentation of the client's pain. 4. Incorrect. Do not use trailing zeros after a decimal point. Always lead a decimal point with a zero (0.5). These are safety issues. Trailing zeros are identified on the Joint Commission on the Accreditation of Hospitals Organization (JCAHO) "Do Not Use" list. The placement of a zero after a decimal point could lead to the inadvertent administration of a medication ten times the prescribed dose if the decimal point was not noted or could not be seen. Nurses should always follow JCAHO standards and guideline for documentation and nursing care.

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

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

A 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 self care. 2. Educate nursing staff to help client in all activities of daily living. 3. Separate tasks into small manageable steps. 4. Relieve family members of stress by advising them to visit 1 time per week. 5. Have nursing staff spend time talking and listening to client.

1., 3., & 5. Correct: All of these should be included in this client's plan of care. Assess the client's ability to perform self care and allow client to perform any care he/she is capable of doing. Separating tasks into small steps helps the client remember the steps. Plan for staff to spend some time talking and listening to the client. 2. Incorrect: Client independence should be promoted. Teach staff to promote self care and independence. If the client is capable of performing activities of daily living, then the client should be encouraged and allowed to do so. 4. Incorrect: Encourage family to visit to maintain socialization. We do not want to limit their visitation time. This will not be helpful to relieve family stress.

A nurse is planning to provide education to a client wishing to breastfeed. What instructions should the nurse include when teaching this client? Select all that apply 1. Apply warm compresses to breast just prior to breastfeeding. 2. Establish a routine for breastfeeding. 3. Massage breasts during feeding. 4. Wear well-fitting bra continuously for first 24 hours after birth. 5. Wash hands before breastfeeding.

1., 3., & 5. Correct: Applying warm compresses or taking a warm shower prior to breastfeeding will help the let-down reflex. Massaging breasts during feeding can help with emptying. Emphasize the importance of hand hygiene prior to breastfeeding to prevent infection. 2. Incorrect: Allow newborns to nurse on demand. Allow newborns to feed 15-20 minutes per breast or until the breast softens. Begin the next feeding session on the breast that was not completely emptied. 4. Wear well fitting bra continuously for at least 72 hours after birth to avoid milk stasis.

A client wishing to stop smoking receives a prescription for bupropion from the healthcare provider. What educational points should the nurse include regarding this medication? Select all that apply 1. This medication can cause a false positive drug screening test. 2. Alcohol intake should be limited to two drinks per day. 3. Nicotine gum may be prescribed in addition to bupropion. 4. An increased interest in sexual activity occurs while taking this medication. 5. Smoking can continue for 1 week after starting this medication.

1., 3., & 5. Correct: Bupropion is an antidepressant medication prescribed for major depressive disorders and seasonal affective disorder. Bupropion is used to help people stop smoking by reducing cravings and other withdrawal effects. This medication can cause a false positive drug screening test so the client should inform the laboratory personnel that the client is taking bupropion. Nicotine patches or gum may be prescribed to further support smoking cessation treatment as bupropion is a nicotine free prescription. The client can continue to smoke for about 1 week after starting the medicine. A date to quit smoking during the second week of treatment is determined. The recommended length of bupropion therapy is seven to twelve weeks. 2. Incorrect: Drinking alcohol may increase risk of seizures. If the client drinks alcohol regularly, they should talk with the primary healthcare provider before changing the amount of alcohol intake. Bupropion can cause seizures in people who drink a lot of alcohol and then suddenly quit drinking when they start using the medication. 4. Incorrect: A common side effect is a decreased interest in sexual activity.

Which discharge instruction should the nurse implement for a client diagnosed with insomnia? Select all that apply 1. Eliminate chocolate in the evening. 2. Drink a glass of red wine 1 hour prior to bedtime. 3. Perform progressive relaxation techniques at bedtime. 4. Take acetaminophen/diphenhydramine 2 tablets at bedtime. 5. Leisurely walk 3 hours prior to bedtime. 6. Increase the air flow on the continuous positive airway pressure (CPAP) machine.

1., 3., & 5. Correct: Consuming chocolate in the evening may cause insomnia. Chocolate contains caffeine and xanthines which are stimulates. The chemicals will suppress melatonin and increase the time to fall asleep. Progressive relaxation techniques are recommended to reduce insomnia. This exercise is a systematic relaxation and tensing of the muscle groups of the body. Insomnia is reduced by increasing muscle relaxation and decreasing the stress level of the client. Nonstrenuous exercises such as a leisure walk performed within 3 hours of bedtime promotes the reduction of the client's stress level. 2. Incorrect: Consuming alcohol prior to bedtime is not recommended. Alcohol consumption increases the start of sleep but reduces rapid eye movement (REM) sleep. The side effect of the alcohol may also cause the client to awaken during night and have difficulty returning to sleep. 4. Incorrect: Diphenhydramine is not recommended for insomnia. The action of the diphenhydramine may cause the client to feel drowsy but provides only temporary increase in quantity of sleep. The hypnotic effect of diphenhydramine will cause client to experience decrease energy levels the next morning. 6. Incorrect: A CPAP is prescribed for a client with obstructive sleep apnea not insomnia. The CPAP machine delivers a constant air pressure to the lungs. The constant air flow will keep the airway open during sleep.

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

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

A client with type 2 diabetes, who is noncompliant, has a HbA1c of 8%. The finger stick blood sugar is 218 mg/dL (12.1 mmol/L) at 0900. The current medications prescribed are metformin and exenatide. Based on this data, what teaching should the nurse reinforce? Select all that apply 1. Nutritional counseling to help improve diet compliance 2. HbA1c measures glycemia control over a period of 1 month 3. Blood glucose testing 4. Vigorous exercise plan to improve glucose control 5. Without glycemic control, eye complications can occur

1., 3., & 5. Correct: The goal of therapy is to have a HbA1c <7.0% Nutritional teaching to promote diet compliance should be tried first because this clients HbA1c is 8% and blood sugar is 218 mg/dL (12.1 mmol/L). Reinforce need to monitor glucose levels several times a day, before meals and at bedtime. Have client keep results in a log. Eye complications include glaucoma, cataracts, retinopathy, blindness. 2. Incorrect: HbA1c measures glycemic control over a period of 3 months. 4. Incorrect: Physical activity under the supervision of the primary healthcare provider is appropriate teaching. Vigorous exercise is not key to improving blood sugar. Exercise does not have to be intense. A normal exercise plan is recommended based on the client's ability.

Which client would be appropriate for the RN to assign to the LPN? Select all that apply 1. Client scheduled for an MRI of the kidneys. 2. Client requiring administration of antineoplastic medications. 3. Client one day post open cholecystectomy with moderate amount serous drainage on dressing. 4. Client post ileal conduit surgery this AM without drainage in the drainage bag. 5. Client diagnosed with osteoarthritis reporting frequent joint stiffness.

1., 3., & 5. Correct: There is nothing in the option regarding the client going for an MRI of the kidneys that would indicate that this client is unstable. This client can be assigned to the LPN. The one day postop client with a moderate amount of serous drainage on the dressing is stable. Skills required to care for this client are within the LPN's scope of practice. The client diagnosed with osteoarthritis reporting frequent joint stiffness can be considered stable and can be cared for by the LPN. The knowledge and skills required to care for these three clients fall within the scope of practice for the LPN. 2. Incorrect: Administration of antineoplastic medications require the skills and knowledge of a qualified registered nurse. 4. Incorrect: An ileal conduit is a procedure that diverts urine from the bladder and provides an alternate cutaneous pathway for urine to exit the body. Urinary output should always be at least 30 mL per hour. This client should be assessed and monitored by the RN to ensure that the stents placed in the ureters have not become dislodged or to ensure that edema of the ureters is not occurring.

The nurse is caring for a client that requires lifting. What techniques should the nurse utilize to prevent injury to self and potentially the client? Select all that apply 1. Tighten stomach muscles. 2. Keep the knees straight. 3. Keep weight to be lifted close to body. 4. Bend at the waist. 5. Avoid twisting the body

1., 3., & 5. Correct: Tightening the stomach muscles provides stability for the movement. Keeping the weight close to the body provides additional support and reduces the risk of a stretching type injury. When the body is in alignment, it is considered to be balanced. Therefore, twisting motions cause the body to be off balanced and make the nurse more susceptible to injury. 2. Incorrect: The trunk should be kept straight, and the knees should be bent. This provides an upright posture to maximize stability and reduce risk of injury. 4. Incorrect: The trunk should be kept straight, and the knees should be bent. This provides an upright posture to maximize stability and reduce risk of injury. Bending at the knees helps prevent back injuries.

The nurse is preparing to speak to a group of clients at the community center about influenza. Which risk factors for influenza complications would be included in the session? Select all that apply 1. Age over 65 years. 2. History of grand mal seizures 3. Diabetes 4. Renal disease 5. Clients who reside in a nursing home.

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

An unconscious client is admitted to the ICU with a closed head injury suffered in a fall. Despite aggressive efforts, the client expired within 24 hours. The nurse must complete postmortem care while awaiting the coroner. The nurse knows what action is not appropriate in this situation? Select all that apply 1. Remove indwelling catheter 2. Disconnect the ET tube from ventilator 3. Remove hospital ID band 4. Cap all intravenous lines 5. Wash body head to toe

1., 3., & 5.CORRECT. The client expired of injuries within 24 hours of being admitted to the hospital, which requires investigation by a coroner. It must be determined if death resulted from fall injuries, or whether any action, or lack thereof, by medical personnel contributed to the client's demise. When completing postmortem care on a "coroner's case", the nurse must leave all invasive lines and tubes in place for investigative purposes. Therefore, it would not be appropriate for the nurse to remove the foley catheter, although the urine can be emptied from the bag. It is also incorrect to remove any hospital identification bands. Washing the body should never be done since evidence could be disturbed or even removed. 2. INCORRECT. This action is acceptable since the client would not be transported while still attached to a ventilator. However, the endotracheal tube itself must remain taped in place when the client is transported to the coroner's facility. 4. INCORRECT. It is not necessary to leave the IV bags attached to intravenous catheters. The tubing and bags may be removed as long as the intravenous catheter itself remains intact on the client. Any variation of this standard procedure would be determined by the facility or coroner in advance.

The nurse is assisting a new mother with breastfeeding her newborn baby. The mother verbalizes concern that the baby is not getting adequate milk. Which observations by the nurse indicate adequate fluid intake? Select all that apply 1. Birth weight regained in 14 days 2. Fontanels soft and depressed 3. Pulse rate of 135/min 4. Six to eight wet diapers a day 5. Baby appears satisfied after feedings

1., 3., 4. & 5. Correct: Are all indicators of adequate fluid intake in a newborn. Gaining weight, a heart rate between 70 to 190 beats per minute (BMP), six to eight wet diapers a day and periods of contentment after feedings alternate with periods of wakefulness indicate adequate breast feeding. 2. Incorrect: Fontanels should be soft, firm and flat. A depressed or sunken fontanel may indicate dehydration. Dehydration is one of the major causes of sunken fontanels.

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

1., 3., 4. & 5. Correct: Keeping moisture from the skin is important for reducing the risk of skin breakdown. Keeping the client dry after using a bedpan is important to maintain healthy skin. As long as the intake of food is adequate, no further action is needed with nutrition. The client who is aware of sensations of pressure on the body has less risk of skin breakdown than those that have lost sensation. 2. Incorrect: If the client is not repositioned at night, the resulting pressure on one site may lead to skin breakdown, even when the sensations of pressure are intact. A client in a state of sleep would not be as likely to respond to sensations of pressure appropriately, so the family would need to do this for her.

The employee health nurse is designing a health promotion plan for a group of workers who have neck and back strain symptoms and repetitive movement pain from long periods of computer work. Which interventions should be included in the plan to reduce these symptoms? Select all that apply 1. Suggest that the workers place the keyboard and mouse close to the body. 2. Adjust computer screen to below eye level. 3. Drop and roll shoulders periodically. 4. Type with forearms parallel to the floor. 5. Keep elbows at the side when typing.

1., 3., 4. & 5. Correct: Keeping the keyboard and mouse close keeps the body in a more neutral position. Dropping the shoulders puts them in a relaxed position. As tension increases, the shoulders tend to rise. This position keeps the neck and back from being stretched and keeps the body in a more neutral position. This allows the shoulders to stay in a more neutral position. 2. Incorrect: The computer screen should be at eye level so that the neck does not become strained as easily.

The nurse recognizes which manifestations as signs of community-acquired pneumonia? Select all that apply 1. Cough 2. Decreased respiratory rate 3. Fever 4. Myalgia 5. Pleuritic chest pain

1., 3., 4. & 5. Correct: Signs of community-acquired pneumonia include cough, crackles, egophony, tactile fremitus, fever, dyspnea, sputum production, myalgias, and pleuritic chest pain. A client with an infection (particularly pneumonia) will exhibit these symptoms. 2. Incorrect: Decreased respiratory rate is not a sign of community-acquired pneumonia; respiratory rate increases with fever and dyspnea.

The nurse is assisting with a client who will receive electroconvulsive therapy (ECT). The anesthesiologist administers succinylcholine chloride intravenously. What adverse effects should the nurse monitor for post procedure? Select all that apply 1. Malignant hyperthermia 2. Hypokalemia 3. Apnea 4. Tetany 5. Arrhythmias

1., 3., 4. & 5. Correct: Succinylcholine is a paralytic used to relax the muscles to prevent severe muscle contractions during the seizure, thereby reducing the possibility of fracture or dislocated bones. Adverse effects include malignant hyperthermia, apnea, and arrhythmias. It causes paralysis of the muscles of the face and those used to breath, so monitoring for apnea is very important. Tetany, spasms or stiffness in the jaw would be adverse effects and can indicate malignant hyperthermia.2. Incorrect: Hyperkalemia can occur. Succinylcholine is a depolarizing muscle relaxant which means during prolonged muscle depolarization, the muscle may release large amounts of potassium into the blood.

The nurse has been caring for a client who is confused. Upon entering the room, the nurse finds the client on the floor. The side rails are up, there is urine on the floor, and an abrasion is noted on the client's forehead. Which information should the nurse include in the incident report? Select all that apply 1. Abrasion on the client's forehead. 2. Client's perspective as to why they fell. 3. Client's confused state. 4. Presence of urine on the floor. 5. Side rails were up.

1., 3., 4. & 5. Correct: The following should be included in an incident report regarding a client's fall: how the fall occurred (if observed); where the fall took place; how the nurse was notified of the fall; the environmental condition (wet, dry, any obstruction conditions); presence of fall deterrents (side rails, call lights, night light); client vital signs; nurse's physical findings (confusion, abrasions); presence of family; and if toileting was an issue. 2. Incorrect: Stay with objective assessments and avoid subjective statements. Only the facts!

A client with type 2 diabetes, who is noncompliant, has a HbA1c of 8%. The finger stick blood sugar is 218 mg/dL (12.1 mmol/L) at 0900. The current medications prescribed are metformin and exenatide. Based on this data, what teaching should the nurse reinforce? Select all that apply 1. Nutritional counseling to help improve diet compliance 2. HbA1c measures glycemia control over a period of 1 month 3. Blood glucose testing 4. HbA1c of 8% tells us that your average glucose level is 180 mg/dL (10 mmol/L) 5. Without glycemic control, eye complications can occur

1., 3., 4. & 5. Correct: The goal of therapy is to have a HbA1c <7.0% (Glucose < 150 mg/dL or < 8.3 mmol/L). Nutritional teaching to promote diet compliance should be tried first because this clients HbA1c is 8% and blood sugar is 218 mg/dL (12.1 mmol/L). Reinforce need to monitor glucose levels several times a day, before meals and at bedtime. Have client keep results in a log. Eye complications include glaucoma, cataracts, retinopathy, blindness. 2. Incorrect: HbA1c measures glycemic control over a period of 3 months.

The nurse is preparing a client for transport to the radiology department for a left lung tissue biopsy. Which actions should the nurse make certain have been completed? Select all that apply 1. The consent form is signed. 2. The operative site is prepped with a razor. 3. The most recent lab work is on the chart. 4. Any preoperative medication is given as prescribed. 5. Person performing the procedure has marked the site.

1., 3., 4. & 5. Correct: The nurse should ensure that the consent form is signed, the lab work is in order, and any prescribed preoperative medication is given. The operative site is marked by the person who is ultimately accountable for the procedure and will be present when the procedure is performed. 2. Incorrect: The site should be prepped with clippers as opposed to a razor, which can cause injury to the client. The goal of preoperative skin preparation is to decrease bacteria without injuring the skin.

The crisis line 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 is the nurse's most appropriate response? Select all that apply 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. "Have another person call 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 crisis line 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 she activates the 911 call.

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

1., 3., 4., & 5. Correct: As rheumatoid arthritis worsens, the joints become progressively inflamed and very painful. On palpation, these joints feel soft and look puffy because of synovitis and effusions, especially in the knees. Swan-neck deformity is a bending in (flexion) of the base of the finger, a straightening out (extension) of the middle joint, and a bending in (flexion) of the outermost joint. Peripheral neuropathy occurs in later stages of the disease due to vasculitis. Subcutaneous nodules or rheumatoid nodules are firm bumps of tissue most commonly form around pressure points, such as the elbows. 2. Incorrect: A 1 kg weight loss over 2 weeks would more likely occur in the early stages of the disease. As the disease progresses, there is moderate to severe weight loss and accompanying anemia.

An occupational health nurse is planning to teach a group of manufacturing workers how to prevent back injuries. What teaching points should the nurse plan to include? Select all that apply 1. Wear comfortable, low-heeled shoes. 2. When sitting, keep knees slightly lower than the hips. 3. Avoid movements that require spinal flexion with straight legs. 4. Squarely face the direction of anticipated movement. 5. Pivot to turn while holding an object.

1., 3., 4., & 5. Correct: Comfortable, low heeled shoes provide good foot support and reduce the risk of slipping, stumbling, or turning your ankle. Flexion of the spine with the legs straight (toe-touches, sit-ups) will injure the back. Avoid twisting of the back by squarely facing the direction of movement. Move toward or away from your center of gravity. Pivoting is a technique in which the body is turned in a way that avoids twisting of the spine. 2. Incorrect: When sitting, keep knees slightly higher than the hips.

The nurse is conducting a developmental screening by first gathering history information from the parent of a toddler. What information obtained by the parent would the nurse consider a risk factor for developmental problems? Select all that apply 1. Birthweight less than 3 pounds, 4 ounces (1.5 kg). 2. Gestational age 38 weeks. 3. Chronic otitis media with effusion for more than 3 months. 4. Lead level of 5.5 mg/dL 2 months ago. 5. Parents with 8th grade education.

1., 3., 4., & 5. Correct: Factors placing the infant or toddler at risk for developmental problems include birthweight less than 3pounds, 4 ounces (1.5 kg), chronic otitis media with effusion for more than 3 months, lead levels above 5.0 mg/dL, and parents with less than a high school education. The months a baby spends in the uterus, along with the first 12 months after birth, are the most important time of brain development. During this period neurons are forming connections with each other, creating the networks that underlie thinking, learning, and feeling. In the last weeks of pregnancy, as many as 40,000 new synapses are being formed every second. Preterm birth (less than 37 weeks gestational age) and low birth weight (less than 2.5 kg) are well-documented risk factors. In addition to threatening healthy overall growth and maturation, premature infants and low birth weight term infants may experience a disruption of important processes involved in early brain development. As a result, preterm and low birth weight children, are at increased risk for a variety of developmental problems related to health, psychological adjustment, and intellectual functioning. There is evidence that sensorineural hearing loss may result from chronic otitis. There is also evidence that the auditory deprivation associated with childhood otitis media may lead to language and speech delays. Lead is a neurotoxic substance that has been shown in numerous research studies to affect brain function and development. Children who have been exposed to elevated levels of lead are at increased risk for cognitive and behavioral problems during development. Studies show that low socioeconomic status, as measured by low income, wealth, or parental education, is associated with poor child development outcomes. 2. Incorrect: Gestational age less than 37 weeks places the infant or toddler at risk for developmental problems.

A nurse is educating the family of a client in the middle stages of Alzheimer's disease how to encourage independence during meals. What points should the nurse include? 1. Serve meal in a quiet environment 2. Give 30 minutes to eat 3. Serve finger foods 4. Serve one dish at a time 5. Do not worry about neatness

1., 3., 4., & 5. Correct: Limit distractions by serving meals in quiet surroundings, away from the television and other distractions. Too many foods at once may be overwhelming. Simplify by serving one dish at a time. For example, mashed potatoes followed by meat. Serve finger foods, which are foods easy to pick up to eat. Do not worry about neatness. Let the person feed self as much as possible. Consider plates with suction, built-up rims and no spill glasses to allow users to more easily place food on their utensils. 2. Incorrect: Give the person plenty of time to eat. Remind client to chew and swallow carefully. Keep in mind that it may take an hour or longer to finish eating.

A client with distended and tortuous veins along the inner aspects of both legs asks the nurse how to decrease the development of these veins. What should the nurse advise? Select all that apply 1. Exercise 2. Follow a low protein diet 3. Wear low heeled shoes 4. Elevate legs above heart several times per day 5. Do not cross legs

1., 3., 4., & 5. Correct: These are varicose veins. Get moving. Walking is a great way to encourage blood circulation to the legs. Low-heeled shoes work calf muscles more, which is better for veins. To improve circulation in legs, take several short breaks daily to elevate legs above the level of the heart. Do not cross legs as it decreases circulation distally. 2. Incorrect: Low sodium diet will prevent swelling caused from water retention. A diet low in protein will not decrease the development of these veins. The key is to keep swelling down so that pressure on the veins is reduced.

What medications should the nurse anticipate the primary healthcare provider prescribing for the client with portal hypertension and bleeding esophageal varices associated with advanced cirrhosis? Select all that apply 1. Oxygen 2. Clopidogrel 3. Propranolol 4. Vitamin K 5. Lactulose

1., 3., 4., & 5. Correct: We know that they need oxygen because they may have been bleeding. Propranolol acts to reduce portal venous pressure and reduce esophageal varices bleeding. Vitamin K is a clotting factor and helps to correct clotting abnormalities because of the damaged liver. Lactulose decreases what? Ammonia, which is elevated with cirrhosis. 2. Incorrect: You don't want to give them a platelet aggregation inhibitor. They are already bleeding.

A client with a history of schizophrenia was admitted with abdominal pain and has been undergoing diagnostic tests. When the nurse enters the room, the client is alone and looking at the wall and states "Why should I hurt them?" What would be an appropriate intervention by the nurse? Select all that apply 1. Directly ask the client "Are you hearing voices?" 2. State "Tell the voice that you do not want to hurt anyone." 3. Focus on reality based topics of conversation. 4. Observe for signs of increasing anxiety in the client. 5. Tell the client "You know that you are not being told to hurt someone." 6. Inquire about what the client believes he or she is being told to do.

1., 3., 4., & 6. Correct: Did you pick up on the cues that this client is experiencing auditory hallucinations? The most obvious cues that this client is hallucinating are the verbal response when there is no one present and the client is looking at the wall when responding. When you think a client is hallucinating, you should directly ask the client about the hallucination by asking such questions as: "Are you hearing voices?" In order to intervene with a client who is experiencing a hallucination, you should focus on reality-based diversions including reality-based topics of conversation. Also, hallucinations can be anxiety producing for clients, so you should observe for any signs of increasing anxiety, which can be a sign that the hallucinations are increasing. The nurse can explore the hallucination experience with this client by asking directly "What are the voices telling you to do?" Another way to specifically explore the hallucination with this client is to ask if they are being told to do something that would cause harm to someone. 2. Incorrect: You never want to react to the client's hallucinations as if they are real. In this case, you would not tell the client to talk back to the "voices" and argue with them or discuss things as if the voices are real. 5. Incorrect: You do not want to negate the client's hallucination experience, but you do offer your own perception that you do not hear the voices. Telling the client that they are not being told something would only escalate their anxiety and perhaps cause them to become irritable or upset. The voices are "real" to the client.

Which nursing action represents measures taken to protect the client from a mode of infection transmission in the chain of infection? 1. Donning personal protection equipment. 2. Administering the Haemophilus influenzae type B (HIB) immunization to a child. 3. Disposing of soiled gloves in the appropriate receptacle. 4. Wearing gloves when coming into contact with client's secretions. 5. Teaching importance of long pants and sleeves and insect repellent to reduce the risk of West Nile Virus. 6. Performing hand hygiene after removal of soiled gloves.

1., 3., 4., & 6. Correct: In this question, can you identify the nursing actions that represent prevention of the spread of infection to other clients at the point of mode of transmission on the chain of infection? The first one identified is the donning of personal protection equipment. This prevents the infectious agent from coming into contact with the nurse's hands that could then spread the infection to other clients. Next, disposing of soiled gloves in the appropriate receptacle assures that the infectious agents are not carried outside of the infectious client's room and then transmitted to other clients. Gloves should always be worn when there is a possibility that the nurse could come into contact with the client's secretions. Hand hygiene is a crucial part of infection control. Hand hygiene by washing the hands and/or using alcohol based sanitizer before and after glove removal reduces the risk of the spread of infection. Both the use of gloves when secretions are present and proper hand hygiene help to prevent the nurse's hands from becoming a mode of infection transmission to other clients. 2. Incorrect: Immunization of a child against Haemophilus influenzae type B (HIB) is an example of a nursing action to prevent infection transmission by disrupting the susceptible host link in the chain of infection. This is accomplished by increasing the resistance of the host to the infectious agent, which in this case is HIB. 5. Incorrect: Teaching clients about the importance of wearing long pants and long sleeves, as well as using insect repellent is an example of nursing action aimed at reducing the risk of West Nile Virus by breaking the chain of infection at the portal of entry link. By wearing the protective clothing and using insect repellent, the vector (mode of transmission) is not as likely to be able to access a portal of entry on the host.

The nurse, caring for a client diagnosed with Alzheimer's Disease (AD), notices the client becoming agitated. What nursing strategies would be appropriate for the nurse to initiate? Select all that apply 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 strategies 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. A calming family member can be asked to stay with the client until the client becomes calmer.

Which nursing action represents measures taken to protect the client from a mode of infection transmission in the chain of infection? Select all that apply 1. Donning personal protection equipment. 2. Administering the Haemophilus influenzae type B (HIB) immunization to a child. 3. Disposing of soiled gloves in the appropriate receptacle. 4. Wearing gloves when coming into contact with client's secretions. 5. Teaching importance of long pants and sleeves and insect repellent to reduce the risk of West Nile Virus. 6. Performing hand hygiene after removal of soiled gloves.

What signs/symptoms would the nurse expect to assess in a client diagnosed with multiple sclerosis (MS)? Select all that apply 1. Fatigue 2. Ptosis 3. Blurry vision 4. Leg weakness 5. Limited facial expression 6. Electric shock sensation when bending neck forward

1., 3., 4., & 6. Correct: Multiple sclerosis causes fatigue which often comes on in the afternoon and causes weak muscles, slowed thinking, or sleepiness. Vision problems are common with this diagnosis and include blurry vision, double vision, and pain on eye movement. Partial or complete vision loss can occur in one eye. Because this disease affects nerves, symptoms often affect movement such as extremity weakness, numbness, tingling, and coordination. Electric-shock sensations that occur with certain neck movements, especially bending the neck forward (Lhermitte sign) develop because of the nerve damage that is occurring. 2. Incorrect: Drooping of one or both eyelids (ptosis) would be seen in myasthenia gravis rather than multiple sclerosis. 5. Incorrect: Limited facial expressions occur in myasthenia gravis rather than multiple sclerosis. The muscles (not nerves) that control facial expressions have been affected.

What nursing interventions should the nurse include when planning care for a client admitted with Guillain-Barre' Syndrome? Select all that apply 1. Monitor for contractures. 2. Place prone for 30 minutes, 4 times per day. 3. Provide therapeutic massage for pain relief. 4. Teach range of motion exercises. 5. Provide high protein meals 3 times a day. 6. Refer to physical therapist.

1., 3., 4., & 6. Correct: This client will have progressive weakness and paralysis. Contractures and pressure ulcers need to be prevented through ROM exercises and frequent turning. Muscle spasms and pain can be relieved by therapeutic massage, imagery, diversion, and pain medication. 2. Incorrect: The client will need to be repositioned every 2 hours to prevent pressure sores and pneumonia and atelectasis. Elevate the head of the bed to help with lung expansion. Prone will interfere with lung expansion ability. 5. Incorrect: Encourage small, but frequent meals that are both well-balanced and nourishing.

A client who needs to have a stool specimen for an occult blood test is instructed by the nurse to avoid which substances two hours prior to testing? Select all that apply 1. Liver 2. Tomato 3. Ibuprofen 4. Sardines 5. Ascorbic acid

1., 3., 4., 5. Correct: The following foods can cause a false-positive reading: red meats, liver, turnips, broccoli, cauliflower, melons, salmon, sardines, and horseradish. Medications altering the test include aspirin, ibuprofen, ascorbic acid, indomethacin, colchicines, corticosteroids, cancer chemotherapeutic agents, and anticoagulants. Ingestion of vitamin rich foods can cause a false negative result. 2. Incorrect: A tomato is not on the food list for false-positive reading and do not have to be avoided.

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

1., 3., 4., 5., & 6. Correct: All of these activities exercise the brain and increase mental functioning. 2. Incorrect: Brain-boosting food is any food high in Omega 3 fatty acids, which has been linked to a lower risk of dementia and improved focus and memory.

What foods should the nurse teach a client who has been diagnosed with iron deficiency anemia to increase in the diet? 1. Chickpeas 2. Milk 3. Oysters 4. Raisins 5. Spinach 6. Tuna

1., 3., 4., 5., & 6. Correct: All of these are high in iron. 2. Incorrect: Milk is not high in iron and slows the absorption of iron

The nurse is teaching comfort measures to a postpartum client with an episiotomy and external hemorrhoids. Which teaching points should the nurse include? Select all that apply 1. Apply ice to perineum for first 12 hours. 2. Take sitz baths at temperature of 107.6°-111.2°F (42-44°C). 3. Use witch hazel compresses on rectal areas for hemorrhoids. 4. Take ibuprofen for pain. 5. Apply topical anesthetics to perineal area. 6. Avoid sexual intercourse until episiotomy has healed.

1., 3., 4., 5., & 6. Correct: Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Chemical ice packs or clean gloves filled with ice may be used during the first 12 hours after a vaginal birth. Witch hazel contains chemicals called tannins. When applied directly to the skin, witch hazel might help reduce swelling and help repair broken skin. Analgesics such as acetaminophen and nonsteroidal anti inflammatory drugs (NSAIDs) such as ibuprofen frequently are prescribed to provide relief for mild to moderate discomfort. Topical anesthetic may be used as needed to decrease surface discomfort and allow more comfortable ambulation. Sexual intercourse prior to healing of the episiotomy may contribute to further perineal damage. 2. Incorrect: This temperature is too hot and can damage the injured tissue. The sitz bath should be at a temperature of 100-104°F (38-40°C).

A community health nurse is planning to discuss how to prevent pesticide ingestion at a local health fair. What should the nurse include in this teaching session? Select all that apply 1. Discard the outer leaves of lettuce. 2. Wash fruits and vegetables with dish soap. 3. Buy organic produce. 4. Peel fruits prior to eating. 5. Dry produce thoroughly with disposable paper towels after washing. 6. Use a scrub brush when washing fresh fruits and vegetables.

1., 3., 4., 5., & 6. Correct: The outer leaves of green, leafy vegetables, such as lettuce and cabbage, should be discarded as pesticide residue likely remains there. Another great idea to reduce overall exposure to pesticides is to buy organic or unsprayed produce. If you can't buy organic, peel fruits and vegetables prior to eating. Washing your fruits and veggies is not enough if you want to reduce the pesticide load you expose yourself to, as it is very important to thoroughly dry them with disposable paper towels as well. This will remove all the remaining pesticide residue and make the produce safer to eat. A scrub brush is very effective in cleaning the crevices and areas around the stem. 2. Incorrect: One of the most common mistakes people make in their attempt to remove all pesticide residue from their produce is that they wash their fruits and vegetables with soap or, even worse, dish soap. Never use detergents, special rinses or soaps of any kind, as this will only do more harm than good. Unless the soap is entirely made of natural and organic materials, it tends to contain harmful compounds that easily penetrate the skin of the fruits, thus doing more harm than the actual pesticides after you ingest them. Simply wash with tap water.

What developmental milestones does the nurse expect to see in a 9 month old infant? Select all that apply 1. Looks for fallen object. 2. Follows 1-step verbal command without gestures. 3. Plays peek-a-boo. 4. Understands the word "no". 5. Picks up cereal o's between the thumb and index finger. 6. Stands while holding on to something.

1., 3., 4., 5., & 6. Correct: When looking for the developmental milestones of a 9 month old, the nurse should expect to see the infant look for an object that has been dropped or that the infant sees someone hide. The infant can play simple games like peek-a-boo or itsy-bitsy spider. The word "no" should be understood by this age. Picking up things like cereal o's between the thumb and index finger is the pincer grasp that is achieved at this age. By nine months the infant should be able to pull self to a stand and stand while holding on to something. 2. Incorrect: The infant begins to follow simple directions like "pick up the toy" around the age of 1 year.

A client is being admitted to the hospital for possible appendicitis. During the admission history and physical, the client reports having fatigue and trouble concentrating. What other client statement during the assessment would lead the nurse to suspect marijuana use? Select all that apply 1. "My eyes have looked bloodshot lately." 2. "I've noticed that my appetite has been decreasing." 3. "I sometimes feel that I am off balance." 4. "I have been losing weight lately." 5. "I don't have the desire to do the things I used to do." 6. "My heart seems to beat fast a lot of the time."

1., 3., 5., & 6 Correct: Red eyes are a classic sign of marijuana use. The red, bloodshot eyes that the client described may be the result of marijuana use, because it can cause vasodilation in the capillaries of the eye, resulting in increased blood flow. Tetrahydrocannabinol (THC), which is the active ingredient in marijuana, can attach to neuron receptors in the brain that disrupt various mental and physical functions. THC can affect pleasure, thinking, memory, concentration, movement, and coordination. That is why this client may feel "off balance" at times. In addition, sensory alterations and problems with time perception may be noted. The statement from the client about not having the desire to do the things that were formerly done may be a sign of marijuana use. Marijuana has been linked to decreasing motivation and diminishing the desire to engage in activities that were formerly rewarding or enjoyable. Another physical sign of marijuana use is increased heart rate, which would correlate with the client's statement about the sensation of the heart beating faster much of the time. 2. Incorrect: The appetite in individuals using marijuana tends to increase, not decrease. This is because the THC activates a part of the brain that is thought to be the reward system. Therefore, marijuana has an effect on the part of the brain that controls the person's response to normal, healthy, pleasurable behaviors such as eating and sex. 4. Incorrect: Not only does the appetite increase, but individuals who use marijuana may also have cravings for snacks. The weight in these individuals tend to increase rather than decrease.

A client diagnosed with gout has received instruction on maintaining a low-purine diet. Which statements, if made by the client, would indicate to the nurse that teaching was successful? Select all that apply 1. "I will eliminate foods from my diet that contain 150 mg or more of purine per serving." 2. "Rather than drinking a glass of wine, I should drink a glass of beer." 3. "Losing weight can help reduce the uric acid levels in my blood." 4. "Potatoes, rice, and barley are high in purine and should be eliminated from my diet." 5. "Vegetables that should be limited to 2 times/week include cauliflower, spinach, and mushrooms." 6. "Increasing fluid intake to 8-10 cups/day will help to eliminate purines through my urine."

1., 3., 5., & 6. Correct: Foods that contain 150 mg or more of purine are considered high purine foods and should be eliminated from the diet. Weight loss has been shown to improve insulin resistance, and therefore reduce uric acid levels in the blood. Vegetables that have high purine content include cauliflower, spinach, peas, asparagus, and mushrooms. These should be limited to no more than 2 times per week. Ensuring a sufficient fluid intake helps to reduce the risk of crystals forming in joints. Keeping hydrated and avoiding dehydration can lessen this risk and help to prevent gout attacks. 2. Incorrect: Alcohol - These cause increased dehydration and interfere with uric acid elimination. The metabolism of alcohol in your body is thought to increase uric acid production, and alcohol contributes to dehydration. Beer is associated with an increased risk of gout and recurring attacks, as are distilled liquors to some extent. The effect of wine is not as well understood. 4. Incorrect: Potatoes, rice, barley, noodles, and pastas are low in purine and can contribute to the 4 or more servings of starches needed per day.

A client has been admitted to the medical unit after sustaining a stroke. The admitting nurse initiates a nursing diagnosis of unilateral neglect related to a decrease in visual field and hemianopia from cerebrovascular problems as evidenced by consistent inattention to stimuli on the affected side. What nursing interventions should the nurse initiate for this client? Select all that apply 1. Instruct client to scan from left to right to visualize the entire environment. 2. Encourage client to practice exercises independently. 3. Position bed in room so that individuals approach the client on the unaffected side. 4. Apply splints to achieve stability of affected joints. 5. Touch unaffected shoulder when initiating conversation with client. 6. Position personal items within view on the unaffected side.

1., 3., 5., & 6. Correct: Instructing the client to scan from left to right will help the client to visualize the entire environment. The client has to be reminded to do this since only one side of the client's visual field is working. By positioning the bed so that individuals approach the client from the unaffected side and by touching the client on the unaffected shoulder, the client is not surprised or frightened when realizing someone is in the room. Placing personal items where the client can see them will allow the client to use the material. Then gradually move personal items and activity to the affected side as the client demonstrates an ability to compensate for neglect. 2. Incorrect: Practicing exercises independently focuses on impaired physical mobility rather than unilateral neglect. 4. Incorrect: Applying splints to affected joints focuses on impaired physical mobility rather than unilateral neglect.

Which tasks are most appropriate for the hospice nurse to delegate to an unlicensed assistive personnel (UAP)? Select all that apply 1. Bathe the client. 2. Provide spiritual support 3. Listen to the client reminisce. 4. Administer routine medications. 5. Weigh the client. 6. Take vital signs

1., 3., 5., & 6. Correct: The UAP can bathe, listen to the client remininsce, weigh, and take the vital signs. These are within the scope of practice of the UAP. These assignments are routine and revolve around activities of daily living. 2. Incorrect: The task of providing spiritual support could best be delegated to the pastor or chaplain. 4. Incorrect: The nurse can not delegate routine medication administration to the UAP. This is not within the UAPs scope of practice. This is an LPN or RN responsibility.

The nurse is providing teaching for a client who is being scheduled for outpatient 24 hour electrocardiogram monitoring using a Holter monitor. What should the nurse tell the client to avoid while monitoring is in progress? Select all that apply 1. Taking a shower or bath 2. Performing daily exercises 3. Working around high voltage equipment 4. Being screened at airport security 5. Eating foods that are sources of potassium

1., 3., and 4. Correct: The nurse should teach this client to continue the usual activities while wearing the monitor with a few exceptions. The monitor should be kept dry to ensure that it functions properly. The client should avoid taking a shower or bath or swimming while wearing the monitor. The electrodes could also become detached from the skin if they get wet, which would also interfere with the accuracy of the reading. The client should be advised to not work around high voltage equipment because areas of high voltage can interfere with the function of the electrocardiogram monitoring. In addition, magnetic fields, such as those used for airport screenings, can interfere with the function of the Holter monitor and should be avoided. 2. Incorrect: This client should be encouraged to continue regular routine unless otherwise directed by the primary healthcare provider. The client can perform the usual daily exercise, but should be advised to avoid activities that may cause excessive perspiration that could lead to the electrodes becoming loosened from the skin. 3. Incorrect: There are generally no dietary restrictions while wearing the Holter monitor unless otherwise prescribed by the primary healthcare provider.

Which medications, if prescribed to a client, should indicate to a nurse that retention of CO2 is a possibility? Select all that apply 1. Narcotics 2. Diuretics 3. Glucocorticoid 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. Sleeping pills 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.

Which discussion points should a nurse plan to include when teaching a group of college students on prevention of sexually transmitted infections (STI)? 1. Safe sex practices 2. Routine human immunodeficiency virus (HIV) testing 3. Proper use of birth control pills 4. Sexual abstinence 5. Vaccinations for STIs

1., 4. & 5. Correct: All of these topics should be included when discussing prevention of STIs. Safe sex practices include proper use of condoms. Abstinence is the best way to prevent STIs. Vaccines are available for some STIs such as human papillomavirus vaccine (HPV). 2. Incorrect: Routine HIV testing is not a way to prevent HIV or other STIs. It will provide early diagnosis. The best course of action is to prevent occurrence.3. Incorrect: Birth control pills help prevent unplanned pregnancy. STIs can still be contracted if proper safe sex techniques are not implemented.

Which discussion points should a nurse plan to include when teaching a group of college students on prevention of sexually transmitted infections (STI)? Select all that apply 1. Safe sex practices 2. Routine human immunodeficiency virus (HIV) testing 3. Proper use of birth control pills 4. Sexual abstinence 5. Vaccinations for STIs

The nurse is caring for a client admitted with heart failure. Which prescriptions would necessitate that the nurse seek clarification from the primary healthcare provider? Select all that apply 1. Furosemide 20.0 mg p.o. daily 2. Rosuvastatin 5 mg p.o hs 3. Digoxin 0.125 mg IVP every 8 hours for three doses 4. Folic acid 1 mg daily 5. Heparin 1000 IU subcutaneously daily

1., 4. & 5. Correct: It is inappropriate to have a trailing zero after a decimal point for doses expressed in whole numbers. It can be mistaken as 200 if the decimal point is not seen. The folic acid order lacks a route, thus needs clarification. The Heparin order should be written as Heparin 1,000 units subcutaneously daily. Use commas for dosing units at or above 1,000 or use words such as one thousand to improve readability. Use units rather than IU (International units) as this can be mistaken as IV or 10.2. Incorrect: This medication order is written correctly.3. Incorrect: This medication order is written correctly.

The nurse is caring for a client on the surgical unit. Which prescriptions could the nurse safely administer to the client? Select all that apply 1. Chlordiazepoxide 10 mg p.o. q 4h p.r.n. for agitation 2. Regular insulin 10 U stat 3. MS 2 mg IVP every 2 hours as needed for pain 4. Cefepime 1 gram IVPB every 8 hours 5. Diphenhydramine 25 mg p.o. hour of sleep for three nights

1., 4. & 5. Correct: These medication prescriptions are correctly written following approved Joint Commission abbreviations. 2. Incorrect: The "U" can be mistaken for "0" (zero), the number "4" (four) or "cc". Units should be written out completely. 3. Incorrect: MS can mean morphine sulfate or magnesium sulfate. Write "morphine sulfate". Write "magnesium sulfate".

A 65 year old client is admitted for management of dehydration with an IV infusion of LR @ 125 mL/hr. What assessment findings would be of concern to the nurse? Select all that apply 1. Anxiety 2. BP 136/80 3. CVP 5 mmHg 4. Crackles noted right posterior lung field 5. S3 heart sound

1., 4. & 5. Correct: Volume overload is an adverse effect of IV therapy in the elderly. Anxiety is an early sign of hypoxia due to FVE. Crackles to the bases are an early sign of fluid volume excess (FVE). S3 heart sounds are also an indication of FVE. 2. Incorrect: This blood pressure is not considered hypertension in this age group. Blood pressure of >140/90 is cause for concern in this age group. Also, one BP is not cause for concern. In assessing for FVE, it is important to compare to the client's baseline. 3. Incorrect: Normal CVP is 2-6 mmHg. A CVP reading of 5mmHg does not indicate FVE.

A pregnant client who had been on a magnesium drip for severe pregnancy induced hypertension (PIH) has had an emergency cesarean section at 35 weeks. The nursery nurse should anticipate what findings in the newborn related to the magnesium therapy? Select all that apply 1. Hypotension 2. Hypoglycemia 3. Hyperreflexia 4. Flaccid muscle tone 5. Respiratory depression

1., 4. & 5. Correct: When magnesium sulfate is administered to the mother for preeclampsia, the intent is to prevent seizures and decrease blood pressure by suppressing the central nervous system, thus preventing premature labor. The dose of this drug and the length of time administered will determine what side effects might be seen in the newborn, since magnesium crosses the placental barrier. The nurse will most likely note hypotension and some degree of respiratory depression in the newborn. Additionally, the newborn may have flaccid or weak muscles along with poor, or even absent reflexes. Treatment of the newborn will be based on the degree of depression. 2. Incorrect: The use of magnesium sulfate in the mother prior to delivery does not affect the blood glucose level of the fetus/newborn. Magnesium sulfate affects the central nervous system, not the pancreas, so blood sugar should be within normal limits. 3. Incorrect: Magnesium is a central nervous system depressant that crosses the placental barrier. Side effects to the newborn would be similar to those noted in the mother, including depressed or absent reflexes. The nurse would not find hyperreflexia.

Which client would be appropriate for the RN to assign to the LPN? 1. Client requiring enemas and antibiotics. 2. Newly admitted client with diagnosis of diabetic ketoacidosis (DKA). 3. Client returning from surgery post right upper lobectomy. 4. Client with frequent reports of nausea and vomiting following chemotherapy. 5. Client requiring frequent sterile dressing changes.

1., 4., & 5. Correct: Administering enemas and antibiotics to a client is within the scope of practice of the LPN. Nausea and vomiting are common side effects after a client receives chemotherapy. The LPN can administer antiemetics and monitor fluid status. It is within the scope of practice for the LPN to perform sterile dressing changes. 2. Incorrect: This client is a new admit who is in DKA and would be unstable. 3. Incorrect: This client will require frequent assessments and monitoring for postop complications.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Assist client to brush and floss teeth. 2. Administer sodium polystyrene sulfonate enema. 3. Evaluate pain relief after narcotic administration. 4. Measure urine output when client voids. 5. Gather supplies to prepare room for isolation. 6. Monitor client for pain while assisting with ambulation.

1., 4., & 5. Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. So, the UAP can assist a client to brush and floss teeth. UAPs can assist with elimination and are taught how to measure output. This would be an acceptable task to assign to the UAP. Gathering needed equipment and supplies is within the scope of duties for the UAP. 2. Incorrect: It is out of the UAP's scope of practice to administer medication. This includes medication enemas. Only a plain enema or soap enema can be given by the UAP. 3. Incorrect: The nurse is responsible for evaluating a client. This would be out of the UAP's scope of practice. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. 6. Incorrect: The nurse is responsible for monitoring a client. This would be out of the UAP's scope of practice. The UAP can ambulate the client and can report to the nurse if the client states that pain is occurring but cannot monitor or collect data.

A client with renal failure has returned to the unit post kidney transplant. Which postoperative interventions should the nurse provide? Select all that apply 1. Administer furosemide. 2. Maintain fluid replacement at 150 ml per hour for 8 hours. 3. Measure abdominal girth every 24 hours. 4. Weigh daily. 5. Measure urine output every 30 - 60 minutes.

1., 4., & 5. Correct: Diuretics are administered to promote postoperative diuresis. Daily weights are done to make sure there is not rapid weight gain which is a pertinent of fluid retention. Careful and frequent assessment of UOP helps determine fluid balance and transplant function. Oliguria is an early sign of acute tubular necrosis and should be detected as soon as possible post-op.2. Incorrect: Fluid replacement is generally calculated to replace urine output over the previous 30-60 minutes, milliliter for milliliter. The stem of the question does not give you enough information about the client to know that this rate of fluid replacement is safe.3. Incorrect: Signs of hemorrhage after this surgery include swelling at the op site, increased abdominal girth, signs of shock and decreased level of consciousness. Assessment for signs of hemorrhage should be done much more frequently than every 24 hours.

What actions would be appropriate for a nurse who is administering ear drops to a six year old child? Select all that apply 1. Position supine with affected ear up. 2. Administer ear drops immediately upon removing from the refrigerator. 3. Open ear canal by drawing back on the pinna and slightly downward. 4. Allow prescribed number of drops to fall along inside of ear and flow into ear by gravity. 5. Have client remain supine for several minutes.

1., 4., & 5. Correct: Supine with affected ear up allows for proper administration of medication. Never attempt to put drops directly on the eardrum. Administer along inside of ear so that drops flow by gravity into ear. Remaining supine for several minutes permits the fluid to be absorbed. 2. Incorrect: If medication is not instilled at room temperature, the client may experience vertigo, dizziness, pain, and nausea. Additionally, cold ear drops cause discomfort. 3. Incorrect: This is the method for a child less than 3 years of age. For older than 3 years, open canal of ear by drawing back on the pinna and slightly upward.

Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Select all that apply 1. Talk to each nurse about concerns related to assigned clients. 2. Call the family of a client suffering from dementia to discuss long term care placement. 3. Briefly assess every client. 4. Complete a client assignment sheet for the oncoming staff. 5. Receive report from the emergency department (ED) on a new client.

1., 4., & 5. Correct: Talking to the nurses about client concerns and completing the client assignment sheet for oncoming staff will provide for a thorough shift change report. It is crucial that the oncoming staff have an opportunity to voice any concerns regarding assignments and clarify any information provided.This proper exchange of information and concerns helps to ensure the safety of clients, provides continuity of care, and possibly prevents problems that might arise if these concerns had not been addressed. Taking the report from the ED could be delayed but is a courtesy to the ED and will provide information about the client that will be useful in making assignments for the next shift. 2. Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. Doing this at the end of the shift could prevent completion of the client assignment sheet for the next shift and possibly create unnecessary overtime for the charge nurse. 3. Incorrect: The charge nurse does not have to assess every client. This will take a lot of time, and the charge nurse can get the information needed from the nurses caring for the clients in order to make appropriate client assignments for the next shift.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Empty the indwelling catheter on the four hour postop client. 2. Instruct a client to soak in a warm bath for 30 minutes when experiencing endometrial discomfort. 3. Monitor the peri-pad count on a client diagnosed with fibroid tumors. 4. Assist client two days post hysterectomy to the bathroom. 5. Encourage a client who is refusing to get out of bed to walk in the hall.

1., 4., & 5. Correct: The UAP can empty a client's catheter bag. UAPs can assist with elimination and are taught how to measure output. Ambulating a stable client to the bathroom is also an acceptable task to assign to the UAP. All personnel should encourage a client to ambulate when prescribed. This can be done by the UAP. 2. Incorrect: It is out of the UAP's scope of practice to teach. The RN cannot delegate teaching to anyone other than another RN. 3. Incorrect: The nurse is responsible for assessing and evaluating a client. This would be out of the UAP's scope of practice. The nurse cannot assign assessment and evaluation of the nursing process to the UAP.

An intravenous infusion of 0.45% normal saline is prescribed at a rate of 1000 mL in 24 hours. The tubing has a drip factor of 15. How many drops per minute (gtts/min) are delivered? Round your answer to the nearest whole number. Provide your answer using numbers and decimal points only.

10 The formula used to calculate drip rates is the total number of milliliters divided by the total number of minutes multiplied by the drip factor. In this circumstance, the minutes portion must be figured first, that is, 24 hours equals 1440 minutes. Then, dividing 1000 by 1440 equals 0.69. This is multiplied by the drip factor, which is 15. Multiplying 15 by 0.694 equals 10.4, which rounds to 10.

The nurse is talking with a new parent regarding activities that promote attachment between the parents and the newborn. What activities should the nurse include? Select all that apply 1. Feed baby on demand. 2. Put baby in bed to sleep with parents. 3. Allow baby to cry for at least 5 minutes. 4. Sing to the baby. 5. Stroke baby's face.

1., 4., & 5. Correct: There is a parenting philosophy called "Attachment Parenting." One of the behaviors that typify the parenting philosophy of attachment parenting is on-demand feeding rather than a routine schedule for feeding. A baby needs consistent warmth and responsiveness, especially in the first 12 months of life. Responding to cries and being sensitive to the baby's signals shows the baby can trust the parent to meet needs. Parental touch, calling the baby by name and talking to the baby in a soothing manner also promote attachment. 2. Incorrect: This is a safety issue. A parent could roll over on the baby causing injury or suffocation. The safest place for a newborn in a basinet or crib. 3. Incorrect: Responding to cries in a timely manner and being sensitive to the baby's signals shows the baby can trust the parent to meet needs.

A nurse has completed education on safe sexual practices to a group of college students. Which comments by the students would indicate that education has been successful? Select all that apply 1. "The best way to prevent HIV is to abstain from sex." 2. "Contraceptives should contain spermicide N-9." 3. "Douching is recommended after intercourse." 4. "Drinking too much alcohol can increase the risk exposure to sexually transmitted disease (STDs)." 5. "If my partner will not use a condom, I will."

1., 4., & 5. Correct: These are correct statements. The best way to prevent HIV or STIs is to abstain from sex. If one decides to have sex, know your HIV status and your partners. Use condoms, male or female. Practice monogamy. Limit sexual partners. Use protection for all kinds of sexual contact. Get screened for sexually transmitted infections (STIs). Don't abuse drugs or alcohol, which are linked to sexual risk taking. 2. Incorrect: Spermicide N-9 will lower chances of pregnancy, but not HIV and other STIs. Spermicide N-9 actually makes your risk of HIV infection higher, caused by irritation of the vagina, which can make it easier for HIV to go into the body. 3. Incorrect: Douching removes some of the normal bacteria in the vagina that protects you from infection. This can increase your risk of getting HIV.

The nurse has completed newborn discharge teaching with the parents. Which statements by the parents would indicate accurate understanding of proper CPR for infants? Select all that apply 1. Place the infant on a firm, flat surface. 2. Use the palm of one hand to do compressions. 3. Give compressions at a rate of at least 1 per second. 4. Compress about one third the anterior-posterior diameter of the chest. 5. Give one breath after every 15 compressions. 6. Time to give breaths should not take longer than 10 seconds.

1., 4., & 6. Correct: A firm surface is needed for compressions to be effective. Keep in mind, if the infant is small enough, the forearm, while holding the infant, can serve as the firm surface. The depth of compressions for infants should be approximately one third of the anterior-posterior (AP) diameter of the chest, which is usually about 1 ½ inches. Interruptions in compressions should be minimized when giving breaths and should be less than 10 seconds 2. Incorrect: For compression in infants, 2 fingers are placed in the center of the infant's chest, just below the nipple line, on the lower half of the breastbone. Placement of fingers on the tip of the breastbone should be avoided. 3. Incorrect: One compression per second would be too slow. The appropriate compression rate for infants is 100-120. 5. Incorrect: The compression to ventilation rate is 30:2. That means that after every 30 compressions, the airway should be opened and 2 breaths should be given.

The nurse educator has provided education to newly hired emergency department nurses regarding mandatory reporting laws. Which suspected instances provided by the new nurses indicates to the nurse educator that education was effective? Select all that apply 1. Financial abuse of an elder 2. Negligence of a colleague 3. Spousal abuse denied by the victim 4. Gunshot victim 5. Client diagnosed with Gonorrhea 6. Client diagnosed with West Nile virus

1., 4., 5., & 6. Correct: Federal and state laws require that certain individuals, particularly those who work in health care with the elderly, with children, and other vulnerable populations, have an affirmative duty to report to a specified state agency when violence occurs against those populations. This includes physical, mental, and financial abuse. Gunshots and knife injuries are reportable to law enforcement. Certain communicable diseases such as gonorrhea and West Nile virus are reportable to the CDC. 2. Incorrect: Suspected negligence of a colleague is not in the realm of mandatory reporting to authorities, but the nurse should discuss with the supervisor. 3. Incorrect: A spouse is not considered a vulnerable person so it is not required by law to report. You should encourage the spouse to report the abuse but you, as the nurse, are not bound by law to do so.

A client of Islamic faith has died and the family wishes to uphold the basic Islamic beliefs for end of life care. What intervention would be appropriate at this time? Select all that apply 1. Upon death, close the eyelids and mouth and pull a covering over the body. 2. Begin necessary preparations for the body to be cremated as soon as possible. 3. Move the body immediately to the morgue for transport to funeral home. 4. Allow someone in the family or mosque to bathe and wrap body in white cloth. 5. Stand quietly or provide privacy as final prayers are offered by family. 6. Place the head of the deceased facing Mecca.

1., 4., 5., and 6. Correct: Based on basic beliefs of the Islamic faith, upon death, the eyes and mouth should be closed. The body should initially be covered with a sheet or similar covering. A practice known as the ghusl is performed which involves the washing of the deceased person's body. This is typically done by an adult family member of the same sex of the deceased, and then the body is enshrouded (wrapped), typically in plain, white cloth. The nurse should show respect to the family by either providing quiet presence as final prayers are offered or by allowing the family to have privacy during this final time with their family member who has died. A practice that may be performed before and/or after the time of death is positioning the head so that it faces Mecca. This may involve moving the bed to where the head faces Mecca or it may involve turning the head to the right side. 2. Incorrect: Cremation is strictly forbidden in the Islamic faith. 3. Incorrect: Islamic practices call for burying the body as soon as possible, which eliminates the need for embalming, unless required by law. However, taking the body to the morgue immediately would not allow the family time to perform the washing and enshrouding of the body and would be disrespectful to both the deceased and the family. In addition, autopsies are not usually allowed unless there is foul play suspected, in which permission may be granted to perform the autopsy. The body of the deceased should be disturbed as little as possible after death

The nurse is caring for a client on the cardiac unit. Which assessments are most important for the nurse to perform prior to the administration of diltiazem? Select all that apply 1. Note the rate and character of the apical pulse. 2. Ausculate the anterior and posterior breath sounds. 3. Check the morning results of serum calcium. 4. Review the last 24 hour urine output. 5. Monitor blood pressure. 6. Assess for chest pain.

1., 5., & 6. Correct: Diltiazem is a calcium channel blocker. It works by relaxing the muscles of the heart and blood vessels. Monitor blood pressure and pulse before and frequently during administration of diltiazem, as it causes systemic vasodilation and suppresses arrhythmias. Diltiazem is used to treat angina, so the nurse should assess for anginal pain. 2. Incorrect: Breath sounds need to be assessed to monitor for signs of heart failure, this would be a complication after diltiazem administration. Breath sounds are not necessarily assessed just prior to administration. 3. Incorrect: Diltiazem is a calcium channel blocker, but the total serum calcium concentration is not affected by it. Calcium channel blockers affect the flow of calcium into muscle cells. 4. Incorrect: A decrease in output would be an indicator of heart failure, which is a complication of diltiazem administration. This would be assessed after giving the medication.

A client diagnosed with a brain injury continues to attempt to get out of the bed without assistance. Which nursing interventions would the nurse implement? Select all that apply 1. Ask a familiar person to stay with the client. 2. Apply position change sensor to the bed. 3. Move client closer to the nursing station. 4. Reinstruct the client to not get out of the bed. 5. Provide positive and negative reinforcement.

1.,2. & 3: Correct: Having a person directly monitor the client will decrease the possibility of the client getting out of the bed. In addition, a familiar person in the room can have a calming effect on the client. Bed alerts will notify the healthcare team that the client is moving in the bed. This will result in a quicker response time to evaluate, if the client is trying to get out of bed. The intervention of moving the client closer to the nursing station will increase the observation of the client. This increased visualization can allow the healthcare team to intervene if the client tries to get out of the bed. 4. Incorrect: Due to the brain injury, the client's ability to process information, including instructions is limited. The client may become agitated and exhibit restless behaviors. Reinstructing the client will not be effective if the client is having difficulty processing the initial instructions. 5. Incorrect: Due to the brain injury, cognitive deficits occur resulting in the decreased ability for the client to interpret information. The client will not have the ability to recognize positive reinforcement messages. The client should not be subjected to any negative reinforcement actions.

The nurse educates a client that the prescribed medication indomethacin is used to manage which symptoms? 1. Pain 2. Inflammation 3. Fever 4. Cough 5. Urticaria

1.,2., & 3. Correct: Indomethacin is a non-steroidal anti-inflammatory agent used to treat pain, inflammation, and fever. 4. Incorrect: Indomethacin does not have any cough suppressant actions.5. Incorrect: Urticaria is a side-effect associated with indomethacin use.

A client returns to the unit after a liver biopsy. Which nursing interventions would the nurse implement? 1. Put a pillow under the costal margin. 2. Place in the right side lying position. 3. Perform passive range of motion exercises to right shoulder. 4. Take vital signs every 10 - 15 minutes for first hour. 5. Instruct the client to avoid strenuous exercise for 1 month.

1.,2., & 4 Correct: The client is placed on the right side and a pillow placed under the costal margin. The pillow will place additional pressure on the rib cage which will assist with applying pressure to the liver capsule. By positioning the client on the right side, the liver capsule at the site of the biopsy is compressed against the chest wall. If the puncture site is not compressed, there is the possibility that blood or bile will leak from the puncture site. The vital signs are measured at 10 - 15 minute intervals for the first hour. Variations of the vital signs will indicate complications such as bleeding, severe hemorrhage, and bile leakage. 3. Incorrect: Passive range of motion exercises is not correct. The shoulder is not placed in a position during and after the biopsy to warrant passive exercises to the shoulder. 5. Incorrect: The client should be instructed to avoid strenuous exercise for 1 week not 1 month. The strenuous exercise is restricted to 1 week to prevent the possibility of liver bleeding.

A client has been admitted to Hospice Care. The hospice nurse is reviewing the nursing care plan for interventions to promote comfort for the terminally ill client. Which nursing interventions for the terminally ill client would the nurse implement? 1. Provide oral care every 2 hours. 2. Provide supportive environment. 3. Encourage 3 meals a day. 4. Administer optical lubricants as needed. 5. Encourage client to ambulate every 4 hours.

1.,2., & 4. Correct: Breathing through the mouth causes the mucous membranes and tongue in the mouth and lips to become dry. Oral care should be initiated every 2- 4 hours to increase oral integrity. As the client becomes progressively weaker the nurse should assist with oral hygiene. By creating a supportive environment, the dying client will experience less anxiety. Reducing the noise level and glare in the room will also create a supportive environment. Other ways to maintain a supportive environment are keeping the linen loose and clean. The client's eyes may become dry due to dehydration and less blinking of the eyelids. Optical lubricant should be applied to the eyes to decrease the burning and itching in the eyes. 3. Incorrect: The dying client should be offered 6 small feedings instead of 3 meals a day. The dying client is weak and is also losing their appetite. 5. Incorrect: The client's activity should be encouraged according to the client's energy level. Metabolic demands, disease status, weakness and fatigue will directly affect the client's ability to ambulate.

Which infant in the newborn nursery requires an immediate intervention by the nurse? 1. Four hours old, who has passed a small meconium stool. 2. Three hours old, who is having tremors. 3. Two hours old, who has several episodes of apnea lasting 10 seconds. 4. One hour old, who has acrocyanosis.

A client has been admitted to Hospice Care. The hospice nurse is reviewing the nursing care plan for interventions to promote comfort for the terminally ill client. Which nursing interventions for the terminally ill client would the nurse implement? Select all that apply 1. Provide oral care every 2 hours. 2. Provide supportive environment. 3. Encourage 3 meals a day. 4. Administer optical lubricants as needed. 5. Encourage client to ambulate every 4 hours.

What discharge instructions should the nurse include for a client following a transsphenoidal hypophysectomy? Select all that apply 1. Sleep with head of bed at 35 degrees. 2. Notify the primary healthcare provider for an increased urinary output. 3. Brush the teeth three times a day followed by rinsing with a commercial mouthwash. 4. Nasal packing will need to be removed in 48 hours. 5. Use a humidifier in the room.

1.,2., 5. Correct. Sleeping with the head of the bed elevated will promote drainage of cerebrospinal fluid. An increased UOP could indicate diabetes insipidus, an adverse reaction to this surgical procedure. Humidified air prevents drying of nasal passages. 3. Incorrect. Because the incision for this surgery is just above the gumline, the client should not brush the front teeth. Oral care should be performed with a sponge until the incision heals. 4. Incorrect. There is no nasal packing. The incision is located just above the gumline of the upper teeth.

Which interventions are appropriate for the nurse to identify for a client admitted to the psychiatric unit for management of anorexia nervosa? Select all that apply 1. Weigh daily. 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. The hour following meals may be used to discard food stashed from tray or to engage in self-induced vomiting. 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.

The nurse is caring for a client on the medical unit. The primary healthcare provider prescribed Lactulose 30 gram orally once a day. Available is Lactulose labeled 10 g per 15 mL. How many mL will the nurse administer? Round answer to the nearest whole number.

10 g : 15 mL = 30 g : x mL 10 x = 450 x = 45

The primary healthcare provider has prescribed 1000 mL of D5W to infuse over a 12 hour period. The drop factor is 20 gtt/mL. How many gtt/min should the nurse administer? Round answer to the nearest whole number.

1000 x 20 12 x 60 = 20,000 720 = 27.777 = 28 Since partial drops cannot be counted, always round to the nearest whole number which is 28.

The primary healthcare provider prescribes an intravenous infusion of D5 W at 125 mL per hour. The tubing has a drop factor of 10 gtt/mL. How many drops per minute should the nurse administer? Round answer to the nearest whole number.

125 x 10 60 = 20.83 = 21 Since partial drops cannot be counted, always round to the nearest whole number which, is 21.

The primary healthcare provider prescribes an intravenous infusion of D5 W at 125 mL per hour. The tubing has a drop factor of 20 gtt/mL. How many drops per minute should the nurse administer? Round answer to the nearest whole number.

125 x 20 60 = 41.666 = 42 Since partial drops cannot be counted, always round to the nearest whole number which, is 42.

A client weighing 140 pounds (63.64 kg) has been admitted to the telemetry unit with a diagnosis of Class III pulmonary hypertension. The primary healthcare provider prescribes digoxin. How many micrograms should the nurse administer now? Round to the whole number. Loading dose of digoxin - 15 micrograms/kg. Give 1/2 of the dose now, Then 1/4 the loading dose every 8 hours times 2 doses.

140 pounds / 2.2 kg = 63.636363663.6363636 x 15 micrograms = 954.545455954.545455 / 2 = 477.272727 or 477 micrograms nowThe following 2 doses would be 239 micrograms.

A primary healthcare provider has prescribed chlorpromazine 150 mg by mouth twice a day. The pharmacy sends chlorpromazine oral concentration: 100 mg/mL. How many mL should the nurse administer for each dose? Round answer using one decimal point.

150 mg : x mL :100 mg : 1 mL100 x = 150100 100divide both sides by 100X = 1.5

A nurse monitors the heart rates of four children on a pediatric unit. Which client requires additional assessment by the nurse? 1. 1 year old child who has a heart rate of 150 bpm and is crying 2. 2 year old child who has a heart rate of 165 bpm and is being rocked 3. 5 year old child who has a heart rate of 100 bpm and is playing quietly 4. 13 year old adolescent who has a heart rate of 90 and is watching television

A child diagnosed with AIDS is scheduled for grade school immunizations. Which immunizations are safe for the nurse to administer to the child? Select all that apply 1. MMR (measles, mumps, rubella) 2. DTaP (diphtheria, tetanus, pertussis) 3. VAR (varicella) 4. HiB (haemophilus influenza) 5. OPV (oral polio virus)

2 & 4. Correct: Children with AIDS are immunocompromised because of the HIV virus. Vaccines are crucial to provide protection against common childhood diseases. However, only vaccines which contain synthetic or inactivated viral components are acceptable for children with active AIDS. Diphtheria, tetanus, pertussis is inactive and is provided in multiple doses, starting at 2 months of age, with a booster at age 6. Haemophilus influenza is critically important since this flu virus can lead to meningitis, pneumonia or epiglottitis. This vaccine is also administered in multiple injections over a period of months, starting at 2 months, and then yearly throughout life. 1. Incorrect: The combination vaccine of measles, mumps, and rubella contains a live virus. Although research is ongoing, the Center for Disease Control (CDC) suggests while children diagnosed HIV+ may receive the vaccine, those with active AIDS should not be administered this vaccine. 3. Incorrect: Varicella is a live vaccine administered to protect children from chickenpox and the potential for shingles later in life. Though the disease and its dormancy in the body can have serious long-term effects, the vaccine is considered inappropriate for children with AIDS. 5. Incorrect: Oral polio vaccine contains the live polio virus and could be deadly to those with an immunocompromised system. The correct form of polio vaccine for AIDS clients is called IPV, or inactivated polio vaccine, and is given by injection.

When assessing a newborn following a breech delivery, what physical findings should the nurse report to the primary healthcare provider as positive indications of congenital hip dysplasia (CHD)? Select all that apply 1. Symmetrical gluteal folds. 2. Limited abduction of one leg. 3. Pain with the Barlow maneuver. 4. Presence of an Ortolani click. 5. Confirmed stepping reflex

2 & 4. Correct: When assessing a newborn, the nurse must determine which findings are normally expected at birth versus abnormal findings that should be reported to the primary healthcare provider. Two expected findings suggestive of congenital hip dysplasia (CHD) include limited abduction of one leg and the presence of an Ortolani click when the affected hip is placed into the "frog-leg" position. 1. Incorrect: Symmetrical gluteal folds are an expected, normal finding when the newborn is placed in the prone position. In an infant with suspected CHD, gluteal folds are notably asymmetrical. 3. Incorrect: During evaluation for congenital hip dysplasia, there is no pain during any assessment procedures. The Barlow procedure, in which one leg is adducted across the body, is currently used, in addition to other examination techniques, to determine any abnormalities with hip/socket placement. 5. Incorrect: The stepping reflex is part of the neurologic evaluation and is a normal finding at birth. When held upright with the soles of the feet lightly touching the table, the infant appears to lift alternate feet as if walking. This reflex disappears in about 2 to 3 months, but will return when the child begins learning to walk.

What preferred lab value would the nurse expect to see the primary healthcare provider prescribe for a client admitted with generalized malnutrition? 1. Albumin 2. Prealbumin 3. Iron 4. Calcium

2. Correct: The preferred lab value to screen for generalized malnutrition is prealbumin. This assessment is preferred because it decreases more quickly when nutrition is not adequate. 1. Incorrect: Albumin is a major serum protein that is below normal in clients who have inadequate nutrition. However, it can take weeks to drop. 3. Incorrect: Low serum iron and anemia indicate an iron deficiency. Again, the prealbumin will decrease sooner than other lab values that assess nutrition level. 4. Incorrect: Older women may have low calcium levels which place them at risk for bone demineralization. But, prealbumin provides more data on generalized nutrition.

A client has developed preeclampsia at 30 weeks' gestation. The nurse is instructing the client on an appropriate diet for preeclampsia. The nurse knows the teaching was successful when the client selects what menu? Select all that apply 1. Caesar salad with feta cheese 2. Grilled cheese with tomatoes 3. Chipped ham on a croissant roll 4. Hot dog with a glass of soda pop 5. Chicken sandwich on wheat toast

2 and 5. CORRECT: A high protein, calcium rich diet is most important for the preeclampsia client who is losing protein in urine. Grilled cheese is an excellent selection for lunch, especially since it contains tomato slices, which adds another level of nourishment and vitamins. Additionally, a chicken sandwich, particularly on whole wheat toast, is very appropriate for this preeclampsia client. 1. INCORRECT: Caesar dressing is made with raw eggs, exposing the client to the potential for salmonella. Pregnant woman should not eat raw foods, including eggs, fish, or meat. Additionally, feta cheese is a 'soft cheese', exposing the client to another bacterium known as listeria. Although a salad could be a good choice, this particular salad is not healthy. 3. INCORRECT: The need to restrict salt is not a priority for preeclampsia clients, but chipped ham is a processed meat containing less protein than other meats and increasing the risk for contracting listeria. The croissant roll is made of refined white flour and sugar. The client would benefit more from whole grain products. 4. INCORRECT: Processed meats, such as hot dogs, are not the healthiest choice for the client, as they increase the risk for listeria. Also, a client with preeclampsia should avoid alcohol, caffeine, and refined sugar to help control the blood pressure. The glass of soda pop is not a healthy selection.

The primary healthcare provider's prescription for a client instructs the nurse to give digoxin 0.125 mg intravenously as a one-time dose. The available medication is in a concentration of 0.25 mg/2 mL. How many milliliters should the nurse give? Round answer using one decimal point.

2 mL x 0.125 mg = 1 mL 0.25 mg

A client is transported to the emergency department following a 20-foot fall from a ski lift. The nurse records initial assessment findings on the chart. Based on that data, what actions should the nurse implement immediately? Exhibit Blood pressure 90/40 Heart rate 125 Respiratory rate 30 and labored JVD 3 cm Sub-Q emphysema noted to right shoulder area. 1. Apply occlusive dressing to chest. 2. Initiate large gauge I.V. line. 3. Prepare for chest tube placement. 4. Administer high-flow oxygen. 5. Position client on right side.

2, 3 and 4. CORRECT. Based on the assessment data recorded by the nurse, the client most likely has a tension pneumothorax secondary to blunt force trauma from the fall. Immediate actions must focus on preventing tracheal deviation and a fatal outcome. The need for intravenous fluids and medications in any trauma requires at least one large-bore I.V. line or more. This client will need immediate chest tube placement to relieve increasing intrathoracic pressure. While preparing the client for this procedure, high-flow oxygen should be administered via non-rebreather mask because of the client's respiratory distress. 1. INCORRECT. There is no indication in the question of an open chest wound, or that a dressing is needed. The occlusive chest dressing will be placed over the insertion site of the chest tube after placement is completed. 5. INCORRECT. This trauma client will be secured to a back board, most likely with a C-collar in place, until x-rays confirm there has not been a cervical spine injury. Placing the client on the right side is counterproductive and in fact could further impair respiratory efforts.

The nurse is caring for a client following a total thyroidectomy. What findings would alert the nurse to potential complications? Select all that apply 1. Neck dressing intact, clean and dry 2. Increased blood pressure and pulse 3. High-pitched, harsh respirations 4. Vocal quality weak and clear 5. Left-sided cheek twitching

2, 3 and 5. CORRECT: There are several potential complications following a thyroidectomy. One life-threatening problem is the potential for a thyroid storm in which a large bolus of thyroid hormone is dumped into the system, causing increased blood pressure and pulse which could lead to intracranial hemorrhage. High pitched, harsh respirations indicate increasing edema and the potential for obstructed airway. A third potential problem may occur if one or more parathyroid glands are removed, placing the client at risk for hypocalcemia, as evidenced by a positive Chvostek's sign. 1. INCORRECT: The surgical dressing around the neck should definitely be intact and dry post-op. Any drainage that may develop would take a while to seep through the dressing. No concerns here. 4. INCORRECT: The client has just had surgery on the thyroid, causing swelling that could affect vocal cords. A weak initial voice is not unusual as long as the vocal quality is clear.

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

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

Which observations should the home health nurse discuss with the parents of a two year old regarding potential safety threats in the home? Select all that apply 1. Security gates at the stairs. 2. Cleaning supplies under sink cabinet. 3. No blinds on windows. 4. Use of space heaters. 5. Water heater temperature 140°F (60°C) 6. Use of tablecloths

2, 4, 5 & 6 Correct: Cleaning supplies should be placed high away from child's reach. Cabinets should have childproof locks. Space heaters need to be checked every year prior to use. Additionally, small children can be burned by space heaters if they get too close. A guard should be applied. Water heaters should be set at no higher than 120°F (48°C). Burns may occur with a 6 second exposure to 140°F water temperature. Children can pull on table cloths and spill hot food or break dishes which could lead to injury. 1. Incorrect: Placing security gates at the stairs will prevent falls. 3. Incorrect: This is not a concern for the child. If there are blinds, the string should be out of the child's reach.

A child diagnosed with gastroenteritis is being given fluids in the emergency room for severe dehydration. Prior to discharge, the nurse instructs the mother how to prepare a BRATT diet. The nurse knows the teaching was successful when the mother selects what foods for the child? Select all that apply 1. Raisins 2. Bananas 3. Apples 4. Toast 5. Rice 6. Tea

2, 4, 5 and 6. CORRECT: The Bratt diet is useful for children following any type of gastroenteritis which included nausea, diarrhea or severe vomiting. This bland diet is used in the first 24 hours to allow the gut to rest and readjust slowly to foods that are low protein, low fat and low fiber. The BRATT diet is for short term use only and consists of bananas, rice, apple sauce, toast and tea. 1. INCORRECT: Although raisins are normally a natural source of healthy fruit, they have too much fiber for an irritated gastric tract. They are not part of the BRAT diet. 3. INCORRECT: Apples are high in fiber and natural sucrose, which is not appropriate for a child with severe gastroenteritis. However, apple sauce is part of the BRAT diet and is an excellent source of nutrition without stressing a weakened gastrointestinal system.

After reinforcing dietary teaching to a client diagnosed with Crohn's Disease, the nurse recognizes client understanding when the client selects which low-residue foods? 1. Broccoli 2. Oatmeal 3. Green peas 4. Spaghetti 5. Cantaloupe 6. Raisins

2, 4,& 5 Correct: A low residue diet is recommended for clients with inflammatory bowel diseases such as Crohn's Disease, diverticulitis or Ulcerative Colitis. This special diet is designed to decrease fiber in order to limit bowel peristalsis while still including nutritional elements for clients. Cooked oatmeal or pasta are both good choices as well as fruits with no skin and little pulp. Insoluble fiber—the kind in raw veggies, fruits, and nuts—draws water into the colon and can worsen diarrhea for those with IBD. But oatmeal has soluble fiber, which absorbs water and passes more slowly through your digestive tract. Cantaloupe is an excellent choice, since it is a great source of nutrients but has little pulp. 1. Incorrect: Broccoli is a very fibrous vegetable that causes excessive peristalsis, even when cooked. This will create excessive gas and increase discomfort for clients. 3. Incorrect: Green or yellow peas are rough, fibrous vegetables that will cause gas and cramping for most clients with inflammatory bowel diseases, even if cooked. This vegetable is discouraged along with beans, lentils, seeds, and nuts. 6. Incorrect: Raisins are high in fiber, as are other dried fruits such as prunes. Even cooked raisins tend to increase peristalsis which will lead to cramping and excessive bowel movements daily. Clients also need to avoid most fresh fruits with skin, pulp, or seeds.

In what order should the nurse assess assigned clients following shift report? Place in priority order. 1. Client diagnosed with cancer who is crying and states, "I am not ready to die". 2. Client admitted with chemotherapy-induced neutropenia with a temperature of 100.8 F (38.2 C). 3. Client one day post splenectomy. 4. Client diagnosed with aplastic anemia needing education regarding ways to decrease infection risk. 5. Client with non-Hodgkin's lymphoma who is refusing prescribed chemotherapy regimen.

2,3,1,5,4 The first client the nurse needs to assess is the one admitted with chemotherapy-induced neutropenia with a temperature of 100.8 F (38.2 C). Any temperature elevation in a neutropenic client may indicate the presence of a life-threatening infection. This client will likely need blood cultures and antibiotics quickly. The second client that should be assessed by the nurse is the client who is one day post splenectomy. There is no indication that this client is in any immediate danger, but as a surgical client one day postop, this client should be assessed prior to moving on to the other three clients. The nurse needs to assess for any possible complications associated with surgery. The third client the nurse needs to see is the client diagnosed with cancer who is crying and states, "I am not ready to die". This client is facing death and is exhibiting grief. The role of the nurse is to respond appropriately to the client's needs by listening carefully and addressing the social, emotional and spiritual aspects of the client's symptoms. This client should be seen after clients who have a physical problem that could be life threatening. The fourth client the nurse should assess is the client with non-Hodgkin's lymphoma who is refusing prescribed chemotherapy regimen. This client does not need immediate care. The nurse needs to talk to the client about why the client is refusing chemotherapy and if any education or referrals are needed. Clients who are stable and awaiting discharge teaching can be seen last.

Which client is legally able to sign a consent for surgery? Select all that apply 1. An 86 year old client who is disoriented. 2. A 62 year old client who speaks only Spanish. 3. A 41 year old client who just received midazolam. 4. A 17 year old client needing an emergency appendectomy whose parents cannot be contacted. 5. A 44 year old with schizophrenia who is hallucinating.

2,4

Which client would be appropriate for the charge nurse to assign to the LPN/VN? Select All 1. The client with a leg cast who needs neurovascular checks. 2. The client diagnosed with arthritis who needs pain medication and heat application. 3. The client reporting abdominal pain and rebound tenderness after a bicycle accident. 4. The client diagnosed with anorexia nervosa who is experiencing muscle weakness and decreased urinary output. 5. The client experiencing nausea and vomiting after receiving chemotherapy.

2,5

The nurse is caring for a client diagnosed with major depression post electroconvulsive therapy (ECT). What nursing interventions should be included in this immediate post-treatment period? Select all that apply 1. Monitor vital signs every hour for eight hours. 2. Position the client on their side. 3. Stay with the client until fully awake. 4. Provide flexibility in scheduling routine activities. 5. Encourage the client to ambulate in room and hall.

2. & 3. Correct: Positioning on the side will prevent aspiration. Stay with the client until they are fully awake, oriented, and able to perform self-care activities without assistance. Safety is priority. 1. Incorrect: Pulse, respirations, and blood pressure should be monitored every 15 minutes for the first hour. Vital signs every hour are too long immediately post-treatment. 4. Incorrect: The client needs a highly structured schedule of routine activities in order to minimize confusion. Also, immediately post-treatment is too soon to address routine activities. 5. Incorrect: The client should remain in bed during the immediate post-treatment period. The client needs to be fully awake prior to ambulation.

What instructions should the nurse include when teaching a mother, whose newborn has hyperbilirubinemia, regarding phototherapy and its effects? Select all that apply 1. Breastfeeding should be discontinued until phototherapy is completed. 2. Feed newborn at least every 2-4 hours. 3. Make sure the newborn's eyes are closed when applying eye patches. 4. Keep the baby quiet and swaddled. 5. Report immediately if the urine becomes dark in color.

2. & 3. Correct: Providing adequate breast milk or formula by feeding at least every 2-4 hours is key in preventing and treating jaundice because it promotes elimination of the bilirubin in the stools and urine. The infant should be monitored for signs of dehydration, including decreased skin turgor and decreased urinary output. Dehydration often results from decreased intake, phototherapy, and diarrhea. When applying the eye patches, the newborn's eyes should be closed to avoid causing a corneal abrasion. 1. Incorrect: Breast feeding is encouraged and is an important part of meeting both the nutritional and emotional needs of the newborn. 4. Incorrect: The infant's clothing is removed to allow maximum exposure of the skin to the phototherapy. The genitalia should be covered. 5. Incorrect: The caregiver should be taught to expect the infant's stools to be green and the urine dark because of photo degradation products (breakdown of bilirubin for excretion).

What interventions should the nurse include in the care plan of a client admitted with Guillain-Barre syndrome? Select all that apply 1. Assess for descending paralysis. 2. Keep a sterile tracheostomy at the bedside. 3. Monitor for heart rate above 120/min. 4. Maintain in side-lying, supine position. 5. Have client perform active range of motion (ROM) every 2 hours while awake.

2. & 3. Correct: This client is at risk for respiratory paralysis as the disease progresses. An emergency tracheostomy may need to be performed so the nurse should watch out for imminent signs of respiratory failure. Signs include heart rate that is more than 120 bpm or lower than 70 bpm and respiratory rate of more than 30 bpm. The nurse should assess for signs of respiratory distress and prepare for intubation if needed. 1. Incorrect: Ascending paralysis should be assessed for with this disease. Paralysis begins in the lower extremities and moves upward. 4. Incorrect: The client should be assisted to a position with head of bed elevated for full chest excursion. 5. Incorrect: The nurse should perform passive range of motion exercises. Active exercise should be avoided during the acute phase as the client is easily fatigued and muscles are weak. Passive ROM stimulates circulation, improves muscle tone and increases joint mobilization.

Which nursing interventions will help to prevent a contracture post-operatively in a client with a below the knee amputation? Select all that apply 1. Keep the residual limb elevated on a pillow at all times 2. Ensure the residual limb is positioned flat on the bed 3. Position the client prone several times a day 4. Keep head of bed elevated with knees up. 5. Apply anti-embolism stockings to the unaffected leg

2. & 3. Correct: We want the limb flat on the bed to prevent a contracture, the prone position will also stretch out any flexion that has occurred as a defensive withdrawal to muscle spasms. 1. Incorrect: This will promote a contracture. Flexion contractures are avoided by preventing hip flexion and elevation of the limb on pillows. 4. Incorrect: This will promote rather than prevent a contracture. The client must avoid positions that promote hips being flexed. 5. Incorrect: Looks good, doesn't it? But what does the stem say? What will help prevent contractures? Anti-embolism hose have nothing to do with contractures do they? No, so again, remember to read the stem carefully and look at each option as a True/False

Who often performs the responsibilities of a case manager? You answered this question Correctly 1. Physical therapist 2. Social worker 3. Dietitian nutritionist 4. Nurse 5. Unlicensed assistive personnel

2. & 4. Correct: A client's case manager can be a nurse, social worker, or other appropriate professional. Case management is a cross-disciplinary practice. It's function is to advocate for the client. 1. Incorrect: The physical therapist focuses on one area which is the client's ability to move and perform functional activities in their daily lives. The physical therapist would not be the client's case manager. 3. Incorrect: The dietitian nutritionist focuses on one area which is human nutrition and the regulation of diet. The dietitian nutritionist would not be the client's case manager. 5. Incorrect: The unlicensed assistive personnel does not have the education and/or training for case management.

Who often performs the responsibilities of a case manager? Select all that apply 1. Physical therapist 2. Social worker 3. Dietitian nutritionist 4. Nurse 5. Unlicensed assistive personnel

What information would be included when a disaster relief nurse counsels parents of young clients who have experienced a disaster? Select all that apply 1. Act as if things are normal. 2. Understand young children may exhibit separation fears and clinging. 3. Sedate the client until the crisis is resolved. 4. Understand nightmares and sleep disturbances may occur in young children. 5. Refrain from talking about the disaster.

2. & 4. Correct: Following a disaster, children exhibit a range of emotional and physiological reactions including separation, fear, and sleep issues. They may also appear confused, passive, fearful, and have somatic symptoms. They have difficulty talking about the event or identifying feelings. 1. Incorrect: Acting as if nothing happened is a nontheraputic parental response. The parents should recognize and acknowledge the child's feelings. 3. Incorrect: Sedation may be an emergency need, but more therapeutic responses are quickly warranted.5. Incorrect: Refraining from talking about the disaster would be nontherapeutic. Again, allowing the child to discuss their feelings will assist the child in working through their fear and worry.

In which situations should the nurse notify the primary healthcare provider of a medication incident? Select all that apply 1. Every occurrence. 2. Client is harmed or dies. 3. Medication incident is a near miss. 4. Nurse administers an incorrect dosage. 5. Client questions the medication color.

2. & 4. Correct: The primary healthcare provider should be notified if harm is brought to the client or death occurs as a result of the medication incident. The primary healthcare provider should be notified if the nurse administers an incorrect dosage to the client, and an incident report needs to be completed in this situation.1. Incorrect: The primary healthcare provider should be notified if harm is brought to the client but not for all events with medications. An incident report should be completed so the hospital can track incident patterns for quality improvement.3. Incorrect: Near misses do not need to be reported to the primary healthcare provider. Following the rights of medication administration every time ensures medication error prevention.5. Incorrect: The nurse should answer questions regarding medication color. Depending on the manufacturer, the shape and color of the medication can vary.

A client has been admitted with a stroke on the right side of the brain. What clinical manifestations does the nurse expect to find when assessing this client? 1. Right sided hemiplegia 2. Impaired judgment 3. Depression 4. Impaired language comprehension 5. Impulsiveness 6. Impaired speech

2. & 5. Correct. The client with right sided brain damage will have left sided hemiplegia and will exhibit impulsive behavior and impaired judgment. 1. Incorrect. This is seen with left-brain damage. 3. Incorrect. This is seen with left-brain damage. 4. Incorrect. This is seen with left-brain damage. 6. Incorrect. This is seen with left-brain damage.

The nurse would make which recommendations when conducting community health teaching about obesity to a group of adolescents? Select all that apply 1. Limit TV viewing and video game playing to 4 hours a day 2. At least 60 minutes of moderate-intensity activity daily 3. Exercise should be structured 4. A strict diet should be followed avoiding all junk food and drinking water only 5. Set a goal of at least 11,000 to 13,000 steps each day

2. & 5. Correct: 60 minutes of moderate-intensity physical activity 7 days a week. Girls should take a least 13,000 steps daily and boys should take 11,000 steps daily. 1. Incorrect: TV viewing and video game playing should be 2 or fewer hours each day. 3. Incorrect: Exercise does not need to be structured. 4. Incorrect: If the diet is too restrictive, it is likely to fail

The nurse is preparing to discharge a client home from the hospital. Which statement made by the client indicates to the nurse that instructions about antibiotic administration have been successful? Select all that apply 1. "I will take the antibiotic until I feel better but save some to take in case the infection returns." 2. "I should follow the instructions on the label." 3. "I need to double the dose for two days so I will get better." 4. "I should double the dose the next time the antibiotic is due after missing a dose." 5. "I will finish all of my antibiotic medication."

2. & 5. Correct: Instruct the client to follow the instructions and finish the entire prescription. Failure to do so could lead to resistance or relapse.1. Incorrect: Not taking the whole prescription can lead to resistance of the organism and cause a relapse of the infection.3. Incorrect: Medication doses should never be doubled. The prescription should be taken as instructed per the primary healthcare provider. 4. Incorrect: Medication doses should never be doubled, even if one dose is missed.

The nurse assesses a client post thyroidectomy for complications by performing which assessment? 1. Accucheck 2. Chovostek's 3. Ballottement 4. Ice water colonic

2. Correct: A positive Chovostek's and Trousseau's is indicative of tetany and low calcium. This can occur when a couple of parathyroids are accidently removed when the thyroid is removed. 1. Incorrect: Accucheck assesses for blood glucose levels, which is not the problem post thyroidectomy. 3. Incorrect: This assessment technique is used in examining the abdomen when ascites is present. It is done by palpating the abdomen to detect excessive amounts of fluid (ascites). 4. Incorrect: If you have never heard of it, no one else has either. The phrase implies using ice water to cleanse the colon and this would never be a good thing, especially for someone post thyroidectomy that would be intolerant to extremes in temperature.

Which tasks can the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply 1. Reporting lab results to the client 2. Measuring intake and output 3. Discontinuing an IV 4. Discussing client condition with the client's spouse 5. Performing oral hygiene for an older client

2. & 5. Correct: Measurement of intake and output and oral hygiene for the older client are tasks that the UAP can perform, and these tasks may be delegated. 1. Incorrect: Reporting of lab results should be accomplished by the nurse who has the knowledge to interpret results. This is not appropriate for the UAP and must be done by a licensed nurse. 3. Incorrect: Removal of the IV requires assessment skills that the unlicensed assistive personnel does not have. 4. Incorrect: Discussion of client's condition should be done by the nurse with the client's permission.

The nurse notices that a client's bedside privacy curtain has been left partially open during the client's bath. Which are appropriate actions for the nurse to take in order to ensure the client's right to privacy? Select all that apply 1. Inform the client that the curtain was left partially open. 2. Close the privacy curtain to protect the client's right to privacy. 3. Since the client did not notice the open privacy curtain no action is necessary. 4. Only a few visitors are on the unit at this time so no action is necessary. 5. Instruct the nurse giving the client's bath about the open curtain and need for privacy.

2. & 5. Correct: The curtain should be closed as soon as the opening is noticed to protect the client's right to privacy. Also the nurse giving the bath should be made aware of the partially open curtain and the need to maintain privacy for the client. 1. Incorrect: Informing the client that the curtain was open is an embarrassment to the client and may lead to a lack of trust in additional care that may be provided. It does not help solve the privacy issue, which the nurse has the responsibility to protect. 3. Incorrect: The "No action is necessary" option is incorrect because the client has the right to privacy. Nurses should take client's rights seriously and carry out needed measures to assure these rights are protected, even when the client is unaware of the situation. 4. Incorrect: The "No action is necessary" option is incorrect because the client has the right to privacy. It is irrelevant how many people may have been in close proximity. The nurse should take the client's rights to privacy very seriously and ensure measures are taken to protect this right.

The nurse receives report about a client who is termed "a drug seeker". The nurse giving report states that the client does not need the pain medication and is just asking for medication because the client is "hooked on it." After receiving report, what actions should the nurse take? Select all that apply 1. Consult with the primary healthcare provider. 2. Assess the client. 3. Increase gradually the time between pain medication. 4. Encourage the client to wait longer before requesting the medication. 5. Utilize a pain scale to determine level of pain.

2. & 5. Correct: The nurse should carefully assess the client. The nurse must serve as an advocate for the client. A pain scale is used to determine level of pain. 1. Incorrect: The nurse must assess the client before consulting with the primary healthcare provider about the medication. 3. Incorrect: This action assumes that the client does not have pain, which does not take into consideration what is wrong with the client. 4. Incorrect: This action assumes that the client is a "drug seeker". The nurse must carefully assess the client.

The client's primary healthcare provider orders a blood transfusion for a client whose hemoglobin level is 5.0 mg/dL (3.103 mmol/L). The nurse informs the client that blood will be drawn for a type and cross-match prior to the blood transfusion. The client avoids eye contact with the nurse and states, "I am a Jehovah's Witness. I thought that was on my chart." The nurse demonstrates the role of client advocate by which response to the client? 1. "Your hemoglobin is very low. I can notify your primary healthcare provider to discuss with you how important it is for you to receive the blood." 2. "I will place that information in your medical record. You have the right to refuse treatment which conflicts with your beliefs." 3. "Your primary healthcare provider ordered this blood transfusion because your hemoglobin is low." 4. "Why do Jehovah's Witnesses choose not to receive blood transfusions?" 5. "Would you like to speak with your primary healthcare provider about other treatment options?"

2. & 5. Correct: The nurse as client advocate supports the client's beliefs and treatment wishes. Reaffirming the client's beliefs and treatment wishes is important to promote a sense of trust and demonstrate respect for the individual. The information that the client is Jehovah's Witness who refuses blood products should be placed prominently in the medical record per the facility's policy to avoid further confusion. Providing reasonable healthcare treatment choices that do not conflict with the client's beliefs is the responsibility of the multi-disciplinary healthcare team. 1. Incorrect: This response disregards the client's wishes and religious beliefs. It is appropriate for the client to be made aware of the low hemoglobin level, but the client's wishes and religious beliefs should be respected without being told that blood should be received. 3. Incorrect: Again, this response disregards the client's wishes and religious beliefs. This comment could belittle the client's wishes and beliefs by making the primary healthcare provider the "authority" or focus here. 4. Incorrect: Questions reasons for religious beliefs and does not focus on client's needs. This response could place the client in a defensive situation. Clients should not be asked to explain or defend personal or religious beliefs.

The client's primary healthcare provider orders a blood transfusion for a client whose hemoglobin level is 5.0 mg/dL (3.103 mmol/L). The nurse informs the client that blood will be drawn for a type and cross-match prior to the blood transfusion. The client avoids eye contact with the nurse and states, "I am a Jehovah's Witness. I thought that was on my chart." The nurse demonstrates the role of client advocate by which response to the client? Select all that apply 1. "Your hemoglobin is very low. I can notify your primary healthcare provider to discuss with you how important it is for you to receive the blood." 2. "I will place that information in your medical record. You have the right to refuse treatment which conflicts with your beliefs." 3. "Your primary healthcare provider ordered this blood transfusion because your hemoglobin is low." 4. "Why do Jehovah's Witnesses choose not to receive blood transfusions?" 5. "Would you like to speak with your primary healthcare provider about other treatment options?"

A new nurse enters the linen room for supplies and finds a pile of sheets on fire. What type of fire extinguisher is most appropriate for the nurse to use in this situation? 1. Foam type 2. Water only 3. Dry powder 4. Carbon dioxide

2. CORRECT. A "water only" fire extinguisher is used for Class A fires, which includes solid combustibles such as wood, paper and textiles. As long as no electric equipment is plugged into a socket in the room, the water only extinguisher is most appropriate. 1. INCORRECT. Although foam extinguishers can be utilized for both Class A and Class B fires, it is not the most appropriate extinguisher for a linen room since the nurse is unaware of electric equipment that may be charging in that room. Foam extinguishers are more appropriate for flammable liquids. 3. INCORRECT. Dry chemical, or powder, extinguishers are good for mixed material fires and electrical fires such as those that may occur in an office. However, these are not recommended for small, enclosed spaces such as a linen room because of the danger of inhaling the dry chemical. 4. INCORRECT. Carbon dioxide extinguishers are best for electrical fires or flammable liquids like paints because CO2 prevents conduction. This Class B type of extinguisher is appropriate for garage, car and truck fires or even tanker fires, but not Class A blazes.

An elderly client has been admitted to the hospital with a diagnosis of cerebral vascular accident (CVA) with right-sided paralysis. When the nurse instructs staff to reposition client every two hours, the family asks about the purpose of this action. What is the best explanation by the nurse? 1. Improves circulation to the affected side of the body. 2. Decreases potential skin breakdown from immobility. 3. Prevents blood stasis in the client's lower extremities. 4. Alleviates sensory deprivation by varying environment.

2. CORRECT. An immobile client is subjected to sheering forces and tissue breakdown because of prolonged contact between the skin and linens. Pressure sores can develop quickly when a client remains in one position over long periods of time, particularly on protruding areas of the body such as hips, elbows, sacrum or heels. Repositioning the client every two hours decreases the potential for skin breakdown and allows for inspection of all vulnerable body areas. 1. INCORRECT. While moving a paralyzed client might stimulate the overall circulation, and even allow for passive range of motion, repositioning a client does not specifically increase blood flow to one side of the body. 3. INCORRECT. Though moving a client can stimulate the circulation, repositioning every two hours is not sufficient to prevent blood stasis in lower extremities, particularly when this client cannot move the right side independently. 4. INCORRECT. Sensory deprivation is not a major concern for the client initially and repositioning is not meant to address sensory needs. The purpose of repositioning is prevention of skin breakdown.

An Asian client, who cannot speak or comprehend English, is brought to the emergency department by family. One family member is able to understand simple sentences of English. How would the nurse best explain how to obtain a clean catch urine to the client? 1. Have the family member repeat the nurse's explanation to the client. 2. Contact Social Services to find an authorized interpreter. 3. Use simple hand motions to explain the procedure to the client. 4. Draw a diagram to demonstrate the use of the sterile cup when obtaining the specimen.

2. CORRECT. Hospitals must have a means of communicating with a variety of non-English speaking clients, as well as deaf clients. It is vital to have interpreters that are capable of translating medical terms or instructions correctly and also to relay the client's specific concerns back to medical staff. Because of the importance of accuracy, only trained and qualified interpreters should be used when communicating with those who do not understand English. 1.INCORRECT. Although the family is present and may be able to translate information from the nurse to the client, the accuracy of that information cannot be guaranteed since the family member has a limited understanding of English and no medical knowledge. It is vital that the procedure be clearly explained to the client, since test results will be affected if the specimen is not correctly collected. 3. INCORRECT. The use of hand motions does not ensure that the client will understand the procedure correctly, and in this particular situation, demonstrating some of the steps could be embarrassing to this client. Hand motions do not provide a means for the client to ask questions about anything that is not clearly understood. 4. INCORRECT. Although there may be circumstances in which a nurse can use alternative methods of communication, such as picture boards or hand gestures, this situation calls for clear instructions on the proper method for obtaining a clean catch urine so that test results are accurate. Additionally, a picture does not allow the client to confirm understanding of the process.

An elderly client with a history of CAD has just been admitted to the telemetry unit following a syncopal episode at home. The admitting nurse places EKG leads on the client and notes the following rhythm on the monitor. When the client indicates the need to void, the nurse knows that what would be the safest action? Exhibit 1. Request prescription for a foley catheter. 2. Assist client with the use of a bedpan. 3. Provided incontinent pads to the client. 4. Have UAP ambulate client to the bathroom.

2. CORRECT. The exhibit shows sinus rhythm with premature ventricular contractions (PVC's), and more specifically, bigeminy. The safest approach for a syncopal client with this rhythm is the use of a bedpan for bathroom needs. Even with assistance, this client would be at risk for falls when ambulating. 1. INCORRECT. Because the client has experienced syncope and is having frequent PVCs, keeping the client in bed is safer than ambulating to the bathroom. However, a foley catheter is an invasive procedure that could place the client at risk of infection. There is a better option. 3. INCORRECT. Using incontinent pads, either on the bed or personal pads for the client, is only appropriate if the client is unable to control urinary flow, or requests the use of same. It is embarrassing to ask clients who are continent to void onto a bed pad. 4. INCORRECT. This client is newly admitted with a diagnosis of syncope. The exhibit shows frequent PVC's, which are non-perfusing beats. Even with assistance from the UAP, ambulating to the bathroom is not the safest action for this client.

A hospitalized client using a K-pad on an injured muscle reports the pad is not warming up. What should be the nurse's initial action? 1. Unplug unit and plug into another wall outlet. 2. Check temperature setting on the heating unit. 3. Call maintenance to repair unit immediately. 4. Increase temperature on unit till pad heats up.

2. CORRECT. The nurse is utilizing the nursing process by first collecting data pertinent to the situation. The actual problem could be related to the temperature dial on the unit, or even a malfunction in the pad itself. However, the nurse must assess the situation by checking the basics, such as whether the equipment is even turned on. 1. INCORRECT. While it is possible the outlet itself may be defective, this is not likely in a large facility. Additionally, an electric appliance should never be re-connected to an outlet while still in contact with the client. 3. INCORRECT. It is unlikely maintenance would be available to examine the device immediately and most repairs should not be attempted in the client's room because of safety considerations. 4. INCORRECT. The exact problem with the heating unit has not yet been established. Simply turning up the temperature setting is not safe since the pad may quickly get hotter, injuring the client.

While programming the client's IV infusion pump the nurse notes that the display screen on the infusion pump is cracked. What is the best action for the nurse to take? 1. Continue to use the infusion pump and request a replacement pump. 2. Stay with the client and monitor the infusion while another staff member obtains a replacement pump. 3. Clamp and disconnect the infusion tubing prior to obtaining a replacement pump. 4. Slow the infusion to a keep-open rate and obtain a replacement pump.

2. CORRECT. The safest action is to stay with the client while a new infusion pump is obtained by another staff member. 1. INCORRECT. When the screen on an infusion pump is cracked, water or other liquids can enter the case causing the pump to malfunction resulting in over-infusion or under-infusion. Defective infusion pumps should be locked out, tagged, and replaced immediately. 3. INCORRECT. You should not completely clamp and disconnect the infusion tubing until a replacement pump is obtained. 4. INCORRECT. While slowing the infusion sounds correct, the pump is cracked and you cannot ensure that it will maintain the set rate. Staying with the client until a replacement pump is obtained is the safest option.

When the surgical transport team arrives to take a client to the operating room, the client is sitting in a chair in the room. What is the best way for the nurse to get the client onto the transport litter? 1. Using a foot stool, assist client to step up and crawl onto litter. 2. Have client return to bed and utilize slide board to transfer to litter. 3. With feet placed apart, grasp client around waist and lift onto litter. 4. Put Hoyer pad under client, using Lift to move client from chair to litter.

2. CORRECT. The safest, most efficient manner by which to place the client on the litter properly is to have client first return to bed. The bed can then be raised to the height of the litter, allowing staff to utilize a slide board to easily position the client onto the litter. This method decreases safety risks for both staff and client. 1. INCORRECT. Even with assistance, stepping up onto a stool greatly reduces the client's stability to that small surface area. Crawling on the litter would make it difficult for the client to get properly positioned. The stool may be too short for staff to even assist. 3. INCORRECT. It is never safe for a nurse to lift a client by grasping around the waist, no matter how feet are positioned. This method could potentially injure both the nurse and client while increasing the risk of a fall. 4. INCORRECT. Positioning a Hoyer lift pad under a sitting client is impractical and nearly impossible. Proper placement can best be accomplished with the client supine in bed. This individual is obviously mobile, negating the need for any lifting device. This is not the best action.

An elderly client with dementia is being admitted to a long-term care facility. When orienting the client to the environment, what is the most important action for the nurse to take? 1. Provide nurse's name upon entering client's room. 2. Show client how to use the call bell in the room. 3. Provide a tour of the facility and grounds. 4. Instruct client on the location of emergency exits.

2. CORRECT: Changes can be very overwhelming for an elderly client, particularly in the presence of dementia. The most important issue is to be sure the client understands how to summon staff at any point. Demonstrating the use of the call bell and allowing the client to provide a return demonstration is the most important action. 1. INCORRECT: This client has dementia and therefore may not be able to process or remember names. This is an appropriate action, but remember safety first. 3. INCORRECT: Though orientation to a new environment would be important, this client's mental status can be easily overwhelmed with too much information. The focus should be restricted to the most basic safety information that the client needs to know. 4. INCORRECT: While emergency exits are critical information, a client with dementia has a limited ability to comprehend a large volume of new information all at once. Multiple exits, depending on the client's location in the facility, is too much complex information initially.

While preparing to administer intravenous of chemotherapy the nurse accidently pulls the tubing apart, spilling the solution onto the floor. After clamping the tubing, what is the nurse's immediate action? 1. Use disposable towels to clean up the liquid. 2. Obtain spill kit specific to this type of solution. 3. Complete an incident report for supervisor. 4. Call housekeeping to help clean up the floor.

2. CORRECT: Chemotherapy spill kits are pre-packaged supplies specific to the type of cytotoxic drugs used and are kept in close proximity to the location the chemo is administered. These kits vary slightly but all follow the basic guidelines. Individuals cleaning up the spill must be completely covered head to toe to prevent any contact with the drug. This includes inhalation. This option contains the word solution, which also appears in the question. 1. INCORRECT: Disposable towels are not acceptable to clean up a chemotherapy spill. Although these towels are absorbent for kitchens and bathrooms, only special absorbent pads can be used to clean up cytotoxic drugs. 3. INCORRECT: While it is true that the nurse will need to complete an incident report regarding the chemotherapy spill, it is certainly not the nurse's immediate action. Focus on staff and client safety first. 4. INCORRECT: The responsibility for cleaning up cytotoxic drugs is for the nursing staff involved at the time. Special training and knowledge is required to handle this issue.

The nurse is admitting an elderly client reporting abdominal pain. During assessment, the client answers inappropriately or just smiles in response to questions. What should the nurse suspect is the most likely cause for this behavior? 1. Developmental delay 2. Hearing difficulty 3. Pain 4. Confusion

2. CORRECT: Clients unable to hear properly are often not aware of the deficit, or may prefer not to acknowledge the situation. Inappropriate responses may indicate the client did not hear the question correctly. Smiling or nodding is occasionally an automatic reaction by a client unable to understand the conversation. 1. INCORRECT: Inappropriate responses, or even just smiling, are not indicative of a developmental delay. Many other causes can account for such behaviors, particularly in elderly clients. There is not enough evidence to support a developmental delay. 3. INCORRECT: Although the client may have abdominal discomfort, the behavior noted by the nurse does not suggest extreme pain. In fact, the client does occasionally smile, which is not generally noted with pain or discomfort. 4. INCORRECT: It is never appropriate to assume that advanced age is automatically associated with confusion or dementia. A client's age should never be automatically equated with mental or physical decline without physical assessment and data to support that theory.

A hospitalized client has developed diabetes insipidus and is given desmopressin. The nurse is aware which laboratory result indicates an improvement in the client's condition? 1. White blood cells of 7,000 mm3 (7 x 10^9) 2. Urine specific gravity of 1.010 3. Hemoglobin of 22 g/dL (220 g/L) 4. Serum sodium of 148 mEq/L (148 mmol/L)

2. CORRECT: In diabetes insipidus, the kidneys excrete huge amounts of urine, causing the specific gravity to decrease from normal levels of 1.010 to 1.030, which would have been verified by urinalysis. The client's lab result indicates specific gravity within normal limits, evidence the desmopressin has begun to correct the client's condition. 1. INCORRECT: The white blood cell count is not affected by diabetes insipidus. This laboratory result is within normal limits of 5,000 to 10,000 mm3 (5-10 x 10^9) and would not reflect any changes from desmopressin. 3. INCORRECT: Diabetes insipidus causes loss of the water component of serum, leaving blood very concentrated and electrolyte levels elevated. A hemoglobin level of 22 g/dL (220 g/L) is elevated for both male and female clients. This result does not indicate any improvement in the client from desmopressin. 4. INCORRECT: A sodium level of 148 mEq/L (148 mmol/L) is elevated from the normal levels of 135-145 mEq/L (135-145 mmol/L). A concentrated level of sodium does not suggest improvement in the client's status yet.

A home care nurse is making an initial visit to an elderly client recently discharged following hip surgery. When evaluating the home environment, what environmental hazard is most concerning to the nurse? 1. Lamp plugged into extension cord. 2. Throw rugs on kitchen tile floor. 3. Gas fireplace in the living room. 4. Non-working wall socket in hall.

2. CORRECT: It is quite common to find throw rugs, or "scatter rugs" in homes to protect carpets and absorb moisture or dirt. However, throw rugs are a common hazard, posing the potential for tripping or catching on wheels. In this situation, a tile floor is generally smooth, making it even more likely to slip on the rugs. 1. INCORRECT: An extension cord, by itself, is not a problem. If the cord was placed under carpeting, it could be a fire hazard. Also, if the cord was too short and hung suspended in air the client could trip. However, just using an extension cord does not present a problem. 3. INCORRECT: Many homes use a gas fireplace which is actually safer than wood burning. The presence of a gas fireplace does not create an immediate danger. 4. INCORRECT: A non-working wall socket does not present any danger to the client. If the socket were sparking, there would be cause for concern. But there are many reasons for a socket not to work, and without any information, the nurse cannot consider this a danger.

2. Correct: Communication is important in delegation, as is follow-up. There may be a good reason that the tray was not served. The key word in the stem is first. The other options may be correct but are not the best first action. 1. Incorrect: The client does need to have food; however, there is another action that should be performed first. The reason for the UAP not feeding the client needs to be determined. 3. Incorrect: The nurse retains the responsibility for the delegated task. The nurse should not assume that the UAP just did not do their job, but needs to ascertain the reason for not feeding the client. 4. Incorrect: The concern here is the client being fed their meal. Speak to the UAP first and then decide if a between meal supplement is needed.

2. CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. 1. INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. This client is not the nurse's first priority. 3. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. 4. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. The nurse has another priority.

A client hospitalized with a deep vein thrombosis (DVT) is on a heparin infusion. The client asks the nurse why it is necessary to have blood drawn every six hours. What is the best explanation for the nurse to provide to the client? 1. "The medicine might make your blood much too thin." 2. "It helps us monitor and adjust the dose to work better." 3. "It is required for anyone getting heparin intravenously." 4. "The test results tell us whether the treatment is working."

2. CORRECT: The nurse has clearly stated the purpose of the frequent venipunctures in a simple and non-technical manner that answers the client's question. 1. INCORRECT: This comment by the nurse does not address the inquiry about every 6 hour bloodwork, plus the phrasing of the statement could easily frighten the client. 3. INCORRECT: This standard response does not answer the client's question about blood work nor does it provide further information about the treatment. 4. INCORRECT: The nurse's statement is vague and does not address the client's question about frequent blood work.

A home health nurse is visiting an adolescent with a myelomeningocele. The nurse realizes more instruction is needed when the client makes what statement? 1. "I might need to get glasses." 2. "I catheterize myself twice a day." 3. "I drink bottled water all day long." 4. "I do upper arm exercises every day."

2. CORRECT: The nurse is looking for a statement that indicates the need to do further instruction for this client. Self-catheterization should be completed every four to six hours. Allowing urine to remain in the bladder longer than six hours greatly increases the risk of infection. This comment indicates that the adolescent needs more instruction on the importance of timing catheterization. 1. INCORRECT: The potential need for glasses is not an issue that the nurse is in a position to evaluate. There are additional health issues the client may encounter, such as the possible need for glasses. But the nurse is not qualified to determine visual needs. 3. INCORRECT: This is a factual statement and requires no further instruction. It is very important for clients with spina bifida to stay well hydrated throughout the day, no matter what type of water is used. 4. INCORRECT: Those with spina bifida often need to use either a wheelchair or bilateral crutches over the course of their life. Maintaining upper body strength is crucial for mobility and decreasing the possibility of complications. This is an accurate statement that will not need to be addressed.

A psychiatric client calmly approaches the day nurse stating, "I almost died in my sleep." What response by the nurse would be most therapeutic for the client? 1. "How do you know what happened in your sleep?" 2. "Tell me how you felt when that situation occurred." 3. "You seem to have recovered very well since then." 4. "Are you sure it wasn't just a really bad dream?"

2. CORRECT: The nurse is seeking to clarify what occurred to the client, including any feelings or emotions regarding the event. Because the client is presently calm in appearance does not mean the situation is resolved. Though a nurse should not feed into client delusions, note this statement focuses on client feelings. 1. INCORRECT: This question by the nurse is sarcastic and even accusatory by confronting the client's claim that an incident occurred while asleep. Such a question is unprofessional and non-therapeutic. 3. INCORRECT: The nurse is acknowledging the client's appearance but in a non-therapeutic manner. This remark makes fun of the client and is a closed-ended comment. 4. INCORRECT: The nurse is inferring the client imagined or dreamed whatever situation may have occurred during the night. With no further data provided by the client, the nurse's assumption does not address the client's feelings.

The charge nurse is reviewing multiple events reported by staff during morning shift. The nurse is aware which event requires a written incident report? 1. A client yells loudly throughout the night shift. 2. A nurse discusses client's prognosis with family. 3. An unlicensed assistive personnel (UAP) spills water pitcher onto client. 4. A nurse tears sterile gloves and applies new gloves.

2. CORRECT: The purpose of an incident report is to document any incident or unusual event inconsistent with routine operations of hospital or staff routine and resulting in injury, or potential liability, for clients, family, or staff. The nurse has violated HIPAA regulations by discussing a client's medical prognosis with family members. The primary healthcare provider is responsible to discuss prognosis with client and only those individuals designated by the client. 1. INCORRECT: Although this client may disturb other clients at night, this event does not meet the criteria for an incident report. 3. INCORRECT: This event requires the UAP to intervene, providing clean clothes for the client. However, while an unfortunate occurrence, this incident would not require an incident report. 4. INCORRECT: Damaged sterile gloves must be removed and replaced immediately to prevent contamination of the field. The nurse followed the correct procedure and no report is needed.

The psychiatric nurse notices a new client sitting alone in the dayroom, shaking and muttering indistinguishable words. What statement by the nurse is appropriate? 1. "Who are you talking to?" 2. "You look like you are cold." 3. "It is always cold in this room." 4. "Do you want to get a sweater?"

2. CORRECT: The scenario does not indicate the client's diagnosis but mentions only physical symptoms. Without more detailed information about the client, the nurse's best approach is to address the visible symptoms in a therapeutic manner. The nurse is focusing on the client and sharing the perception the shaking may indicate feeling cold. This is a good initial therapeutic interaction. 1. INCORRECT: Demanding an explanation from the client is not an appropriate therapeutic technique, except for threatened personal harm. Quite often the client is unable to provide a response to a direct inquiry or may feel threatened by such an authoritative question. 3. INCORRECT: This comment by the nurse does not focus on the client or any current needs. While the nurse may be inferring the room is cold based on the client shaking, this is a closed statement that does not encourage the client to respond. 4. INCORRECT: This question is closed and non-therapeutic. Additionally, the focus assumes the client is cold and needs a sweater, rather than attempting to initiate interactive communication.

A client admitted for debridement of a leg wound has been diagnosed with vancomycin-resistant enterococci (VRE). What is the nurse's priority action? 1. Place with another client in contact isolation for methicillin-resistant staphylococcus aureus (MRSA). 2. Move the client to a private room with contact precautions. 3. Alert staff to use masks, goggles and gown to provide care. 4. Notify family members to gown and glove before entering room.

2. CORRECT: VRE normally lives in healthy intestines, but in an immunocompromised client, it can be found in a number of locations, including urinary tract, intestines, blood or wounds. A client diagnosed with VRE must be placed alone in contact isolation for the entire hospital stay, or until there are three negative cultures of that area, each one week apart. 1. INCORRECT: The location of this client's VRE is not noted, and it cannot be assumed that it is in the leg wound. A client with VRE must be placed in a private room. This client definitely cannot be placed in the same room as a client with MRSA just because both require contact isolation. Cross-contamination may occur between the two clients. 3. INCORRECT: VRE requires contact precautions. Anyone entering the room must first apply a gown and gloves. Before exiting the room, the gown and gloves are removed, discarded inside the room and hands washed prior to leaving. Goggles and mask are not required in this situation. 4. INCORRECT: Anyone entering the room will need to follow the contact isolation protocols, including staff, visitors and family. A gown and gloves must be used when entering the room, then removed and discarded prior to leaving the room. However, this is not the nurse's priority.

Staff notifies the nurse that a client receiving tube feedings has increased liquid stool with new rectal excoriation. Following an assessment, the nurse is most concerned about what additional symptom? 1. Reports feeling increasingly tired. 2. Trousseau's sign noted when taking blood pressure. 3. Increased resistance to care activities. 4. Reports abdominal cramping.

2. CORRECT: When a client begins to lose large amounts of stool, important electrolytes such as magnesium are lost also. The presence of Trousseau's sign indicates the client has developed hypomagnesemia, and is at risk for more serious problems. The nurse should notify the primary healthcare provider immediately. 1. INCORRECT: The client has many health issues which could contribute to fatigue, including hospitalization, illness and tube feedings. Dehydration secondary to the feedings could increase fatigue and the nurse will need to investigate further. However, another symptom is more concerning. 3. INCORRECT: Resisting care could be related to the discomfort of frequent turning and cleaning of the skin breakdown, even though this activity is necessary. It is important for hospitalized clients to remain mobile if possible, and encouraged to participate in care. But this is not the greatest concern. 4. INCORRECT: There is no data on why the client was hospitalized; therefore, abdominal cramping may be an already existing symptom. This is not the most concerning problem currently.

A client diagnosed with obsessive compulsive disorder has multiple personal care rituals. Which of the client's routines is most concerning to the nurse? 1. Knocks on each hallway door ten times. 2. Flosses teeth five times after each meal. 3. Washes hands three times before a meal. 4. Brushes hair vigorously morning and night.

2. CORRECT: When determining the impact of a client's ritual, the nurse must decide if that routine could cause harm to the client. While each of these routines may be concerning, flossing teeth five times after every meal could lead to gum erosion as well as small cuts in gum tissue. Such aggressive gum care might lead to mouth, or throat infections. 1. INCORRECT: Though there is no indication of the number of doors in the hallway, it is possible that repeated knocking might cause skin abrasions and breakdown on the knuckles. The nurse might suggest wearing gloves, or even limiting the knocking to specific doors. However, this ritual is not the nurse's greatest concern. 3. INCORRECT: Washing hands three times before every meal could certainly cause some skin excoriation; however, it is not the most injurious action the client is completing. Using a mild soap and applying cream after this routine could alleviate potential skin breakdown. 4. INCORRECT: Brushing hair was previously considered a positive daily treatment for hair, and even vigorous brushing twice a day is unlikely to create serious problems for the client. The nurse would not be primarily concerned about this activity.

Which finding in fetal heart rate during a non-stress test would indicate to the nurse that a potential problem for the fetus may exist? 1. Increases 30 beats per minute for 20 seconds with fetal movement. 2. Increases 8 beats per minute for 10 seconds with fetal movement. 3. Remains unchanged with maternal movement. 4. Increases 5 beats per minute for 30 seconds with maternal movement.

2. Correct. A non-reactive test is when the FHR accelerates less than 15 beats per minute above baseline. This may indicate fetal compromise. 1. Incorrect. This would be a reactive test. This is characterized by acceleration of fetal heart rate of more than 15 beats per minute above baseline, lasting for 15 seconds or more. 3. Incorrect. This test does not look at fetal heart rate with maternal movement. 4. Incorrect. This test does not look at fetal heart rate with maternal movement.

Which assessment finding in a client 5 hours post open cholecystectomy would require the nurse to notify the surgeon? 1. Absent bowel sounds. 2. Jackson Pratt drain has 90 mL of blood. 3. Urinary output of 180 mL since return from surgery. 4. Client report of abdominal pain of 8/10.

2. Correct. An open cholecystectomy will usually result in the placement of a drain. The drainage should be green (bile). Blood is a problem and needs immediate intervention. 1. Incorrect. It is not uncommon for bowel sounds to be absent after abdominal surgery. This client is only 5 hours postoperative. The client needs to remain NPO until bowel sounds return. 3. Incorrect. The urine output is greater than than 30 mL/hour which is an acceptable amount. There is not a baseline to compare to, so greater 30mL/hour is not abnormal. 4. Incorrect. Pain for this client is an expected finding 5 hours after surgery.

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. This is the responsibility of the RN.

A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book, crushing the tablet and mixing 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 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. The drug reference book does not provide guidelines for meeting developmental needs when administering the medication. This is something that the nurse must look up if uncertain about developmental tasks. 3. Incorrect. There is nothing in the stem about a problem with the medication dose or route. Once the medication has been mixed in applesauce, the supervising nurse would not be able to compare the dose to the prescribed amount. Therefore, this would not be an appropriate action. It would not address the developmental task that is the underlying issue here. 4. Incorrect. This is an appropriate action. However, it is not the priority. The new nurse should be competent in medication administration but is needing guidance with the developmental considerations related to medication to a nine month old.

A pediatric nurse notes a "chubby" toddler who is pale. According to the parent, the toddler is easily fatigued. Based on this data, what initial question should the nurse ask the parent? 1. "How much weight has your child gained in the past month?" 2. "How much milk does your toddler drink in a day?" 3. "How many hours does your toddler sleep within a 24 hour period?" 4. "Do you give your child vitamins every day?"

2. Correct. Paleness and easily fatigued are common signs of anemia. Drinking large amounts of milk puts the child at increased risk for iron deficiency anemia. Breast milk and cow's milk are poor sources of iron. Milk also inhibits absorption of iron. 1. Incorrect. This is not the most important question to ask first. The nurse needs to know how much milk the toddler is consuming as it will decrease iron consumption. 3. Incorrect. This is not the most important question to ask first. The nurse needs to know how much milk the toddler is consuming as it will decrease iron consumption. 4. Incorrect. This is not the most important question to ask first. The nurse needs to know how much milk the toddler is consuming as it will decrease iron consumption. Also, the nurse needs to ask specifically about iron supplements.

What is the first intervention the emergency department (ED) nurse should implement when caring for a lethargic toddler with a diagnosis of near-drowning? 1. Torso warming 2. Start intravenous infusion 3. Administer oxygen 4. Prepare for nasogastric intubation

3. Correct: Hypoxia is the primary problem because it results in brain cell damage 1. Incorrect: While warming protocols will likely be needed, hypoxia is the first priority 2. Incorrect: Fluid resuscitation will most likely be needed, hypoxia is the first priority 4. Incorrect: Nasogastric intubation may be needed but hypoxia is the first priority

A client scheduled for electroshock therapy becomes anxious prior to the initial treatment and refuses the procedure. What is the nurse's priority at this time? 1. Administer pre-op sedation to help the client relax. 2. Notify the primary healthcare provider of the client's refusal. 3. Remind the client that the consent is already signed. 4. Ask the family to help convince the client to re-consider.

2. Correct. The client has withdrawn consent for the procedure; therefore, the primary healthcare provider should be informed immediately to cancel the treatment. The primary healthcare provider may wish to speak with the client, but the client can legally refuse any procedure at any time. 1. Incorrect. Pre-op sedation is considered part of the procedure for which the client has withdrawn consent. Giving this medication would violate the client's right to refuse treatment and could be considered assault by the nurse. 3. Incorrect. Signing a consent form indicates that the primary healthcare provider has informed the client of all potential risks of the procedure. The client's signature represents an acknowledgement and understanding of that explanation. It is not an iron-clad contract agreeing to have the procedure. 4. Incorrect. Involving family members to try to convince the client to have this procedure would be unethical and could be considered coercion. Depression does not make the client incompetent to make decisions about healthcare options.

The family of a client recently placed on antipsychotic medications for the treatment of schizophrenia calls the nursing hot line and reports that the client's temperature is 105.1ºF (40.6ºC), and that the client's muscles are stiff. What should the nurse tell the family? 1. Continue to monitor for signs and symptoms of infection. 2. Transport the client to the emergency room. 3. The signs and symptoms will subside within a day or so. 4. They should call the primary healthcare provider tomorrow.

2. Correct. The client may be experiencing neuroleptic malignant syndrome, a potentially life threatening adverse reaction. Symptoms include high fever, unstable blood pressure and myoglobinemia. The client should be taken to the ER.1. Incorrect. The client may be developing neuroleptic malignant syndrome. This high fever is not associated with infection. Immediate treatment is necessary.3. Incorrect. The symptoms will progress and may lead to death. Remember, do not delay treatment.4. Incorrect. The symptoms will progress and the client may die without treatment. Do not delay treatment!

Which client should the nurse assign to a room closest to the nurse's station? 1. A multigravida admitted with a new diagnosis of gestational diabetes 2. A primigravida admitted with a diagnosis of placenta previa 3. A primigravida admitted with a diagnosis of complete abortion 4. A pregestational diabetic admitted for glycemic control

2. Correct: A client with a diagnosis of placenta previa is at high risk for bleeding and must be monitored closely. Placenta previa is a complication of pregnancy in which the placenta is either partially or wholly inserted in the lower uterine wall and blocks the cervix. It is the leading cause of antepartum hemorrhage. Clients with this complication will have to have a C-section to prevent harm to the mother and fetus from bleeding. 1. Incorrect: This client's primary needs are monitoring and education. While important to educate this client to ensure the health of the mother and fetus, this does not take priority over monitoring a client that is at risk for hemorrhage. 3. Incorrect: All the products of conception are expelled with a complete abortion, and she is at low risk for hemorrhage. 4. Incorrect: This client's primary needs are monitoring and education and are not priority over a client that is at risk for hemorrhage.

What would be most important for the nurse to teach parents in order to promote sleep and rest in the preschool child? 1. Allow the child to choose own bedtime based on degree of fatigue. 2. Develop a consistent routine before going to bed. 3. Assess how much sleep the child requires. 4. Set a consistent wake-up schedule.

2. Correct: A consistent routine helps to prepare the child for sleep. Reading or telling stories before bedtime may help the child to relax and fall asleep more easily. Routines are very important for this age group. Doing specific things before bedtime can signal to the child that it is time to get ready for bed and to go to sleep. 1. Incorrect: Although important, this is not the priority. Establishing a routine is most important. A cool environment will promote rest. A child's sleep cycle is sensitive to light and temperature. Melatonin levels help to regulate the drop in internal temperature needed to sleep. 3. Incorrect: Assessing the amount of sleep needed can help with promoting sleep and rest but routine is priority in the preschool age group. 4. Incorrect: Setting a wake-up time prevents a child from over sleeping on weekends and holidays. Those extra hours can disturb the sleep cycle. For a preschooler routine is the priority answer to promote sleep and rest at night.

Health Promotion and Mantainance The nurse is teaching a community health class for cancer prevention and screening. Which individual does the nurse recognize as having the highest risk for colon cancer? 1. Diagnosed with irritable bowel syndrome 2. Has a family history of colon polyps 3. Diagnosed with cirrhosis of the liver 4. Has a history of colon surgery

2. Correct: A family history of colon polyps and/or colon cancer is the greatest risk factor for development of colon cancer. Other factors include increasing age and a low fiber diet of processed foods. 1. Incorrect: Irritable bowel syndrome is not a risk factor for developing cancer of colon. 3. Incorrect: Cirrhosis of the liver is not a risk for cancer of colon. 4. Incorrect: Having had colon surgery does not increase a person's risk for developing cancer of colon.

A community health nurse prepares a presentation about decreasing the risk of the spread of influenza in the community. Which information should the nurse include in the presentation? 1. The flu is spread via the influenza vaccine. 2. Use a shirtsleeve when coughing or sneezing. 3. Tissues are the most effective means to decrease the spread of the influenza. 4. Antibiotics are effective in treating influenza.

2. Correct: A shirtsleeve should be used as a barrier when coughing or sneezing. This prevents germs being spread via the hands.1. Incorrect: The flu vaccine contains a dead virus that is not capable of causing the flu. Clients may experience flu-like symptoms from the flu vaccine, but they won't contract the virus.3. Incorrect: Tissues are effective in decreasing the spread of the flu if disposed of in the trash after use. Hand washing is also very important in decreasing the spread of germs. 4. Incorrect: Antibiotics are not effective in treating the flu. The flu is treated with antipyretics, fluids, and rest. Antibiotics are used for infections, not viruses.

The nurse has been working on a health plan promoting increased physical activity for a sedentary client. Which client outcome would indicate that the interventions were successful? 1. Walks 10 minutes per day periodically. 2. Establishes a routine of 30 minutes of brisk walking three days per week. 3. Reports there is not enough time for exercise. 4. Reports walking daily for about two weeks out of the last three months.

2. Correct: A successful outcome would indicate a change in behavior. A routine of walking three times per week indicates behavioral change. Therefore, the interventions were successful. 1. Incorrect: Periodic walking does not demonstrate a positive outcome for the plan. Perhaps barriers exist that keep the client from a routine. Further assessment would be needed.3. Incorrect: The client's report indicates perceived barriers to action. The client needs help to identify small blocks of time.4. Incorrect: The behavior changed for a brief period; however, the new behavior did not continue. Further evaluation should be performed.

The nurse is teaching a group of high school students about car accident prevention. Who would the nurse include as the highest risk for a motor vehicle crash (MVC)? 1. Males who have just turned 19 years of age. 2. Drivers who have recently acquired a driver's license. 3. A group of students that carpool to the senior prom. 4. Female students who drive to weekly football games.

2. Correct: According to the Centers for Disease Control and Prevention(CDC), crash risk is particularly high during the first year that teenagers are eligible to drive. Though teenagers who are 19 years old, carpooling to the senior prom, and driving to weekly football games are also at risk for an MVC, they are not the highest-risk teenage group.1. Incorrect: The risk for all teens is higher than any other driving group, however, by the age of 19, the teen has generally been driving for several years and the statistical risk of having an accident drops.3. Incorrect: Carpooling to the senior prom does not by itself increase a teen's risk for having a wreck. Driving while under the influence of alcohol will, so a designated driver is key.4. Incorrect: Driving to a football game weekly does not by itself increase a teen's risk for having an accident. The female gender does not increase the risk of MVC.

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

2. Correct: All actions are important but assessment is the nurse's immediate priority. Clear and equal bilateral breath sounds along with equal chest wall movement would confirm that the endotracheal tube has been correctly inserted into trachea. 1.Incorrect: Although suctioning after intubation is an appropriate action, the nursing process requires assessment first. Clearing secretions will be more effective if the endotracheal tube is actually in the correct location in the lungs. 3.Incorrect: Prior to securing the endo tube to the client's mouth/face, it is more important to verify that tube is in the correct location within the lungs. If the tube is not placed properly, the client will not be adequately ventilator, and the tape would have to be removed for reinsertion. 4.Incorrect: Follow up chest x-rays are needed to verify that the endotracheal tube has been properly placed in the lungs. However, this action is not an immediate priority for the nurse. Assessment is the nursing priority.

A nurse is reviewing serum laboratory data for four clients. Which client would require the most immediate assessment? Client Lab Test Result Normal Ranges A Thyroid-stimulating hormone (TSH) 12 mU/L (12µU/mL) 2 -10 mU/L (2-10 µU/mL) B Free T4 (thyroxine) 5.0 ng/dL (0.39 pmol/L) 0.8 - 2.8 ng/dL (10-36 pmol/L) C Growth hormone 8 ng/mL (8 mcg/L) 0-6 ng/mL (0-6 mcg/L) D Glucose 150 mg/dL (8.3 mmol/L) 70 - 110 mg/dL (3.9-6.2 mmol/L)

2. Correct: An excess of thyroid hormone is the most life-threatening of the findings listed due to its effects on the cardiovascular system of hypertension and tachycardia. The client should be assessed for impending thyroid storm. 1. Incorrect: An elevated TSH level occurs in hypothyroidism. TSH is needed to ensure proper synthesis and secretion of the thyroid hormones which are essential for life. Not life-threatening. 3. Incorrect: An elevated growth hormone produces acromegaly with resulting bone and soft tissue deformities and enlarged viscera. But this is not life threatening. 4. Incorrect: Though the glucose level is elevated, a level of 150 mg/dL (8.3 mmol/L) does not require immediate assessment or intervention.

The nurse is caring for a hypertensive client who has been taking a loop diuretic while hospitalized. Upon discharge, the nurse must teach the client about the need for adequate electrolyte intake through foods and/or dietary supplements. Which foods should the nurse suggest to the client? 1. Cereals and breads 2. Avocados and apricots 3. Table salt and spinach 4. Blueberries and strawberries

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

The community health nurse is developing a presentation for adolescents on dealing with gun violence in school. What initial action should the nurse take? 1. Design a booklet for school districts on handling aggression. 2. Survey students to determine attitudes towards weapons. 3. Provide information on anger management to grade schools. 4. Investigate existing safety procedures in the schools.

2. Correct: Based on teaching/learning theory, the most important initial step is to determine if the client (in this case, a group of adolescents) is receptive to learning. Motivation is vital to successful learning. By first surveying student attitudes, the nurse gathers the data needed to prepare an age appropriate presentation that is more likely to be successful. 1. Incorrect: In this option, the nurse is implementing an action without collecting appropriate data. In addition, a booklet, while useful, is not what the nurse is to prepare. The correct issue is gun violence, not general aggression. 3. Incorrect: While it is true that anger management can influence violence, particularly at a young age, it is not the issue in this question. The idea of presenting information at the grade school level is logical but this nurse is to prepare an adolescent-based presentation. 4. Incorrect: This option does discuss collecting data; however, the information being collected does not address the topic in the question, which is gun violence. Safety procedures in schools could focus on many diverse concerns other than the issue of gun violence.

During a physical assessment of a client who was started on haloperidol 5 days ago, the nurse notes restlessness, muscle weakness, drooling, and a shuffling gait. What should be the nurse's first action? 1. Hold the next haloperidol dose. 2. Administer the prn benztropine mesylate. 3. Notify the primary healthcare provider to discontinue the haloperidol. 4. Draw a blood sample for drug level.

2. Correct: Benztropine mesylate is an anticholinergic that counteracts the extrapyramidal symptoms (EPS) seen with the use of haloperidol. 1. Incorrect: Holding a single dose of haloperidol does not correct the extrapyramidal symptoms. 3. Incorrect: The primary healthcare provider has prescribed benztropine mesylate to combat the side effects of the haloperidol. There is no need to notify the primary healthcare provider, which will delay treatment. 4. Incorrect: The client is showing extrapyramidal symptoms associated with haloperidol therapy. Benztropine mesylate is an anticholinergic agent that can be used to treat the extrapyramidal effects that may be seen as a side effect of haloperidol therapy.

A client is prescribed phenobarbital to control seizures. Which medication prescribed for the client would the nurse recognize interacts with phenobarbital? 1. Lovastatin 2. Loratadine 3. Lansoprazole 4. Lactulose

2. Correct: Both of these drugs can cause CNS depression. There is a drug to drug interaction between antiseizure medications and antihistamines. Loratadine is the only medication in the answer options that can cause CNS depression. 1. Incorrect: Lovastatin is indicated for the treatment of increased cholesterol and triglyceride levels. There is no drug to drug interaction that exists between phenobarbital and lovastatin. 3. Incorrect: Lansoprazole is a proton-pump inhibitor indicated for the treatment of stomach ulcers and GI complaints. There is no drug to drug interaction that exists between phenobarbital and lansoprazole.4. Incorrect: Lactulose is an ammonia reducer and laxative. It is indicated for the treatment of constipation and to decrease the ammonia level in the treatment of client's with liver disease. There is no drug to drug interaction that exists between phenobarbital and lactulose.

How would a tendency toward stereotyping and countertransference affect the nurse's ability to complete a client's cultural assessment? 1. Facilitate the care planning process 2. Promote decisions based on the nurses value system 3. Utilize an open honest approach while responding to the client's concerns 4. Develop an unbiased approach to care.

2. Correct: Both stereotyping and countertransference will decrease the nurse's sensitivity to the client's needs and the culture they represent. Nurses who impose these values upon clients will make decisions based on their attitudes, values and beliefs and not those of the culturally different client. 1. Incorrect: Both stereotyping and countertransference also interfere with the treatment process you can't base your care plan on your general views toward a client's culture. Care plans, must be individualized and not based on stereotypes. 3. Incorrect: The nurse will make automatic responses based on preconceived ideas and expectations. The nurse is unable to be open and honest about client concerns. Remember, stereotyped behavior is based on the assumption that all people in a similar cultural, racial or ethical group think and act alike. 4. Incorrect: The nurse's need to maintain an unbiased care is important because the client's needs remain unmet. Value clarification by the nurse will assist in preventing stereotyping and countertransference to other clients. The nurse will never have an unbiased approach to care for clients unless the nurse understands and removes unhealthy values affecting the assessment process.

Which assessment finding identified in a client diagnosed with Guillain-Barre Syndrome would indicate that the nurse needs to notify the primary healthcare provider? 1. Vital lung capacity of 900 mL. 2. Breathlessness while talking. 3. Heart rate of 98 beats per minute. 4. Respiratory rate of 24 breaths per minute.

2. Correct: Breathlessness while talking indicates respiratory fatigue. Preparation for intubation needs to be made. 1. Incorrect: If the vital lung capacity drops below 800 mL, mechanical ventilation is warranted. 3. Incorrect: Imminent signs of respiratory failure include a heart rate greater than 120 beats per minute or less than 70 beats per minute. 4. Incorrect: Imminent signs of respiratory failure include a respiratory rate greater than 30 breaths per minute.

The nurse is discharging a client who had a kidney transplant and the primary healthcare provider has prescribed mycophenolate. Which nursing instruction is priority regarding this medication? 1. Take the medication with food 2. Notify primary healthcare provider at first signs of an infection 3. Nausea, vomiting, and diarrhea are common side effects 4. Use sunscreen when planning to be outdoors

2. Correct: Calling the primary healthcare provider at the first signs of an infection is priority because mycophenolate is an immunosuppressant. It diminishes the body's ability to identify and eliminate pathogens. 1. Incorrect: It is recommended the client take the medication on an empty stomach but the drug may be taken with food if the client experiences stomach upset. This is not the priority teaching point. 3. Incorrect: These side effects may be experienced but this is not the priority teaching point. 4. Incorrect: Sun exposure should be avoided and clients should be advised to use sunscreen because it can make the client more prone to sunburn but this is not the priority teaching point.

A female client receiving chemotherapy for breast cancer reports vomiting, stomatitis, and a 10 pound weight loss over the past month. The primary healthcare provider orders an antiemetic and daily mouthwashes. When the home care nurse evaluates the client one week later, what change described by the client would best indicate improvement? 1. Eating three meals daily. 2. Weight gain of two pounds. 3. No further mouth pain. 4. Improved skin turgor.

2. Correct: Chemotherapy typically causes gastrointestinal disturbances severe enough to interfere with a client's ability to eat or absorb nutrients. A ten pound weight loss over one month is significant but expected because of the reported vomiting and stomatitis. A weight gain of two pounds in a week would be the best specific indicator of improvement. 1. Incorrect: The ability to eat three meals daily does not mean that the client is actually absorbing those nutrients successfully. This option suggests that the antiemetic is working well, but there is not enough evidence to demonstrate significant client improvement. 3. Incorrect: The client's denial of any further mouth pain signifies that the mouthwashes have decreased mouth inflammation and stomatitis. While this is a positive change in the client's condition, it is not the best evidence noted by the nurse. 4. Incorrect: Skin turgor specifies the hydration status of a client. Since this client had previously been vomiting, improved skin turgor would indicate the antiemetic is working well and the client is able to retain fluids. While this is a positive change, it is not the most significant indicator of client improvement.

What information would the nurse include when participating in community health training about sexually transmitted infections? 1. Clients are screened for chlamydial infection and/or gonorrhea only if the client is experiencing cervical discharge, dyspareunia, and dysuria. 2. Women with chlamydial infection or gonorrhea are likely to be asymptomatic. 3. In many instances, chlamydia infection and/or gonorrhea will go away without intervention. 4. It is only necessary for females to be treated for chlamydial infections and/or gonorrhea due to the potential damage to a female's reproductive system.

2. Correct: Chlamydial infections of the cervix and gonorrhea often produce no symptoms. 1. Incorrect: All sexually active women aged 25 and younger should be screened annually. 3. Incorrect: If left untreated, chlamydial infections and gonorrhea can result in serious complications. 4. Incorrect: Partners do need to be treated.

Following report, which newborn infant should the nursery nurse assess first? 1. Positive Babinski reflex noted. 2. Has circumoral cyanosis. 3. Negative Ortolani's sign noted. 4. Has telangiectatic nevi.

2. Correct: Circurmoral cyanosis is bluish discoloration of and around the lips. It is an indicator of cyanotic heart defect. 1. Incorrect: The +Babinski reflex is normal in a newborn up until the child starts to walk. Then it should be negative. 3. Incorrect: A positive (not negative) Ortolani's sign indicates congenital hip dislocation. So this is normal.4. Incorrect: The common term for this type of nevi is "stork bites", which are a normal newborn finding.

A distraught client arrives at a mental health crisis center following a house fire that also took the life of a young family member. The nurse knows what action is most important when initiating crisis intervention for this client? 1. Assist the client to verbalize feelings of grief. 2. Assess client for any suicidal behaviors. 3. Admit client to general mental health unit. 4. Assign client to a grief counseling group.

2. Correct: Client safety is always the nurse's priority concern where no other life threatening issues exist. A distraught client in crisis from such overwhelming events does not always think or act clearly. The loss of home combined with the death of a family member places the client at potential risk for suicide. Because the client has presented to the mental health crisis center, the nurse must assume the worst and assess for unexpected responses. 1. Incorrect: While it is true that encouraging the client to verbalize feelings is therapeutic in a crisis, that is not the most important initial action by the nurse at this time. Recall the nursing process when considering an irrational action. 3. Incorrect: Arriving at a mental health crisis center does not automatically require admission to the hospital. This client is overwhelmed by circumstances which include the death of a family member; however, ideally the client may respond to counselling or medications without the need for inpatient care. 4. Incorrect: Following evaluation by a primary healthcare provider, this client will definitely receive counseling, perhaps both individualized and in a support group for those under extreme duress. However, this is not the initial concern for the nurse.

The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. What should the nurse do first? 1. Feed the client after warming the food. 2. Speak to the UAP to determine what happened with the feeding. 3. Pick up the tray and tell the UAP that they didn't do a good job. 4. Provide a between meal supplement to the client.

A nurse asked the charge nurse on the psychiatric unit, "Why did you ask that client to explain the meaning of 'It's raining cats and dogs?'" What is the charge nurse's best response? 1. "I was attempting to get the client to admit to being afraid of cats and dogs." 2. "I am assessing the concreteness of the client's form of thought." 3. "Phrases like this one will help the client improve their abstract thinking ability." 4. "Concrete thinking is a higher form of thinking and means that the client's form of thought is improving."

2. Correct: Concreteness, or literal interpretation of the environment, represents a regression to an earlier level of cognitive development. Abstract thinking is very difficult. The client with schizophrenia would have great difficulty describing the abstract meaning of "It's raining cats and dogs". 1. Incorrect: Asking the meaning of "It's raining cats and dogs" has nothing to do with fear of the animals. 3. Incorrect: The purpose of asking the meaning of "It's raining cats and dogs" is to assess concreteness of the client's form of thought. Explaining the meaning of this phrase will not improve abstract thinking. 4. Incorrect: Abstract thinking is a higher level of thinking. Abstract thinking is the ability to conceptualize ideas.

A 13 year old found unresponsive in the park is brought into the emergency department (ED). 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 attempts to call them have 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 for administration of normal saline. 3. Give Glucagon IM and then wait for the arrival of a parent to consent to further treatment. 4. Notify the pirmary healthcare provider.

2. Correct: Consent for a minor is not needed in the event of an emergency. Begin treatment for Diabetic Ketoacidosis (DKA). 1. Incorrect: Consent for a minor is not needed in the event of an emergency. The social worker does not give consent in this situation. 3. Incorrect: This client is exhibiting signs of DKA, so glucagon is not needed. Emergency treatment can be provided without parental consent for a minor. 4, Incorrect: The primary healthcare provider cannot give consent or treatment in the ED. The ED physician and nurses can provide treatment in an emergency.

A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). Which of the following RNs should not be assigned to this baby? 1. A nurse just back from maternity leave. 2. A nurse who is 10 weeks pregnant. 3. A nurse who is breastfeeding her 4 month old. 4. A nurse who is on hormone replacement therapy.

2. Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. 1. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. 3. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. 4. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure.

The son of a client diagnosed with Alzheimer's Disease who is listed as a person who has access to the client's health information asks the nurse why his father has been prescribed donepezil. What response should the nurse make? 1. "Depression is often treated with this medication." 2. "This medication is used to treat confusion." 3. "Behavioral problems are diminished when the client receives this medication." 4. "This medication will address sleep disturbances."

2. Correct: Donepezil is a cholinesterase inhibitor. It improves the function of nerve cells in the brain. It works by preventing the breakdown of acetylcholine. People with dementia usually have lower levels of this chemical, which is important for the processes of memory, thinking, and reasoning. Donepezil is used to treat mild to moderate dementia caused by Alzheimer's disease. 1. Incorrect: Common antidepressant medications used for treating depression related to Alzheimer's are the selective serotonin reuptake inhibitors (SSRIs). 3. Incorrect: Antipsychotics and Benzodiazepines are used for behavioral problems such as agitation, physical aggression, and disinhibition. 4. Incorrect: Zolpidem is the most common prescription used to help with sleep disturbance found in the client diagnosed with Alzheimer's Disease.

The nurse is assessing a client who was admitted to the inpatient psychiatric unit five days ago for exacerbation of psychotic symptoms, as evidenced by delusions of grandeur. Which type of client remarks indicate continued delusions of grandeur? 1. Comments with fear as a theme. 2. Comments with a theme of being grand or powerful. 3. Comments related to missing body organs. 4. Comments related to being under someone else's control.

2. Correct: Delusions of grandeur include thoughts that the person has exaggerated power or importance. Clients experiencing these feeling believe they are a deity, have special powers, rare abilities or hidden talents. They often feel they should be praised and publicly recognized for these powers. 1. Incorrect: Such comments would indicate delusions of persecution. These delusions occur when a client falsely believes they are being conspired against by others, being spied on, or anything that invokes fear in the events of their daily life. 3. Incorrect: These comments indicate somatic delusions in which the client experiences a false belief that relates to body functions and/or physical appearance. 4. Incorrect: These comments indicate delusions of control or influence in which there is a false belief that an eternal being, group, or energy is capable of controlling their thoughts and influencing their behavior.

The nurse is providing care to a 5 year old client who has been experiencing moderate pain. Which intervention is appropriate for the nurse to use with this client? 1. Encourage the client to talk about the pain. 2. Provide distraction by turning on the TV. 3. Contact the primary healthcare provider for a pain medication prescription. 4. Request that the parents leave the room.

2. Correct: Distraction is a good technique to use with the toddler/preschooler. Other distractions might be to read a book, or look at pictures. Heat and cold therapies should also be considered. 1. Incorrect: The client at this age does not have the cognitive abilities to discuss pain other than to say that he/she has pain and to tell where it is. They can rate their pain at age 5-8 but describing or qualifying pain occurs at age 10 and older. 3. Incorrect: Distraction and other techniques should be used before pain medication. If there is something you can do to fix the problem, do that first. 4. Incorrect: Separation from the parents could cause more anxiety for the child. Parents should be allowed to stay with the client unless they are hindering safe care.

Which prescription should the nurse question when a client is receiving spironolactone 25 mg by mouth daily? 1. Digoxin 0.125 mg by IVP daily 2. Potassium chloride 40 mEq orally t.i.d. 3. Cimetadine 200 mg IVPB q6h 4. Metoprolol 100 mg p.o. daily

2. Correct: Do not give potassium supplements, salt substitutes, or angiotensin-converting enzyme inhibitors to clients taking potassium sparing diuretics because these drugs can increase the risk of developing high to extremely high blood potassium levels.1. Incorrect: This medication does not adversely interact with potassium sparing diuretics; however, the nurse should be on the alert for digoxin toxicity with hyper or hypokalemia.3. Incorrect: Cimetadine is a H2 receptor antagonist indicated for ulcers and GI complaints. It does not adversely interact with potassium sparing diuretics.4. Incorrect: This medication is a beta blocker, which may be given in addition to a diuretic for hypertension control.

The nurse on an inpatient psychiatric unit has been assigned to care for a group of clients. Which client should receive priority during morning round assessment? 1. 40 year old woman who is being discharged today. 2. 80 year old man with suicidal thinking. 3. 45 year old man who has suicidal thinking. 4. 50 year old woman with history of acute panic attacks.

2. Correct: Elderly males have the highest risk of suicide in the US. This is the client that is priority and should be assessed first. 1. Incorrect: This client normally would require less intense attention. If this client is being discharged today then they are considered stable. 3. Incorrect: This client should be checked frequently; however, another client listed is at higher risk. This client would be assessed second but the elderly male is at a higher risk. 4. Incorrect: Panic attacks are uncomfortable and the nurse should stay with the client; however, there is no reason to think that the client is currently in distress. The client has a history of acute panic attacks. There is no indication that the client is currently experiencing a panic attack.

A client admitted to the psychiatric unit is diagnosed with depression. What is the nurse's best response? 1. I understand what you are feeling. I have been left by someone I loved before. 2. You feel upset and unhappy by the loss of your significant other? It is ok to cry. 3. Don't worry. You will feel better once we start giving you medication for depression. 4. Crying isn't going to help anything. Let's talk about your past medical history now.

2. Correct: Empathy is the ability to see beyond outward behavior and to understand the situation from the client's point of view. Therapeutic language is necessary for this client and this acknowledges the clients feelings, restates for clarification, and allows the clients expression of feelings in a trusting environment. 1. Incorrect: This shows sympathy rather than empathy. With sympathy the nurse shares what the client is feeling and experiences a need to alleviate distress. This also takes the focus away from the client, and puts the attention on the nurse, which is self-centered and nontherapeutic. 3. Incorrect: This is giving false reassurance to a client that is sharing pertinent information related to the diagnosis and treatment plan. 4. Incorrect: This ignores the client's feelings by passing judgment and then changes the subject without solving the issue at hand.

After obtaining vital signs, which prescribed medication should the nurse hold when caring for a client on the cardiac unit? Exhibit T - 98 ° (36.7°) P - 74 R - 20 BP - 88/50 1. Rosuvastatin 2. Enalapril 3. Digoxin 4. Clopidogrel

2. Correct: Enalapril is an angiotensin converting enzyme (ACE) inhibitor. An ACE inhibitor will lower the client's blood pressure. The blood pressure in the stem's exhibit is low. Lowering the client's blood pressure more could have a negative effect on the client's condition. 1. Incorrect: Rosuvastatin is a lipid lowering medication. The client's blood pressure has no bearing on whether or not to administer the medication. 3. Incorrect: Digoxin is an antiarrhythmic/inotropic agent. It will slow the heart rate and increase the force of myocardial contraction. This action could actually increase the blood pressure. 4. Incorrect: Clopidogrel is an antiplatelet agent. The client's blood pressure would not have a bearing on whether or not to administer the medication.

A female client arrives at the community health clinic seeking a form of contraceptive and tells the nurse that she really desires getting an intrauterine device (IUD). Following the assessment, the nurse realizes that the IUD would be contraindicated for this client. What factor would be an absolute contraindication for this client receiving an IUD? 1. History of irregular menstrual cycles 2. Ongoing pelvic infection 3. History of an ectopic pregnancy 4. Current fibrocystic breast disease

2. Correct: Factors that are considered absolute contraindications for IUD use include an ongoing pelvic infection, pregnancy, significantly distorted uterine anatomy, and gestational trophoblastic disease with persistently elevated beta-human chorionic gonadotropin levels. When the client has an ongoing pelvic infection such as pelvic inflammatory disease, cervicitis that has not been treated, a postpartum infection, endomyometritis, pelvic tuberculosis, or a post-abortion infection, the client should not receive an IUD, as these are considered absolute contraindications. The placement of the IUD in clients with these infections should be delayed until the infection has been successfully treated, no sign of persistent infection remains, and 3 months has passed following treatment. 1. Incorrect: A history of irregular menstrual cycles. This may indicate a condition that should be explored, but is not a contraindication for receiving an IUD. 3. Incorrect: It is considered safe to receive an IUD in clients who have a history of an ectopic pregnancy. 4. Incorrect: Fibrocystic breast disease should be monitored, but is not a condition that would cause a uterine problem that would serve as an absolute contraindication to receiving an IUD.

The nurse is caring for a client that is receiving blood that was started 2 hours ago. The nurse observes that the client has flushed cheeks. What should the nurse do first? 1. Inform the primary healthcare provider. 2. Stop the blood infusion. 3. Obtain a blood sample from the client. 4. Take vital signs.

2. Correct: Flushing is an adverse reaction to blood transfusion. Stop the infusion immediately, then notify primary healthcare provider. 1. Incorrect: Notify the primary healthcare provider after stopping the blood transfusion. 3. Incorrect: Blood samples will be collected from the client to evaluate the reaction, but stop the transfusion first. 4. Incorrect: Take vital signs after stopping the blood transfusion

A home health nurse is educating a female client about home care considerations for intermittent catheterization. Which statement by the client would let the nurse know that the client understands what has been taught? 1. "After insertion, I will tape the tubing to my lower abdomen." 2. "I will wash the rubber catheter thoroughly with soap and water after use." 3. "It is important that I keep the drainage bag below the level of my bladder." 4. "Catheterization should be done hourly."

2. Correct: For intermittent catheterization in the home, the client should follow clean technique. Wash rubber catheters thoroughly with soap and water after use, then dry and store in a clean place. 1. Incorrect: There is no drainage bag for intermittent catheterization. If there was an indwelling catheter, it would be secured to the woman's upper thigh. 3. Incorrect: With intermittent catheterization, there is no drainage bag. This would be an incorrect comment if made by the client. 4. Incorrect: Intermittent catheterization should be done first thing in the morning and just before going to bed at night. In most cases, self catheterization should be done every 4 to 6 hours. The client may need to self catheterize more frequently if oral intake of fluids has increased.

A client has recently been diagnosed with rheumatoid arthritis. The nurse anticipates which class of pharmacologic agents will likely be a part of the client's treatment regimen? 1. Mitotic inhibitors 2. Systemic glucocorticoids 3. Antifungals 4. Anticoagulants

2. Correct: Glucocorticoids (steroids) are an appropriate pharmacologic treatment for rheumatoid arthritis. Other treatment options include the use of NSAIDs, biologic and nonbiologic DMARDs (methotrexate and others). Remember, all the other problems associated with the use of steroids.1. Incorrect: Mitotic inhibitors are a class of chemotherapeutic agents and are not indicated for the treatment of rheumatoid arthritis. Medications in this class include plant alkaloids (vincristine) and taxanes (paclitaxel).3. Incorrect: Antifungals are not indicated for the treatment of rheumatoid arthritis. Rheumatoid arthritis is an autoimmune disease, not associated with a fungal disorders. 4. Incorrect: Anticoagulants are indicated for the treatment and prevention of thrombolytic disease and are not indicated for the treatment of rheumatoid arthritis. Salicylate (aspirin), an antiplatelets, may be used as an anti-inflammatory agent.

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 pain and inflammation that occurs when too much uric acid crystallizes and deposits in the joints. This is a good choose 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.

A primigravida client at 35 weeks gestation has been diagnosed with human papillomavirus (HPV). The nurse knows that the most important information to discuss with this client is what? 1. The infant will not be able to breast feed. 2. The mother will need frequent follow up Pap smears. 3. The fetus will need to be delivered by C-section. 4. The mother must start metronidazole immediately.

2. Correct: HPV is a sexually transmitted viral infection that can cause genital warts or even precancerous lesions. This virus is spread by direct contact with infected mucous membranes and is transmitted through sexual contact. Although HPV generally clears itself through the human immune system, clients diagnosed with this infection are recommended to have a follow-up Pap smear every six months for the first year, particularly if infected with HPV 16 or HPV 18. 1. Incorrect: The risk of transmitting HPV in breast milk is extremely minimal. Research has shown that the miniscule amounts of HPV which could be transmitted do not outweigh the benefits of allowing the infant to breastfeed. 3. Incorrect: The chance of transmitting HPV during vaginal birth is small. Even in the presence of non-cancerous genital warts, the greatest concern is whether the birth canal is blocked by these growths. The existence of warts does not mean the client will automatically need a cesarean section. 4. Incorrect: The primary healthcare provider will treat the mother and all sexual partners for the HPV, usually with a medication such as metronidazole. However, this information is not the most important topic for the nurse to discuss with the client at this time.

A client being treated in the intensive care unit following methamphetamine intoxication states, "Snakes are crawling all over the room, get me out of here!" How does the nurse document this assessment finding? 1. Delusions 2. Hallucinations 3. Flashbacks 4. Depersonalization

2. Correct: Hallucinations are false sensory perceptions not associated with real external stimuli. When the client begins to respond to a stimuli that is not visible to the nurse, this is a hallucination. 1. Incorrect: Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background. These beliefs are not consistent with reality. Often the client will either feel all powerful or have extreme unrealistic fears. 3. Incorrect: Flashbacks are a spontaneous recurrence of the hallucinogenic state without ingestion of the drug. These can occur months after the drug has been taken. 4. Incorrect: Depersonalization can occur, but it is the observation of oneself having an experience. The client may report feelings of being an outside observer of their own thoughts or body with a sense of loss of control. This is sometimes described as an out-of-body experience for the client.

Which assessment finding by the nurse is likely to indicate an increased level of stress in a client? 1. Weight at normal level. 2. Daily experience of headaches and other body aches. 3. Use of the problem solving method to handle daily annoyances. 4. Reports of increased creativity in the job situation.

2. Correct: Headaches and other body aches may indicate increased levels of stress. Body aches may even be an indicator of depression. Restlessness and fatigue may also indicate increased levels of stress. 1. Incorrect: Normal weight is not an indicator of increased stress. If stress levels are increased, most people experience weight loss or a gain.3. Incorrect: This does not indicate an increased level of stress. Use of the problem solving method is an effective way to deal with stress.4. Incorrect: This does not indicate an increased level of stress. Creativity is usually decreased when stress levels are increased.

A client with hemophilia has been scheduled for extraction of wisdom teeth. The nurse anticipates that the client will receive what priority intervention before this procedure? 1. Prophylactic antibiotics 2. A unit of cryoprecipitate 3. Packed red blood cells 4. Fresh frozen plasma

2. Correct: Hemophilia is a heredity disease characterized by a deficiency of specific clotting factors, including Factor VIII, Factor XIII, and fibrinogen. Clients with hemophilia are given cryoprecipitate prophylactically prior to invasive procedures to replace these deficient factors and prevent hemorrhaging. 1. Incorrect: The priority concern is the potential for bleeding during the procedure. Although infection is always a concern and antibiotics may be considered, it is not the main issue for this client. 3. Incorrect: Packed red blood cells (PRBC's) mean the liquid portion of the blood has been removed so only the cells are infused. PRBC 's are generally administered in the face of severe hemorrhaging or very low hemoglobin and hematocrit. Bleeding is the main concern for this client, but packed red blood cells would not be the correct intervention prior to the procedure. 4. Incorrect: Although hemophilia affects the blood's coagulation ability, fresh frozen plasma (FFP) is not the correct intervention. FFP is generally used in situations such as massive hemorrhaging, severe anemia, cardiac bypass, or DIC. Another prophylactic intervention would be considered priority for the hemophilia client.

The nurse has just received a client from the special procedures lab for a liver biopsy. What is the position of choice for this client post procedure? 1. Fowler's 2. Right side 3. Left side 4. Prone

2. Correct: How do you stop bleeding from a puncture site? With pressure, right? Yes. So where is the liver? In the right upper abdomen under the rib cage. So position the client on the right side so that pressure is applied to the liver's puncture site. Then apply pressure with a sand bag or rolled up towel. This will help to stop bleeding. 1. Incorrect: This will not help control the bleeding. Pressure needs to be applied to the liver, so we want the liver coming forward toward the abdominal wall and pressure to be applied with a sand bag or rolled up towel. 3. Incorrect: The liver is on the right, not the left. Without the liver next to the abdominal wall, pressure cannot be exerted on the liver's puncture site. 4. Incorrect: We don't turn client onto abdomen. You will not be able to assess for bleeding with the client in this position.

The nurse is assigned to care for a client with the diagnosis of schizophrenia. The client tells the nurse, "I am having trouble tuning out the voices." What is the nurse's best response to this statement? 1. "There is nothing to help with this problem." 2. "You might hum when the voices are so troublesome." 3. "You should ask your primary healthcare provider to increase your medication." 4. "Wear earplugs to block out the voices."

2. Correct: Humming or listening to music may help to decrease the intrusive voices. This increases time spent in reality based activities and decreases preoccupation with delusional and hallucinatory experiences. 1. Incorrect: There are things that the client may do, such as humming or listening to an iPod. Telling the client that there is nothing to help them is not therapeutic. 3. Incorrect: The medication may need to be adjusted, but further assessment is needed. Remember, stay away from drugs as long as possible on the NCLEX. 4. Incorrect: Earplugs suggest blocking external stimuli; hallucinations are internal voices. Earplugs will not help internal voices and saying this could make the client think that the nurse hears the voices. Remember, The nurse is not supposed to go along with the hallucinations.

A client diagnosed with systemic lupus erythematosus (SLE) has been started on hydroxychloroquine sulfate to decrease joint pain and swelling. What statement by the client indicates to the nurse the medication teaching has been effective? 1. "I will be prone to infections while on this medication." 2. "I need to see my eye doctor at least once every year." 3. "I might develop a red rash on my nose and cheeks." 4. "I can stop this medicine after my symptoms are gone."

2. Correct: Hydroxychloroquine sulfate(Plaquenil) is in the category of DMARDs (disease modifying anti-rheumatic drug) and was originally developed to treat or prevent malaria. When taken once or twice daily, this medication reduces swelling and joint pain while also decreasing skin problems in Lupus clients. Though there are relatively few side effects, the most serious is retinal toxicity which requires treatment by an ophthalmologist. It is imperative for clients on this medication to have an eye examination every 6 to 12 months. 1. Incorrect: This medication is an antimalarial which has been shown to decrease pain from arthralgia in clients with SLE. Minimal side effects are generally limited to gastrointestinal disturbances such as nausea or diarrhea. This medication does not increase the client's risk of infection at all. 3. Incorrect: Clients with SLE frequently develop the classic red "butterfly rash" across the nose and cheeks which becomes worse when exposed to the sunlight. This symptom occurs because of the disease process and is not related to any medications the client may be taking. 4. Incorrect:

A client diagnosed with Addison's disease has been prescribed prednisolone. Which statement by the client indicates that the client's medication instructions for prednisolone have been effective? 1. "I should avoid foods high in protein." 2. "I will take prednisolone in the morning." 3. "I need to schedule an eye examination every 2 years." 4. "Infections will be reduced while taking prednisolone."

2. Correct: If prednisolone is prescribed once a day, the medication should be taken in the morning. The body's production of cortisone is at a higher level in the morning. The cortisone prescription if taken in the morning will affect the pituitary-adrenal feedback less. 1. Incorrect: Side effects of corticosteroid therapy include decreased muscle mass and wound healing. Clients should be encouraged to consume a diet high in protein. Protein aids the body in repairing damaged tissues. 3. Incorrect: Yearly eye examinations are recommended. Prolonged prescription of prednisolone can result in cataracts and glaucoma. The yearly eye examination is necessary to monitor the client's eyes for any vision changes. 4. Incorrect: Infections will not be reduced while taking prednisolone. Prednisolone is an anti-inflammatory and immune system suppressant. There will be

The nurse is caring for a client taking lithium. Which comment by the client indicates lack of understanding of the therapeutic regimen? 1. "I must keep my sodium intake steady over time. " 2. "If I miss a dose of lithium, I should make it up with the next dose." 3. "I must check with my primary healthcare provider before changing my diet for weight loss." 4. "I must keep my exercise routine the same or discuss with my primary healthcare provider. "

2. Correct: If a client misses a dose of lithium, the client should take the next dose as prescribed without doubling it. If the client adds the missed dose, toxicity may occur. If sodium intake is reduced or the body is depleted of its normal sodium (due to sweating, fever, diuresis), lithium is reabsorbed by the kidneys, increasing the possibility of toxicity.1. Incorrect: This comment indicates understanding. The client should keep sodium levels the same over time as lithium and sodium are both excreted by the kidney.3. Incorrect: This comment indicates understanding. Food intake should remain constant. Therapeutic levels should be monitored closely while the client is losing weight. Sodium reduction can lead to lithium reabsorption in the body causing toxicity.4. Incorrect: This comment indicates that the client does understand the treatment regimen. Any changes that would change the concentration of the drug in the bloodstream should be discussed with the primary healthcare provider. Activities that cause excess sodium loss, such as heavy exertion, exercise in hot weather, or saunas should be avoided.

What should the nurse who is educating about the most common initial visual changes associated with glaucoma inform the client? 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.

A nurse is caring for four pediatric clients. In what order should the nurse attend these clients? Prioritize the clients by placing them in order from first to last.

4 year old child with intravenous heparin infusing at a maintenance rate 12 month old child who is due for an inhalation treatment of ribavirin 10 year old child who has been prescribed intravenous cefoxitin 7 year old child needing a consultation with a certified diabetic educator

What would the nurse expect to see when performing a neurological assessment on a 1 day old neonate suspected of having asphyxia in utero? 1. Grasps nurse's finger when placed in neonate's hand. 2. Toes curl downward when soles of feet stroked. 3. Turn's toward nurse's finger when cheek is touched. 4. Extends arms when nurse claps hands.

2. Correct: If the neonate's toes curl downward when the soles of the feet are stroked, it may be evidence that neurologic damage from asphyxia has occurred. A normal response would be for the toes to curl fan out when the soles of the feet are stroked. 1. Incorrect: This is a normal response seen in the neonate. 3. Incorrect: This is a normal response seen in the neonate. 4. Incorrect: This is a normal response seen in the neonate.

The nurse cares for a client who is scheduled for an upper GI series. The nurse teaches the client about the test. Which statement by the client indicates an understanding of the nurse's teaching? 1. I'll have to take a strong laxative the morning of the test. 2. I'll have to drink contrast while x-rays are taken. 3. I'll have a CT scan after I'm injected with a radiopaque contrast dye. 4. I'll have an instrument passed through my mouth to my stomach.

2. Correct: In an upper GI series (sometimes called a barium swallow test), the client swallows barium contrast while x-rays are taken. 1. Incorrect: Laxatives are taken the night before a colonoscopy to ensure stool is cleared from the colon. Waiting to take the laxative the morning of the test would be ineffective and uncomfortable for the client. 3. Incorrect: Radiopaque dye injected before a CT (computed tomography) scan is not part of a GI series. This would be a totally different diagnostic test from the upper GI. 4. Incorrect: In a gastroscopy (sometimes called a gastric endoscopy), a scope is passed through the mouth to the stomach to visualize the inner lining of the upper GI tract.

Which menu selection by the client diagnosed with cholelithiasis indicates to the nurse that teaching of proper diet was understood? 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, and cakes, red meats, 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. Broiled shrimp is a seemingly healthy choice; however, butter sauce and bread pudding are high in fat content.

The nurse is caring for a client in the emergency department following an argument with the spouse. The client describes a verbal argument that began to get physical with shoving of the client. There is a history of domestic violence. Which phase of the cycle of violence is the client describing? 1. Honeymoon phase 2. Tension-building phase 3. Acute battering phase 4. Remorse phase

2. Correct: In the tension-building phase, minor physical or emotional abuse may occur as well as verbal arguments. The victim feels growing tension and tries to control the situation. 1. Incorrect: The honeymoon phase is characterized by remorse with promises never to hurt the victim again. The abuser is sorry and apologetic. 3. Incorrect: The acute battering phase includes the release of tension through extreme physical violence. This is also called the explosion phase. 4. Incorrect: There is no remorse phase, but remorse is expressed during the honeymoon phase. There are 3 phases: tension building, acute battering (explosion) and honeymoon phase.

The nurse, assessing the lung sounds of a client diagnosed with pneumonia, notes diminished lung sounds and dull percussion in the lower lungs bilaterally. What intervention is correct by the nurse? 1. Place the client in a left lateral recumbent position. 2. Instruct the client to perform incentive spirometry every hour. 3. Encourage the client to increase fluid intake of at least 50 mL/ hour. 4. Have the client use the bedpan to avoid overexertion and exacerbation of symptoms.

2. Correct: Incentive spirometry promotes maximum lung expansion, mobilizes secretions, and encourages coughing. 1. Incorrect: The client should be placed in a semi-Fowlers position and told to change positions frequently. 3. Incorrect: The nurse should encourage hydration up to 2 to 3L/day for adequate hydration. 4. Incorrect: The nurse encourages rest but the client must continue to move to enhance secretion clearance and pulmonary ventilation.

A client shares with the nurse that they are having difficulty staying asleep. Which sleep hygiene intervention would the nurse share with the client to promote falling asleep? 1. Take a cool bath. 2. Include a daytime exercise plan. 3. Take an antihistamine at bedtime. 4. Scan the news feeds on the computer.

2. Correct: Including a daytime exercise program is a sleep hygiene recommendation that will increase the quality of sleep. The exercise program increases metabolism and reduces stress. Activities after 1700 should be avoided if they a strenuous. 1. Incorrect: As the cycle of falling to sleep begins, the temperature of the hands and feet increases and the core temperature decreases. When the client takes a warm bath or shower, this will increase the temperature of the hands and feet. It is the cooling down of the body after the warm bath that promotes sleep. By taking a cool bath the temperature of the hands and feet will decrease at a faster pace. 3. Incorrect: Antihistamine are drugs that counteract histamine in the body. A side effect of histamines is sleepiness, which might assist one to fall asleep. Routine use of antihistamines is not recommended for insomnia, since tolerance for the antihistamines can occur and the medication is intended for short term use. 4. Incorrect: Scanning the news feeds on the computer is not a sleep hygiene recommendation. The news feeds can be disturbing and the light from the computer has a stimulating effect .

A client is undergoing outpatient psychiatric treatment for somatization disorder. Prior to the beginning of group therapy, the client tells the nurse, "I keep having headaches that are killing me! This has never happened to me before." What is the nurse's best response to this client? 1. You need to sit down, because we need to start the group session now. 2. I will notify the primary healthcare provider about your headaches, after the group session. 3. I guess we can discuss your pain now. Group therapy will have to start later. 4. Your headaches are not real, so ignore them. Go on into therapy so we can start.

2. Correct: Initially, the nurse would fulfill the client's urgent dependency needs, but gradually withdraw attention to physical symptoms. Minimize time given to response to physical complaints. Gradual withdrawal of positive reinforcement will discourage repetition of maladaptive behavior. However, all new symptoms should be reported to ensure physician assessment of the complaint. 1. Incorrect: This is a nontherapeutic response. The client's feelings and concerns should not be denied. This will increase the anxiety level of the client. Do not totally ignore the client's complaint. 3. Incorrect: By postponing the group session the nurse is reinforcing the clients somatization disorder. The group session should start on time. 4. Incorrect: The pain is real to the client. This response is not therapeutic communication. The direct ignoring of the client's complaint will increase their anxiety level.

The nurse should teach the client with chronic pancreatitis how to monitor for which problem that can occur as a result of the disease? 1. Hypertension 2. Diabetes 3. Hypothyroidism 4. Graves disease

2. Correct: Insulin is produced in the pancreas. When the client has chronic pancreatitis, the pancreas becomes unable to produce insulin, thus resulting in diabetes. 1. Incorrect: No, not associated with chronic pancreatitis. 3. Incorrect: No, not associated with chronic pancreatitis. 4. Incorrect: No, not associated with chronic pancreatitis.

The nurse notices that the primary healthcare provider, who has been looking at a client's morning laboratory results, walked away from the computer work station without logging out of the system, leaving the page of client medical information visible on the computer screen. What is the most appropriate action by the nurse? 1. Log the primary healthcare provider off the facility's health information system. 2. Minimize the screen so that the client information is no longer visible, and then ask the primary healthcare provider if the computer can be logged out. 3. Do not interfer since the primary healthcare provider is responsible for this information. 4. Read the health information that the primary healthcare provider left visible on the computer screen to see if the document was completed.

2. Correct: It is appropriate to minimize or hide the screen so that the information is no longer visible, then inquire whether the user will be returning to the computer work station. The nurse is held responsible to ensure that client information on a computer screen remains confidential. Legislation legally protects a client's right to privacy and confidentiality of personal health information. 1. Incorrect: Simply logging the other person off the computer system could be a correct option if that person cannot be found, but it is professional to ask if they will be returning and safeguard client's personal health records. 3. Incorrect: The nurse needs to take action to protect client's confidential health information. Professionally remind the primary healthcare provider that they did not log out and left client information visible to unauthorized persons. 4. Incorrect: It is better to ask primary healthcare provider. The nurse can not accurately determine if the primary healthcare provider is finished.

Immediately following a below-the-knee amputation (BKA), the nurse positions the client to prevent complications. What intervention related to position of the residual limb is a priority at this time? 1. Flat on the bed 2. Elevate foot of the bed 3. In a position of comfort 4. In a dependent position

2. Correct: It is normal to experience post-operative swelling after a BKA. Immediately after surgery, the foot of the bed should be elevated to reduce swelling. An ACE compression bandage will be used to reduce swelling and prevent hemorrhage. The other positions would not be as appropriate since swelling is an issue after a below-the-knee amputation. 1. Incorrect: Flat on the bed will not relieve swelling. Post-operatively for a BKA, hemorrhage and swelling are the biggest concerns immediately following surgery. 3. Incorrect: Position of comfort may increase swelling. Immediately following a BKA, elevating the foot of the bed and the ACE compression wrap are used to present hemorrhage and swelling. Positioning for comfort is not appropriate. 4. Incorrect: Placing in a dependent position will increase swelling. Swelling post-operative is a normal occurrence and elevating the foot of the bed and the use of an ACE wrap will help prevent swelling.

How should a nurse prepare to administer a Measles, Mumps, Rubella (MMR) vaccination to a 6 year old child? 1. 3 mL syringe with 23 gauge, 1" needle for IM injection 2. Use a 25 gauge, ¾" needle for subcutaneous (Sub-Q) injection. 3. Prime intranasal spray for administration. 4. Tuberculin (TB) syringe with 28 gauge, 3/8" needle for intradermal injection.

2. Correct: MMR is given Sub-Q. Subcutaneous injections are administered in the fat layer, underneath the skin. When administering SQ injections use a 23-25 gauge needle, needle length for infants (1- 12 months) is 5/8", children 12 months and older 5/8" - ¾". 1. Incorrect: MMR is given Sub-Q. An intramuscular injection is used to deliver medication deep into the muscles. 3. Incorrect: MMR is given Sub-Q. The intranasal spray is given by nasal delivery route. 4. Incorrect: MMR is given Sub-Q. Intradermal injections are given into the dermis, just below the epidermis and commonly used for tuberculin and allergy tests.

A client has been admitted for observation after having a minor automobile accident. During the admission history, the client admits to being an alcoholic. Two hours after admission the nurse notes the client's cardiac rhythm displayed on the telemetry monitor. The client reports shortness of breath, chest discomfort, and nausea. What initial action should the nurse take? Exhibit 1. Cardiovert at 200 joules. 2. Administer magnesium 1 gm IVP over 30 seconds. 3. Begin cardiopulmonary resuscitation (CPR). 4. Obtain a 12 lead ECG.

2. Correct: Magnesium is the drug of choice for suppressing Torsades and terminating the arrhythmia. Magnesium can be given at 1-2 g IV initially in 30-60 seconds, which then can be repeated in 5-15 minutes. 1. Incorrect: In an otherwise stable client, cardioversion is kept as a last resort because Torsades is paroxysmal in nature and is characterized by its frequent recurrences following cardioversion. Although torsade frequently is self-terminating, it may degenerate into ventricular fibrillation, which requires direct defibrillation. 3. Incorrect: This client is awake and has a pulse. CPR is not indicated at this time. 4. Incorrect: Getting a 12 lead ECG will not fix the problem and it is delaying treatment. Do something to fix the problem.

An occupational health nurse is reviewing the current medications of a client who has recently been prescribed propranolol for hypertension. Which current medication taken with propranolol by the client should be of concern to the nurse? 1. Cyanocobalamin 2. Melatonin 3. Cetirizine 4. Esomeprazole

2. Correct: Melatonin is a manmade form of the hormone that is key in regulation your body's internal clock. It is often used in treating sleep disorders. Melatonin can raise blood pressure in people who are taking beta blockers to control blood pressure. Avoid using it in conjuction with propanolol or any other beta blockers. 1. Incorrect: There are no known interactions between propranolol and Vitamin B12 (cyanocobalamin). Vitamin B12 is one of the essential vitamins and can be found in meat, fish and dairy. 3. Incorrect: There are no known interactions between propranolol and Zyrtec (Cetirizine). Cetirizine is an antihistamine used to treat cold or allergy symptoms. This medication may cause severe drowsiness. 4. Incorrect: There are no known interactions between propranolol and Nexium (esomeprazole). Esomeprazole is a proton inhibitor that decreases stomach acid, and remember, it is not used for immediate relief of heartburn symptoms.

A postpartum client is receiving methylergonovine maleate 0.2 mg by mouth three times a day. What is most important for the nurse to monitor with this client? 1. Dizziness 2. Hypertension 3. Nausea and vomiting 4. Headache

2. Correct: Methylergonovine affects smooth muscle of a woman's uterus. It improves muscle tone and strength. It is used after childbirth to help deliver the placenta. Cardiovascular side effects have included palpitations, hypertension, hypotension, acute myocardial infarction, transient chest pains, arterial spasm (coronary and peripheral), bradycardia, and tachycardia. These need to be reported to the primary healthcare provider. 1. Incorrect: Dizziness is a rare side effect and not as life threatening as hypertension. 3. Incorrect: Nausea and vomiting are minor signs and symptoms and not as life threatening as hypertension. 4. Incorrect: Headache is a minor symptom and not as life threatening as hypertension.

A client who is 20 weeks pregnant and diagnosed with pelvic inflammatory disease is given a prescription for metronidazole. What should the nurse inform the client to avoid in order to prevent an interaction with metronidazole? 1. Furosemide 2. Alcohol 3. Doxycycline 4. St. John's Wort

2. Correct: Metronidazole is an antibiotic used for the treatment of vaginal infections. Metronidazole and alcohol can interact with each other, causing severe nausea and vomiting as well as cramping and flushed appearance. 1. Incorrect: Furosemide is a diuretic and does not interact with metronidazole.3. Incorrect: Doxycycline is a tetracycline antibiotic and does not interact with metroindazole.4. Incorrect: St. John's wort is an herbal supplement and does not interact with metronidazole.

The emergency department nurse is assigned to care for four pediatric clients with varying symptoms. Which client should the nurse examine first? 1. 12 year old reporting a severe headache 2. 6 month old with respiratory rate of 68/min while sleeping 3. 2 year old with a broken arm who is crying and appears in pain 4. 8 year old with cellulitis of the left leg and an elevated body temperature

2. Correct: Normal respiratory rate for a 6 month old is 30-50 breaths a minute. A 6 month old who is sleeping is not exerting themselves, and the respiratory rate should be within normal limits. A rate of 68 should alert the nurse to a problem that needs to be addressed. 1. Incorrect: This client does not prioritize higher than one experiencing a respiratory problem. 3. Incorrect: This client's findings are expected behavioral responses to a broken bone. Remember that pain does not prioritize higher than a respiratory problem. Pain never killed anyone!4. Incorrect: Elevated body temperature is an expected physiological response to cellulitis. This problem does not prioritize higher than a respiratory problem.

A client diagnosed with advanced cirrhosis is admitted with dehydration and elevated ammonia levels. While discussing dietary issues, the client requests larger portions of meat with meals. Which response by the nurse provides the most accurate information to the client? 1. I will ask the dietician to add more meat with dinner. 2. Protein must be limited because of elevated ammonia levels. 3. You need to drink more fluids because of your dehydration. 4. We can ask for between meal snacks with more carbohydrates.

2. Correct: Normally, protein is broken down into ammonia, which the liver converts into urea, and the kidneys then easily excrete. However, in a diseased liver, this conversion is not possible, and ammonia continues to build up in the body, ultimately affecting the brain. The nurse would be aware that additional protein would be harmful for this client. 1. Incorrect: Increasing meat at mealtimes would be detrimental to the client's health. When protein is taken into the body, a healthy liver will convert this into urea that is then excreted by the kidneys. However, this client's impaired liver is not able to make that conversion; therefore, the ammonia levels would continue to increase. The nurse can discuss with the client other foods that might safely be added to meals. 3. Incorrect: While it is true this client is dehydrated, the issue is that the client wants to increase the amount of meat at mealtimes. This response does not address the client's request nor does it provide any teaching that would help the client once discharged. 4. Incorrect: Although this response indicates that the nurse is focusing on the client's issue with food, this reply does not address the request for more meat with meals. This would be the appropriate opportunity to educate the client on the need to limit daily protein in the diet.

The emergency department called the labor and delivery unit to give report on a 24 year old primigravida at term, having contractions every 5-8 minutes. The unit is very busy, and all the RNs are with other clients. What action by the charge nurse would be most appropriate? 1. Request that the emergency department hold the client until one of the RNs is available to do the initial assessment. 2. Instruct the LPN/VN to obtain initial vital signs and connect the client to a fetal monitor, then report this data to the charge nurse. 3. Assign an LPN/VN to complete the nursing history and an initial obstetric assessment on this client. 4. Inform one of the RNs that a client is coming from the ED and that a nursing history should be completed as soon as possible.

2. Correct: Obtaining vital signs and placing clients on electronic fetal monitors are within the scope of practice of LPN/VN. 1. Incorrect: The ED is not staffed to care for a client in labor. The client should be transferred to the labor and delivery unit. The change nurse would then make the appropriate nurse assignment. 3. Incorrect: LPN/VNs are not qualified to perform the initial assessments. 4. Incorrect: At least, baseline data should be obtained on this client (vital signs, fetal heart and contraction patterns). Someone must assume care of the client and the LPN/VN can obtain the vital signs and connect the client to the fetal monitor.

The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which statement by the client indicates an understanding of foot care? 1. "I will soak my feet for 30 minutes a day." 2. "I will avoid using a heating pad on my feet." 3. "I can use scissors to remove the corns on my toes." 4. "I enjoy walking without my shoes around the house."

2. Correct: One of the long-term complications of diabetes is peripheral neuropathy. As the neuropathy progresses the feet have reduced sensation and may eventually become numb. The client should avoid using heating pads and hot water bottles. Due to the decrease sensation of the feet, the client is in danger of blistering and burning the feet. 1. Incorrect: A complication of diabetes is an increased risk of foot infections. The client is immunocompromised which impairs the leukocytes that destroy bacteria. The client should not allow moisture to accumulate between the toes. 3. Incorrect: Due to the possibility of the client experiencing peripheral neuropathy, the client should not remove any corns from their toes. If a cut occurs while removing the corn, the client is a risk for an ulcer developing. A primary healthcare provider should prescribe the appropriate treatment for corns. 4. Incorrect: Walking without appropriate shoes is dangerous for the client diagnosed with diabetic peripheral neuropathy. After stepping on an object, the client cannot feel the damage to the skin which could result in a scratch or cut.

The nursing staff have not been able to control the outbursts of a violent adult client. The primary healthcare provider prescribes physical restraints to be applied for the next 8 hours. What is the nurse's best action? 1. Apply the restraints for the 8 hours, with a trial release every 2 hours. 2. Explain to the primary healthcare provider that the prescription will have to be reissued in 4 hours. 3. Refuse to place the client in restraints unless the primary healthcare provider gets a permit signed from the family. 4. Apply the restraints, and observe the client hourly.

2. Correct: Orders for restraints or seclusion must be reissued by a primary healthcare provider every 4 hours for adults age 18 and older, every 2 hours for children and adolescents ages 9-17, and every hour for children less than 9 years. 1. Incorrect: Orders for restraints or seclusion must be reissued by a primary healthcare provider every 4 hours for adults age 18 and older, every 2 hours for children and adolescents ages 9-17, and every hour for children less than 9 years. 3. Incorrect: A permit is not needed if the client is a risk to self or others. The primary healthcare provider must write a prescription for restraints. 4. Incorrect: Clients in restraints or seclusion must be observed and assessed every 10-15 minutes with regard to circulation, respiration, nutrition, hydration, and elimination.

The nurse is caring for a client with chronic pyelonephritis. Which lab value noted by the nurse indicates a problem? 1. Estimated glomerular filtration rate - 90 mL/min/1.73 m2 2. Serum creatinine - 2.1 mg/dL (186 micro mol/dL) 3. Blood urea nitrogen - 19 mg/dl (6.78 mmol/L) 4. Urine culture isolates Escherichia coli

2. Correct: Other than the glomerular filtration rate, the creatinine level is considered the best indicator of renal function, since it is not affected by diet or fluid intake. This creatine level is high and should alert the nurse to a progressive renal problem 1. Incorrect: The estimated glomerular filtration rate (eGFR) is the best test to measure the client's level of kidney function. This eGFR is normal and would not indicate a problem. 3. Incorrect: Blood Urea Nitrogen (BUN) is not as sensitive an indicator of renal function as creatinine because factors other than renal failure can cause an increase in urea levels. And since this value is within normal limits, it does not indicate a problem. 4. Incorrect: E. coli is the common culprit of UTIs including pyelonephritis. This would not indicate a problem, but rather validate the diagnosis.

The nurse is assessing a pregnant client returning for her first, one month check-up. The client has normal vital signs, blood count, and urinalysis, but has gained 6 pounds (2.7 kg). What is the most important assessment at this time? 1. Blood glucose level 2. Ankles for edema 3. Twenty-four hour diet recall 4. Confirmation of last menstrual period

3. Correct: What is she eating? how much? Are the calories healthy? This is too much weight. 1. Incorrect: Weight gain: think eating or fluid, not blood sugar 2. Incorrect: First month: this weight gain is from excessive eating, snacking, etc. 4. Incorrect: Not an indication that the date is wrong

The primary healthcare provider has prescribed hydromorphone 2 mg intravenously (IV) every 4 hours as needed for pain. When should the nurse plan to administer the medication to the client? 1. Only when requested. 2. Prior to onset of intense pain. 3. With reports of acute pain lasting for at least one hour. 4. Continuously every 4 hours to keep the client pain free.

2. Correct: Pain is best managed before acute pain has developed. If the client waits until the pain is intense, the pain medication may not work as effectively or not at all. 1. Incorrect: Clients sometimes need pharmacologic treatment for pain even if not requested. Nurses should monitor the client for physical signs of pain. Vital sign changes and facial grimacing may be signs of pain. The word "only" is too limiting. 3. Incorrect: Clients should be treated for pain before acute pain develops when possible. The client should be educated to report pain prior to experiencing it for at least one hour. 4. Incorrect: The order is as needed, not continuously. Also, the goal of being pain free may be unrealistic. The nurse wants to keep the client's pain at a tolerable level. Always measure pain on a pain scale such as 0-10.

A client is admitted to the LDR from the emergency department at 34 weeks gestation with profuse, painless, bright red vaginal bleeding. The priority action by the nurse is to prepare for which procedure?. 1. Sterile vaginal exam 2. Ultrasound exam 3. Amniocentesis 4. Contraction stress tes

2. Correct: Painless, bright red vaginal bleeding is a sign of a placenta previa. Ultrasound can confirm this diagnosis with minimal risk to the mother and her fetus. This is the safest action for this client and best for fixing the problem. 1. Incorrect: If the placenta is over the cervix, a finger can go right through the placenta and cause hemorrhage and fetal death so vaginal exams would be absolutely contraindicated. 3. Incorrect: Amniocentesis is done for genetic analysis or to determine fetal lung maturity when delivery is likely. It is preferable to delay delivery until the fetus is term. It would not be safe to puncture the abdomen of a client that is already hemorrhaging. 4. Incorrect: Contractions can cause further detachment of the placenta from the cervix, which would also cause hemorrhage.

A child diagnosed with acute lymphocytic leukemia (ALL) is receiving vincristine sulfate during the induction phase of chemotherapy. What client side effect should the nurse report immediately to the primary healthcare provider? 1. Anemia 2. Paresthesia 3. Nosebleeds 4. Alopecia

2. Correct: Paresthesia is an uncommon but serious reaction to chemotherapy, particularly vinca alkaloids like vincristine sulfate. The abnormal tingling or pins and needles sensation is caused by pressure or damage to peripheral nerves which may include both motor and sensory sensations. The nurse should immediately notify the primary healthcare provider of this critical side effect of vincristine therapy. 1. Incorrect: Anemia is an expected side effect of many types of chemotherapy, including vincristine sulfate. Chemotherapy drugs attack rapidly dividing cells, including those that create red blood cells. Anemia contributes to fatigue, shortness of breath and lack of energy. This should definitely be evaluated, but is not the most urgent concern for the nurse at this time. 3. Incorrect: Vincristine sulfate has many side effects, including depletion of platelets which are responsible for blood clotting. When platelets are depleted, the client can experience nose bleeds, bruising, or bleeding gums. While this is of concern, it is not the side effect which needs to be reported immediately to the doctor. 4. Incorrect: Alopecia is a very common, expected side effect of chemotherapy. Damage to hair follicles commonly occurs after the first two treatments. While this side effect can impact the client psychologically, it is not an issue that the nurse must immediately report.

A nurse notes redness, warmth, and pain at a client's intravenous (IV) insertion site. What does the nurse suspect? 1. Colonization 2. Phlebitis 3. Infectious disease 4. Bacteremia

2. Correct: Phlebitis refers to inflammation of a vein and it can be caused by any insult to the blood vessel wall, impaired venous flow, or coagulation abnormality.Clinical evidence includes redness, heat and pain. These signs and symptoms show that the client is experiencing a localized inflammation such as phebitis. 1. Incorrect: Colonization is used to describe microorganisms present without host interference or interaction. There is an absence of tissue invasion or damage. 3. Incorrect: Infectious disease is the state in which the infected host displays a decline in wellness due to the infection. Clinical signs and symptoms may or may not be present.4. Incorrect: Bacteremia is determined by presence of bacteria in the bloodstream. Bacteremia can lead to sepsis and signs and symptoms such as fever, hypothermia, tachycardia, tachypnea and inadequate blood flow to internal organs.

The nurse is teaching a client about the use of a cane. Which is the correct cane technique? 1. Place the cane on weaker side of the body to support the weaker leg. Using the cane for support, the client should step forward with strong leg, and then move the weaker leg and cane forward to the strong leg. 2. Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. 3. Place cane on weaker side of body. The cane is placed forward 6 to 10 inches while the client advances weaker leg to the cane. 4. Place cane on stronger side of body to help support weaker leg. Using cane for support, step forward with the strong leg and then move the weaker leg and the cane forward to the strong leg.

2. Correct: Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. The body weight is divided between the strong leg and the cane. 1. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 3. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 4. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling.

The nurse observes an unlicensed assistive personnel (UAP) performing AM care for a client with a plaster leg cast applied 12 hours ago. Which action by the UAP should the nurse intervene? 1. Lifting the affected leg with the palms of the hands 2. Covering the affected leg with a blanket to avoid chills 3. Placing plastic over the entire cast prior to bathing 4. Elevating the casted leg on two pillows

2. Correct: Plaster cast take 24-48 hours to completely dry. During this time they release heat. The new cast should not be covered so that heat from the cast can evaporate. If the heat is not allowed to dissipate, drying will take longer. 1. Incorrect: Plaster cast take 24-48 hours to completely dry. During this time the cast should be handled carefully as to avoid indentations. Handling the cast carefully with the palms and not the fingertips will prevent indentations. Indentations in the cast could cause skin breakdown inside the cast. 3. Incorrect: Yes, will keep cast from getting wet. Plaster casts should never get wet. The plaster cast does not hold up well in water. Wet casts can also irritate the skin underneath.4. Incorrect: Yes, may elevate the leg. Fractures are prone to swelling. Elevating fractures while casted is a common occurrence. Elevation prevents swelling.

A client with a diagnosis of endocarditis and a new peripherally inserted cential catheter (PICC) line has been discharged home to receive daily intravenous antibiotics for six more weeks. The home health nurse is making an assessment visit today. What instruction by the nurse is most important initially? 1. Take antibiotics before dental procedures. 2. Brush and floss teeth at least twice daily. 3. Report any flu like symptoms immediately. 4. Include rest periods throughout the day.

2. Correct: Poor dental hygiene is one of the chief causes of endocarditis in adults, leading to growth of vegetation on heart valves, emboli, strokes, or even death. Instructions on proper oral care is considered primary or preventative teaching and encourages the client to take an active role in personal health care. Decreasing mouth bacteria or disease will decrease the potential for a reoccurrence of endocarditis. 1. Incorrect: Although primary healthcare providers may order antibiotics prior to a dental visit, it depends on what procedure the dentist is going to perform. Invasive mouth procedures where bleeding is likely generally require pre-visit antibiotics. However, this is not the most important information by the nurse initially. 3. Incorrect: Flu like symptoms are an indication of a possible exacerbation or reoccurrence of endocarditis. The client would be instructed to report such signs as fever, chills, malaise, or night sweats immediately to the primary healthcare provider. While it is important for the client to understand what to report, preventative measures are more important at this time. 4. Incorrect: Infection within the heart is very serious and, despite aggressive treatment, may have lasting effects on the client's cardiovascular system. Decreasing the workload of the heart during treatment and recovery time would certainly assist with the healing process. However, the need for frequent rest periods throughout the day is determined by a variety of factors, such as the client's age and morbidity factors, general health, amount of damage to the heart, and response to antibiotics. Rest is not the most important instruction the nurse must present initially.

A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. What is the most appropriate action by the charge nurse? 1. Assign more daily tasks to the UAP. 2. Provide positive feedback to the UAP. 3. Allow the UAP to work without supervision. 4. Teach the UAP to change surgical dressings.

2. Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. This individual should be provided appropriate comments of appreciation for this accomplishment. 1. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. It would not be appropriate to overload this new employee with extra work. 3. Incorrect: The scope of practice for the UAP encompasses basic personal care needs, ambulating, and taking vitals; however, the nurse must still verify that all tasks are accomplished in a safe manner. 4. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. The nurse cannot allow the UAP to perform advanced tasks.

A client has been admitted to the labor and delivery unit with a diagnosis of preeclampsia. During afternoon rounds, which assessment finding by the nurse should be reported to the primary healthcare provider immediately? 1. Deep tendon reflexes of plus three. 2. Urine output of 80 mL over four hours. 3. Respiratory rate of 24 breaths/minute. 4. Severe headache with blurred vision.

2. Correct: Preeclampsia is a condition in which the client's blood pressure is consistently elevated, with a systolic greater than 140 mm Hg and a diastolic above 90 mm Hg. The greatest main concern is decreased perfusion to the placenta, endangering mother and fetus, potentially accompanied by seizures, kidney or liver failure. This client has had only 80 mL of urine in four hours, indicating an output less than the minimum required of 30 mL per hour. This indication of possible kidney failure should be reported to the primary healthcare provider immediately. 1. Incorrect: Deep tendon reflexes (DTR'S) range from 0 to +5 and are used to assess the neurologic integrity of the body. Normal reflexes for the body range around +2 but become elevated in preeclampsia. The possibility of seizures increases as DTR's increase over the normal range. This symptom is serious but expected in a client with preeclampsia. The nurse should continue monitoring this. 3.Incorrect: As blood pressure increases in the preeclampsic client, both respirations and heart rate would also begin to elevate. The client may display excessive swelling of hands and feet, occasionally accompanied by facial swelling. Although a respiratory rate of 24 is a bit elevated, it is nothing the nurse needs to report immediately. 4. Incorrect: The combination of increased blood pressure and swelling in preeclampsia frequently results in severe headaches and blurred vision. If the blood pressure reaches life-threatening levels, clients have been known to develop blindness because of retinal response to the decreased body perfusion. Although headache and blurred vision are serious symptoms, this is not completely unexpected and therefore does not need to be reported to the primary healthcare provider immediately.

A client with a history of cardiac disease has safely delivered a full term infant. When discussing discharge instructions, the nurse knows the teaching was successful when the client makes what statement? 1. "Now that the baby is born, I can eat more salt." 2. "I must include lots of fiber to prevent constipation." 3. "I should return to my previous dose of cardiac medication." 4. "I will need extra fluids to help with breast feeding needs."

2. Correct: Pregnancy stresses an impaired cardiovascular system and requires careful monitoring even after delivery of the infant. The heart needs time to recover from the strain to the body. Constipation can be a problem after delivery, caused by relaxed muscle tone, hemorrhoids, or surgical repair. Increasing fiber in the diet, along with mild exercise, can prevent constipation. 1. Incorrect: Salt is not restricted during pregnancy because the fetus needs iodine for brain and nervous system development. But increasing salt after delivery would result in unhealthy amounts of sodium in the diet, which is unsafe for cardiac clients. 3. Incorrect: Since this client's cardiac medications would have been altered during the pregnancy, it is important to meet with the cardiologist following delivery to evaluate current medication needs. Simply returning to pre-natal medications or dosages would not be appropriate due to extreme changes in the client's overall health status and postpartum condition. 4. Incorrect:Even though adequate fluids are necessary for breast-feeding mothers, clients with cardiac issues must be cautious of overloading the heart with large amounts of fluids. The risk of post-partum cardiac complications will continue for several months, including the possibility of cardiomyopathy or a myocardial infarction. Breast feeding mothers need an extra 300 - 500 calories, particularly foods rich in calcium, and not excessive amounts of fluid.

A preschooler has been hospitalized for observation. The unlicensed assistive personnel (UAP) offers to sit with the child and asks the nurse to suggest an appropriate activity. The nurse knows the best activity choice for a preschool child is what? 1. Children's television show 2. Small stacking blocks 3. A checker board game 4. Children's card game

2. Correct: Preschool children, ages 3 to 5, are in the Erikson stage of "initiative versus guilt" where the learning goals involve exploration and manipulation of the environment. Motor skills are developing, and playing is used to increase self-esteem through imagination and creativity. Stacking small blocks to build structures or create creatures is definitely appropriate for this age group and can easily be done on the bedside table. 1. Incorrect: A preschool child may not have the patience to sit through an entire television show. Additionally, this would not address the developmental needs of this age group, which focuses on creative activities such as coloring, painting, playdough, or building blocks. Even hospitalized children must have their developmental needs addressed. Television may appeal more to adolescents. 3. Incorrect: Table games like checkers are more appropriate for school age children, who tend to like group activities, particularly with peers of the same age and sex. Playing checkers is too tedious and inactive for a young preschooler. 4. Incorrect: Card games, even those designed for children, are generally too boring for youngsters. Preschool children prefer activities which require imagination and activity with others. Dressing up in clothing, riding bikes, or other physical games are good for engaging this age group. In the hospital, creativity can be encouraged with drawing, chalk, or playdough.

The charge nurse is observing a nurse perform a dressing change on a client with a Stage III pressure ulcer. What observation by the charge nurse would indicate a need for further teaching? 1. Irrigates the pressure ulcer with 50 mL normal saline. 2. Irrigates the pressure ulcer with half-strength hydrogen peroxide. 3. Packs the wound with sterile gauze soaked in normal saline. 4. Applies a hydrocolloid dressing over the wound after cleansing.

2. Correct: Pressure ulcers should not be cleaned with substances that are cytotoxic such as hydrogen peroxide, betadine or Dakin's solution. Cytotoxic means toxic to cells, or cell-killing. Any agent or process that kills cells. These solutions can kill or damage cells, especially fibroblasts. Dakin's solution is a type of hydrochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine is the active ingredient in Dakin's solution. 1. Incorrect: Normal saline is an appropriate solution and is used to clean pressure ulcers. This does not kill or damage cells. 3. Incorrect: Normal saline is an appropriate solution and pressure ulcers may be packed with sterile gauze. This helps remove necrotic tissue. 4. Incorrect: The wound should be covered with an appropriate dressing after cleaning. Hydrocolloid dressings support healing in clean granulating wounds and autolytically debride necrotic wounds. Hydrocolloid dressings are occlusive, so they provide a moist healing environment, autolytic debridement, and insulation.

Which prevention measure should the nurse include when instructing a client on avoidance of otitis externa? 1. Gently cleaning the ear canal with a cotton tipped applicator daily. 2. Use of astringent drops after bathing. 3. Taking preventative antibiotics prior to swimming in lakes or ponds 4. Routine use of nasal saline to clear the sinuses and eustachian tubes.

2. Correct: Prevention and avoidance measures for otitis externa include thorough ear canal drying and use of acidifying or astringent drops after swimming or bathing.1. Incorrect: Clients should be taught to NEVER stick objects, including cotton tipped applicators, into the ear canal. This could result in rupture of the tympanic membrane.3. Incorrect: Taking preventative antibiotics is unnecessary and increases the risk for antibiotic resistance.4. Incorrect: Use of saline may be useful in keeping the sinuses cleared thereby reducing accumulation in the eustachian tubes. While this might be beneficial for otitis media, it would serve no benefit in otitis externa.

When caring for a client on extended bedrest, which intervention should the nurse implement to decrease the risk of contractures? 1. Use a large pillow to support the head and shoulders. 2. Properly reposition every 2 hours. 3. Use a knee gatch to place knees at a 30 degree angle. 4. Place a trochanter roll along the inner aspect of each thigh.

2. Correct: Properly repositioning every 2 hours is the best way to prevent contracture. 1. Incorrect: A small rather than large pillow should be used to prevent neck flexion contracture. A small pillow should be used under their head and shoulders. 3. Incorrect: Avoid the use of knee gatch and pillows under the knees for extended times to avoid knee contractures. Knee gatch can be used but the position will need to be changed every 2 hours. 4. Incorrect: A trochanter roll is used on the outside of the thigh to prevent external rotation of the hips. This technique will not prevent contractures.

A clinic nurse completed teaching the parents of a 9 month old baby how to prevent otitis media infections in their baby. Which statement by the parents indicates to the nurse that further teaching is necessary? 1. "Our baby should sit up for feedings." 2. "It is fine to prop up a juice bottle for our baby to drink at night." 3. "Since our baby has ear tubes, ear plugs should be worn when swimming." 4. "We need to keep our baby away from people who are smoking."

2. Correct: Propping up a bottle can contribute to otitis media and dental caries with a propped bottle, the liquid pools in the back of the mouth and can back up through the eustachian tube. Bacteria may then enter through the tube and cause an ear infection. 1. Incorrect: This is a correct response. Reflux of milk up the eustachian tubes is less likely in the vertical or semi-vertical position during feedings. 3. Incorrect: This is a correct statement. Parents should keep bath water and shampoo water out of the ear, if possible. Swimming without earplugs poses a slightly increased risk of infection. 4. Incorrect: This is a correct statement. Second hand smoking increases the risk of persistent middle ear effusion by enhancing attachment of the pathogens that cause otitis to the middle ear space, prolonging the inflammatory response and impeding drainage through the eustachian tube.

Which nursing intervention represents secondary prevention level? 1. Teaching the effects of alcohol to elementary school children. 2. Providing care for abused women in a shelter. 3. Leading a group of adolescents in drug rehabilitation. 4. Ensuring medication compliance in a client with schizophrenia.

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

The family of a client receiving treatment for substance abuse asks why they should get involved in treatment plan. Which statement by the nurse would best explain the rationale for including the family in the treatment plan? 1. "The treatment plan consists of having the family confront the client about the harm substance abuse causes." 2. "Family involvement reduces distress in family relationships to lessen the risk for relapse by the client" 3. "Involving the family helps the family learn ways to protect the client from additional harm." 4. "The family assists in ways to help reduce temptations for substances by the client."

2. Correct: Reducing distress in relationships lessens risk of relapse. 1. Incorrect: The family is not responsible for confronting the client. 3. Incorrect: The client is responsible for consequences related to client's behavior. 4. Incorrect: The family is not responsible for reducing temptations.

A traumatized soldier goes to the infirmary after being told he almost died in a gun battle. He tells the nurse, "I do not remember any of the details of this event. What is wrong with me?" What is the nurse's best response? 1. "I understand you are upset, but you will have to go back to your unit sooner or later." 2. "You are repressing this event because it was frightening and painful for you." 3. "In my professional opinion, you are trying to undo what happened in the battle." 4. "You are splitting from the bad you, so that the good you survives."

2. Correct: Repression is the unconscious blocking from awareness an event or memory of something that is threatening or painful. It is the mind's way of forgetting or experiencing temporary amnesia until it can cope with an overwhelming circumstance. The nurse's response is concise and honest for a client that needs a trusting therapeutic relationship after a traumatic event. 1. Incorrect: The nurse is being aggressive and judgmental which is inappropriate and not therapeutic for the client. 3. Incorrect: Undoing is canceling out a behavior or trying to make amends. This is not a correct assessment of what the client has reported to the nurse. 4. Incorrect: Splitting occurs when a person cannot stand the thought that someone might have both good and bad aspects, so they polarize their view of that person as someone who is "all good" or "all bad."

At a monthly staff meeting in a long-term care facility, the charge nurse requests staff input to create new activities for the clients. An RN has been assigned to gather information for staff consideration. What method would provide the RN with the best data for this project? 1. Ask clients' families which activities they would like to have available. 2. Research professional articles for guidelines to activities in long-term care. 3. Have clients peruse a variety of games and select what interests them. 4. Contact other facilities to inquire what types of programs they provide.

2. Correct: Research based criteria generally have a high rate of success because the testing has been completed under controlled circumstances and are practice based. 1. Incorrect: Although it would be acceptable to speak with the clients' families, this would not provide the most complete data for the project. Families would not likely understand pertinent considerations such as cost of supplies, number of staff required to assist, or clients' ability to participate. 3. Incorrect: While encouraging client input does allow for some independence, multiple choices can be overwhelming for elderly clients. There would also be an unnecessary expense in purchasing and providing multiple choices for the clients. 4. Incorrect: Most facilities individualize activities based on clientele, funding, and even location. Activities that work in one long term care facilities may not be appropriate for another facility.

The parents of a child admitted with rheumatic fever (RF) ask why the child has been placed on bedrest. The nurse explains that bedrest serves what primary purpose for the client? 1. Prevents permanent joint damage. 2. Decreases workload on the heart. 3. Helps regulate body temperature. 4. Reduces joint pain and body aches.

2. Correct: Rheumatic fever is a secondary, infectious process that occurs several weeks after an unresolved streptococcal infection, such as strep throat. The Group A beta-hemolytic strep can cause inflammation in the myocardium or epicardium, ultimately affecting the valves of the heart, particularly the mitral valve. The resulting thickening and fibrosis leads to cardiac stenosis which could lead to heart failure. During this illness, decreasing the workload on the heart is vital to help prevent cardiac complications. 1. Incorrect: Rheumatic fever causes increased body temperature, muscle aches and swollen painful joints, particularly knees, ankles and wrists. Although clients may need ibuprophen for pain and swelling, there is no permanent damage to the joints. Bedrest serves another purpose for this client. 3. Incorrect: It is true that these clients can run a high fever at times and even develop a red rash over the torso. However, the purpose of bedrest is not related to controlling body temperature. 4. Incorrect: It may seem logical that bedrest would decrease joint pain and body aches, but this is not the primary purpose for bedrest.

A primagravida asks the nurse about the purpose of the RhoGam injection. What would be the best explanation by the nurse? 1. RhoGam changes the RH positive fetus to Rh negative. 2. RhoGam prevents the mother from forming Rh antibodies. 3. RhoGam inhibits Rh antibodies in the newborn infant. 4. RhoGam destroys antibodies in the RH positive mother.

2. Correct: RhoGam is an immunoglobulin given via injection to an Rh negative mother following the birth of an Rh positive infant. The mixing of mother and fetal blood during birth causes the mother to develop antibodies which can be fatal to the next fetus. RhoGam prevents the formation of these antibodies in the mother. 1. Incorrect: RhoGam has no effect on the Rh factor in the fetus. RhoGam is administered to the mother and does not alter the Rh factor at all. RhoGam works to prevent antibody formation in the mother. 3. Incorrect: RhoGam is never given to an infant because the fetus does not form RH antibodies. Only the mother will form antibodies. 4. Incorrect: RhoGam does not "destroy" antibodies; rather, it prevents the actual formation of antibodies in the mother. Also, RhoGam is only given to Rh negative mothers.

The nurse is working on health promotion plans for a small group of school-aged children who are at risk for obesity. Which baseline data would support the 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 he 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.

Which comment made by a new nurse regarding sodium polystyrene sulfonate indicates to the charge nurse that the new nurse understands the effects of this medication? 1. "Sodium is exchanged for potassium in the blood." 2. "Fluids will need to be encouraged after administration." 3. "This medication will increase potassium and decrease sodium." 4. "Sodium polystyrene sulfate is only given as an enema."

2. Correct: Sodium polysterene sulfonate (kayexalate) is used to treat hyperkalemia, and it works by helping your body get rid of the extra potassium by exchanging sodium ions for potassium ions in the intestines. Sodium level increases after administration and this increase causes some dehydration. Pushing fluids will offset the dehydration. 1. Incorrect: This is an incorrect statement by the new nurse. Sodium is exchanged for potassium in the GI tract, and the majority of the exchange occurs in the large intestine where potassium ions are excreted in larger amounts. 3. Incorrect: Potassium will decrease and sodium will increase. Remember, this medication is used for hyperkalemia. 4. Incorrect: Sodium polystyrene sulfonate can be given as a liquid by mouth, through a stomach feeding tube, or as a rectal enema.

A client, who is receiving an IV vesicant agent, reports pain at the intravenous site. What is the priority nursing action? 1. Apply a cold compress to the IV site 2. Stop the infusion 3. Check the IV for a blood return 4. Notify the primary healthcare provider

2. Correct: Stop the infusion to stop the vesicant from getting into the tissue and causing more extravasation.

A nurse monitors the heart rates of four children on a pediatric unit. Which client requires additional assessment by the nurse? 1. One year old child who has a heart rate of 150 bpm and is crying 2. Two year old child who has a heart rate of 165 bpm and is being rocked 3. Five year old child who has a heart rate of 100 bpm and is playing quietly 4. Thirteen year old adolescent who has a heart rate of 90 and is watching television

2. Correct: The 2 year old child with a heart rate of 165 requires additional assessment. The normal heart rate for a 2 year old child is 80-120 beats per minute. This child is experiencing tachycardia that warrants further investigation. 1. Incorrect: Although a 1 year old's heart rate ranges from 80-130, the rate can increase to 150 with vigorous crying. If the child was at rest, a rate of 150 would warrant further investigation. 3. Incorrect: The normal heart rate for a 5 year old child is 70-100 beats per minute. 4. Incorrect: Teenagers have heart rates that generally range from 60-90 beats per minute. Children who are athletic may have even lower heart rates, especially at rest.

The nurse is working in the term nursery. Which task should be performed first on a newborn? 1. Prepare the circumcision equipment for a two day old newborn. 2. Assess the five minute APGAR of a newborn. 3. Perform the gestational age assessment on a 30 minute old newborn. 4. Obtain a blood sample for metabolic testing on a 24 hour old newborn.

2. Correct: The APGAR is done to determine whether a newborn needs help breathing or is having heart trouble. It looks at the newborn's breathing effort, HR, muscle tone, reflexes, and skin color and is the most important initial assessment for a newborn. 1. Incorrect: This task is not emergent and can be performed later at an appropriate time. 3. Incorrect: This task is not emergent and can be performed later at anytime during the transition stage of the newborn's nursery care. 4. Incorrect: This task is not emergent and can be performed at anytime between 24 hours and 7 days old. Typically it is done before the newborn is discharged home.

An elderly, confused client with dehydration is admitted to the medical unit. Which intervention would be appropriate for the RN to delegate to the LPN? 1. Encourage client contribution in care decision making. 2. Reinforce the teaching plan with the client's family. 3. Maintain fresh fluids at bedside. 4. Evaluate I & O for adequate fluid replacement.

2. Correct: The LPN can reinforce teaching. 1. Incorrect: The LPN can encourage the client to participate in care decision making. However, the client is confused and is not capable at this time to be involved in their plan of care. 3. Incorrect: This can best be accomplished by the unlicensed assistive personnel (UAP), it can be done by LPN but not best use of resources. 4. Incorrect: Evaluation is a role of the RN, not LPN. LPN can observe and data collect but not assess and evaluate on the NCLEX.

Which nursing intervention should the nurse implement when administering a medication through a nasogastric (NG) tube? 1. Place the client in a high-Fowler's position for medication administration. 2. Flush the tubing between administering medications 3. Turn the client onto their left side after medication administration. 4. Mix the medication directly into the tube feeding

2. Correct: The NG tube should be flushed with appropriate facility approved amount of fluid between medications. The amount of the flushing solution should be added to the intake amount. 1. Incorrect: Semi-Fowler's position is the position of choice for administering tube feedings. This position helps prevent aspiration and promotes digestion. The volume of fluid administered with medication administration is usually much smaller than with tube feedings, so high-Fowler's is not required. 3. Incorrect: The left side position slows gastric emptying, which could lead to aspiration. The right side is the position that best promotes gastric emptying. 4. Incorrect: Do not mix medications in the enteral feeding solution. The tube feeding rate may be prescribed at different rates or the tube feeding can be held for a designated time. The proper administration of the medication could not be determined.

A client diagnosed with bipolar mania was prescribed lithium carbonate 2000 mg daily two months ago. What is the nurse's best action? Exhibit 1. Record the lab results in the chart and recheck in one month. 2. Inform the primary healthcare provider that the lithium level is too high. 3. Notify the primary healthcare provider because the sodium level is too high. 4. Let the primary healthcare provider know that the magnesium level is too low.

2. Correct: The appropriate serum lithium level for acute mania is 1.0 to 1.5 mEq/L. For maintenance it is 0.6 to 1.2 mEq/L. Levels exceeding 1.5 to 2.5 mEq/L begin to produce toxicity. 1. Incorrect: All lab results should be documented; however, the lithium needs to be reported so that the dose can be adjusted. 3. Incorrect: The sodium level is normal: 135-145 mEq/L (135-145 mmol/l). 4. Incorrect: The magnesium level is normal: 1.3 - 2.1 mEq/L (0.65-1.05 mmol/l).

A client diagnosed with bipolar mania was prescribed lithium carbonate 2000 mg daily two months ago. What is the nurse's best action? Exhibit Sodium - 143 mEq/L (143 mmol/L) Potassium - 4.5 mEq/L (4.5 mmol/L) Magnesium - 1.9 mEq/L (0.8 mmol/L) Serum Lithium - 1.8 mEq/L 1. Record the lab results in the chart and recheck in one month. 2. Inform the primary healthcare provider that the lithium level is too high. 3. Notify the primary healthcare provider because the sodium level is too high. 4. Let the primary healthcare provider know that the magnesium level is too low.

A client with a deep partial-thickness burn to the right forearm has returned from surgery with a skin graft to the burned area. Which graft site intervention would the nurse implement within the first 24 hours? 1. Monitor temperature every 12 hours. 2. Position arm to prevent pressure to the graft site. 3. Prepare to change the 1st dressing within 24 hours. 4. Perform passive range of motion exercises to the right arm.

2. Correct: The arm should be situated so there is no compression on the graft site. Applying pressure to the graft may cause the graft to move which may result in damage to the graft site. 1. Incorrect: The temperature should be monitored at least every 8 hours or less. An elevated temperature may indicate an infection under the graft or at another area. If the temperature is elevated, the source of the infection should be addressed. 3. Incorrect: The first dressing change is planned 2 to 5 days after surgery. The dressing is not changed in the first 24 hours to prevent any disturbance to the skin graft. 4. Incorrect: The burn is located on the forearm. Passive range of motion exercises are implemented to improve joint function. The client is not having difficulties with the wrist, elbow, or shoulder joints. The movement to the arm should be done cautiously to prevent any damage to the graft.

A nurse wants to find out a better way to perform oral care on unresponsive clients. What is the best first action for the nurse to take in order to achieve this goal? 1. Try different methods of oral care on unresponsive clients to see what works best. 2. Discuss the issue with the leader of the "best practices" committee. 3. Read all the current literature related to oral care on unresponsive clients. 4. Ask the primary healthcare provider to suggest the best oral care procedure.

2. Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. An experienced person who can research "best practice" regarding the issue is needed. The best practice committee works to improve clinical practice based on current research 1. Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. The best practice committee utilizes current research in their recommendations. 3. Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. The nurse could definitely be part of the committee. But the evidence-based care leaders are trained to help nurses through the proper process of evidence based research. 4. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. The primary healthcare provider may have suggestions but this is not the best first action.

The nurse is caring for a client diagnosed with heat exhaustion. Which finding by the nurse suggests a problem? 1. Temperature 101 degrees F (38.3 degrees C) 2. Hot, dry skin 3. Profuse sweating 4. Headache

2. Correct: The body cools itself by sweating and allowing that sweat to evaporate. This requires enough fluid in the body to make sweat, air circulating across the skin, and low enough air humidity to allow that sweat to evaporate. 1. Incorrect: With heat stroke the body's temperature reaches more than 104 degrees F (40 degrees C). 3. Incorrect: Sweating is seen in heat exhaustion. Sweating stops with heat stroke. 4. Incorrect: Clients with heart exhaustion usually have flu like symptoms with headache, weakness, nausea and/or vomiting.

Four clients arrive at the emergency department. Which client should the nurse triage as the highest priority for care? 1. Adult with severe upper gastric pain. 2. Child with stridor and excessive drooling. 3. Adult with an open fracture to the right radius. 4. Child with fever of 103ºF (39.44 °C) and blood streaked sputum.

2. Correct: The child with stridor and excessive drooling is in respiratory distress from epiglottis. Epiglottis is a potential life-threatening condition and should be seen first. This client is exhibiting signs of respiratory distress. 1. Incorrect: Pain important, but not before airway. This client is not exhibiting any life threatening symptoms. The severe pain should be assessed but not prior to an airway complication. Pain never killed anyone. 3. Incorrect: The open fracture needs to be evaluated as soon as possible due to the potential of compression syndrome and infection. The child however has an airway complication which takes priority over this client. 4. Incorrect: Fever and blood streaked sputum significant, but not before airway. Children with an axillary fever should be examined. The client has blood streaked sputum as well. But the priority client is still the child with the life threatening airway obstruction.

BASIC CARE AND COMFORT The telemetry unit nurse is assessing a newly admitted client following a fall at home. The client has been diagnosed with a left sided cerebrovascular accident (CVA), including aphasia, and a sprained wrist. What is the most effective method the nurse could use to assess the client's pain? 1. Monitor vital signs for elevations. 2. Observe client's non verbal behaviors. 3. Assess sleeping position client chooses. 4. Ask client to point to the pain rating scale.

2. Correct: The client has had a left sided stroke which damages the left hemisphere of the brain. Although the question does not specify whether this is receptive or expressive aphasia, the client may have great difficulty identifying the location or amount of pain. Because of the client's difficulty in communicating at this time, the nurse must rely on non-verbal cues such as facial expressions, vocalizations (moaning, crying) or client attention to the injured portion of the body (massaging or holding the painful area). 1. Incorrect: Despite the fact that vital signs often become elevated in the presence of pain, this is not a reliable indicator, particularly since the vital signs could be impacted by the recent CVA. Additionally, tolerance to pain varies, and changing vitals would not provide the most accurate data about the severity or even the location of the client's pain. 3. Incorrect: This method is the least reliable approach in evaluating client discomfort. Waiting for the client to fall sleep delays effective treatment, assuming the client is able to rest at all while experiencing pain. Also, the nurse is assuming that the client would be able to position self in a manner indicating what area is most painful. The impact of a stroke in the left brain might prevent the client from accurately locating or identifying the exact painful area. 4. Incorrect: The client has had left hemisphere damage to the brain with resulting aphasia. There is no data provided in the question regarding the category of aphasia; therefore, the nurse would be aware the client may not be able to indicate the correct location or severity of pain, even if utilizing the smiling face picture scale. This client also may not be able to understand instructions on the use of the scale, or to self evaluate the actual level of pain.

A nurse draws arterial blood gases (ABGs) for a client diagnosed with Guillain-Barré syndrome while the client is receiving oxygen therapy at 2 liters per nasal cannula. How should the nurse interpret the client's ABG result? ExhibitABGs Blood Gas TestClient's Value pH= 7.32 PaCO2= 51 mm HgHCO3 =28 PaO2 = 91 mm Hg 1. Hypoxemia with respiratory acidosis 2. Normal oxygenation with respiratory acidosis 3. Partially compensated respiratory alkalosis 4. Fully compensated respiratory acidosis

2. Correct: The client has respiratory acidosis with normal oxygenation. The pH of 7.32 indicates a state of acidosis. An elevated PaCO2 of 51 mm Hg indicates that carbon dioxide is being retained and that the source of the acidosis is respiratory in nature. A HCO3 level of 28 is elevated slightly, indicating that the body is beginning to compensate for the acidosis, but not enough to correct the body's pH. The oxygenation level, PaO2, is within the normal reference range.

What preoperative information should the nurse provide to the client who is scheduled for an exercise stress test tomorrow morning? 1. Eat a light breakfast two hours before the test. 2. Dress in loose, comfortable clothing. 3. Take nitroglycerin dose 15 minutes prior to test. 4. Limit drinks with caffeine to 8 ounces (240 mL) within 12 hours.

2. Correct: The client should dress in loose, comfortable clothing the day of the test because the stress test consists of intense exercise. 1. Incorrect: Don't eat or drink anything except water for 4 hours before the test. The fullness from a meal makes it difficult to perform the stress test. 3. Incorrect: Clients are asked to hold beta-blockers, calcium channel blockers, and nitroglycerin medicines prior to a stress test. These medications either increase or slow down the heart rate, which can affect the test. 4. Incorrect: The client should avoid products containing caffeine for 24 hours prior to the stress test. Caffeine increases the heart rate and can affect the results of the test.

The following clients arrive to the emergency department (ED) at the same time. The triage nurse gives priority to which client? 1. A client with a possible fracture of the tibia 45 minutes ago. 2. A client with left hemiparesis and aphasia beginning 1 hour ago. 3. A client smelling of alcohol and reporting of severe abdominal pain. 4. A client involved in a motor vehicle accident (MVA) with a possible fractured pelvis.

2. Correct: The client who is started experiencing hemiparesis and aphasia 1 hour ago is likely having a stroke. The window for treatment with fibrolytics is 3 hours, thus taking priority over the other clients. Time is brain! 1. Incorrect: This client has a possible fracture of the tibia. This is not a large bone, which would be at risk for hemorrhage. Splinting and ice packs could be used until after seeing the client having a stroke.3. Incorrect: With this client, you would worry about pancreatitis. This client needs to be seen soon but not prior to the client having a stroke.4. Incorrect: The MVA client could have bleeding from a fractured pelvis. This client is high on the admit list, but after the client having a stroke.

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

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

The nurse is checking a 2 month old's developmental status. What finding would be of concern to the nurse? 1. Not able to hold head steady. 2. Does not bring hands to mouth. 3. Not able to roll over in either direction. 4. Does not push down with legs when feet are placed on a hard surface.

2. Correct: The nurse should be concerned if a 2 month old does not bring the hands to the mouth. 1. Incorrect: The nurse should be concerned if a 4 month old cannot hold head steady. 3. Incorrect: The nurse should be concerned if a six month old cannot roll over in either direction. 4. Incorrect: Not pushing down with legs when feet are placed on a hard surface would be of concern if unable to do by the age of 4 months.

A client in the third trimester of pregnancy arrives at the emergency room reporting general illness. The client is noted to have a blood glucose level of 390 mg/dL and is diagnosed with gestational diabetes. The primary healthcare provider prescribes 30 units of NPH insulin subcutaneously stat. What is the nurse's priority action? 1. Administer the dose of insulin immediately. 2. Question the type of insulin prescribed. 3. Insert an IV for an insulin infusion. 4. Question the dose of the insulin.

2. Correct: The client's blood glucose is extremely high and needs to be quickly reduced. The prescription given by the primary healthcare provider is for 30 units of NPH insulin, an intermediate acting insulin whose onset is about 1 ½ hours. That is too long to wait to start reducing this elevated glucose. This client should have been prescribed a rapid acting insulin. 1. Incorrect: While this client should indeed receive insulin immediately to start reducing the blood glucose, there is a problem with the prescription that the nurse must address before implementing. 3. Incorrect: Even though the primary healthcare provider has not prescribed an insulin drip, an IV would be an important intervention with a pregnant female whose blood sugar is very high. However, there is another problem that takes priority first. 4. Incorrect: Thirty units of insulin is not an unreasonable dose for a blood glucose level of 390 mg/dL. However, the amount of insulin is not the problem here. There is another issue of greater concern for the nurse.

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

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

A client receiving electro-convulsive therapy (ECT) tells the nurse, "I don't know if I can take another treatment." What is the nurse's best response? 1. "Remember to focus on the fact that you will be fine after you complete all of your treatments." 2. "The therapy must be difficult for you at times. How do you feel about your progress at this point?" 3. "Hang in there. It's for your own good and times will get better." 4. "What makes you say that? You know it will make you well."

2. Correct: The correct answer allows the client to continue discussing feelings and redirects the client to thoughts of progress and effectiveness of the treatment. Acknowledge the client's feelings and then asking an open-ended question are both appropriate a therapeutic communication techniques. 1. Incorrect: This response gives false reassurance which is inappropriate and negates the therapeutic trusting relationship between the nurse and the client. 3.Incorrect: This response is a trite expression or cliché which minimizes the importance of the client's feelings. This is also a close-ended statement that does not allow for any further expression of feelings by the client. 4.Incorrect: This response is demanding an explanation for the client's thoughts, feelings, or events. It makes the client have to be defensive.

A schizophrenic client tells the nurse, "The President of the United States just told me to leave the hospital immediately because a spy is on the way to tap into the secret information in my brain." What is the nurse's best response? 1. The voice you heard is because of your illness and will go away in time. 2. I know you think the President of the United States is talking to you, but I do not see the President. We are the only ones here. 3. I find it hard to believe that you have talked to the President of the United States. This is not the White House! 4. I think the primary healthcare provider needs to increase your medication dose, since you are still hearing voices.

2. Correct: The correct answer is to present reality. When a client has a misperception of the environment, the nurse defines reality or indicates his or her perception of the situation to the client. This delusion is called "thought withdrawal". It is the belief that thoughts have been removed from one's mind by an outside agency. 1.Incorrect: This response gives reassurance. In fact, it is false reassurance because the voices may not completely go away. Remember that the client believes what they think is real. You are not going to help them by blaming it on their illness. 3.Incorrect: This response is disagreeing. Never challenge the client or belittle the client with your response. 4.Incorrect: This response gives an opinion and does not bring reality into the conversation. You need to report the hearing of voices, to the primary healthcare provider, but this is not therapeutic for the client.

An elderly client is admitted to the outpatient unit with anemia and is receiving a blood transfusion. What is the nurse's priority assessment? 1. Monitor for peripheral edema. 2. Assess breath sounds. 3. Keep bedrails up at all times. 4. Monitor hemoglobin every 6 hours.

2. Correct: The elderly client receiving a blood transfusion is at greater risk for fluid volume overload. The nurse should recognize that the very old and the very young are at increased risk for fluid volume overload which could manifest as wet breath sounds. 1. Incorrect: Monitoring for edema is valuable in assessing for fluid volume overload, but the priority is the lung assessment. 3. Incorrect: Safety is important, especially with an elderly anemic client, but monitoring for fluid volume excess is the priority. Physiologic needs prioritize higher than safety needs. 4. Incorrect: Monitoring hemoglobin is important but not necessary every 6 hours.

The nurse manager is performing a chart audit for clients who were restrained. For which client would the side rails in the up position be considered a restraint? 1. The client who requests that the rails be placed in the up position. 2. The client who is confused and wanders about the unit. 3. The client who is ambulatory and places the side rails up without staff assistance. 4. The client who asks the family to place all the rails up before leaving.

2. Correct: The intent of the side rails in the up position is to limit movement; therefore, they are considered a restraint. The nurse cannot restrain or limit a client's movement without a primary healthcare provider prescription.1. Incorrect: The client may request that side rails be raised at any time.3. Incorrect: The ambulatory client can put his/her own side rails up if that increases feelings of security.4. Incorrect: The family may place the rails up at the request of the client. That action would not be considered a restraint.

A community health nurse is presenting a seminar to teen parents on the topic of infant safety. What priority topic presented by the nurse represents the leading cause of injury or death among infants? 1. Monitoring the infant for food allergies. 2. Placing the infant in rear-facing, approved car seat. 3. Never propping bottle to feed when infant is alone. 4. Positioning infant prone when sleeping or napping.

2. Correct: The leading cause of death among infants under the age of one year is motor vehicle accidents. When instructing first time or young parents, it is vital to teach the need to have the infant snuggly restrained in an appropriately sized, approved infant car seat in the back seat and rear-facing. 1. Incorrect: While discussing the signs or symptoms of food allergies is an important topic for new parents, this is not the most vital information the nurse could present to the teen parents. 3. Incorrect: An infant should never be left unattended while feeding, and propping a bottle could lead to aspiration or respiratory distress. This is a dangerous practice that needs to be discussed by the nurse; however, there is another topic that is more urgent. 4. Incorrect: The research studies to date indicate the safest sleeping position for newborns and infants is supine, not prone. Positioning is always a nursing concern, and teaching new parents about the potential for sudden infant death syndrome (SIDS) would be crucial. However, another topic presents more important information.

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 Blood Pressure = 88/42 mmHg Heart Rate=112 bpm Respiratory Rate =32 breaths/min Temperature = 103oF (39.4oC) Oxygen Saturation = 94% 1. Lung assessment finding 2. Blood pressure reading 3. Elevated temperature 4. Urine description and output

2. Correct: The low blood pressure indicates that systemic tissue perfusion is not adequate. The blood pressure needs to be improved rapidly. 1. Incorrect: The oxygen saturation is 94%, so the adventitious lung sounds do not need immediate intervention. 3. Incorrect: The second priority is to treat the infection that is likely the cause of the temperature elevation and hypotension. 4. Incorrect: This is the likely cause of the sepsis, but the priority is to improve the blood pressure. The second priority is to treat the infection.

The nurse is teaching a client regarding herbal therapy. What is the main goal of herbal therapy? 1. To treat a specific disease or symptom by taking prescription medications. 2. To restore balance within the body by supporting the client's self-healing ability. 3. To avoid the use of toxic chemicals within the body. 4. To incorporate Eastern healing practices into Western medicine.

2. Correct: The main goal of herbal therapy is to restore balance within the body by supporting the client's self-healing ability. When teaching clients, the main goal should always be included.1. Incorrect: The main goal of drug therapy is the treatment of a specific disease or symptom. Herbal therapy should not treat diseases. They are for support only. 3. Incorrect: The main goal of herbal therapy is to restore balance and support healing. Many times herbal therapy is considered less toxic but the question is asking for the main goal of herbal therapy.4. Incorrect: Not the main goal of herbal therapy. This is not the main goal of herbal therapy. The main goal is to restore balance within the body by supporting the client's self-healing ability.

The charge nurse is planning the staff assignments for the clients on a neurological unit. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? 1. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. 2. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. 3. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. 4. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96.

2. Correct: The medical nurse can be assigned to this client. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an antiseizure medication. The stem does not indicate any loss of neurological function resulting from the seizure activity. 1. Incorrect: This client is exhibiting early signs of increased intracranial pressure. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. 3. Incorrect: An experienced neurological nurse should be assigned to this client due to the possibility that damage to the hypothalamus which controls body temperature has occurred. An increased temperature will have a direct effect on the brain's metabolism and function. There is a possibility that a hypothermia blanket may be prescribed. 4. Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. An experienced nurse would be assigned to this unstable client due to the possibility of a reoccurring hemorrhagic stroke resulting from the client's hypertension.

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

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

A client with severe depression and a previous history of attempted suicide has been receiving inpatient therapy for months. The nurse notes at breakfast the client is showered, in clean clothes with hair combed. What response by the nurse is most therapeutic at this time? 1. "You look very pretty so you must be feeling better." 2. "I see you are wearing a bright blue sweater today." 3. "Has something changed in your life this morning?" 4. "Today must be a very special occasion for you."

2. Correct: The nurse is focusing on the 'here and now' by acknowledging the client's changed appearance without adding any personal comments. This response avoids common communication blocks which may seem positive but actually represent a judgment by the nurse. The nurse's broad statement shares an observation in an open-ended manner. 1. Incorrect: This remark provides false reassurance to the client by assuming the change in visual appearance must be based on emotional improvement. This is both misleading and non-therapeutic for the client. 3. Incorrect: Questions can be positive communication tools if presented in an open-ended format. Asking about life changes in this manner could be answered yes or no, which indicates a closed-ended question. A sudden improvement in appearance may be one of the warning signs of suicidal ideations, but the nurse's question would not necessarily lead to further information. 4. Incorrect: The nurse is inferring the client needs a special occasion in order to be clean and well-kempt. Such a comment is presumptuous and judgmental.

A client with severe depression and a previous history of attempted suicide has been receiving inpatient therapy for months. The nurse notes at breakfast the client is showered, in clean clothes with hair combed. What response by the nurse is most therapeutic at this time? 1. "You look great today, so you must be feeling better." 2. "I see you are wearing a bright blue sweater today." 3. "Has something changed in your life this 4. "Today must be a very special occasion for you."

2. Correct: The nurse is focusing on the 'here and now' by acknowledging the client's changed appearance without adding any personal comments. This response avoids typical communication blocks such as "you look great", which seems positive but is considered a judgment by the nurse. The nurse's broad statement shares an observation in an open-ended manner. 1. Incorrect: This remark provides false reassurance to the client by assuming change in visual appearance must be based on emotional improvement. This is very misleading and non-therapeutic for the client. 3. Incorrect: Questions can be positive communication tools if presented in an open-ended format. Asking about life changes in this manner could be answered yes or no, which indicates a closed-ended question. A sudden improvement in appearance may be one of the warning signs of suicidal ideations, but the nurse's inquiry would not provide the information needed. 4. Incorrect: The nurse is inferring the client needs a special occasion in order to be clean and well-kempt. Such a comment is presumptuous and judgmental.

A client with severe depression and a previous history of attempted suicide has been receiving inpatient therapy for months. The nurse notes at breakfast the client is showered, in clean clothes with hair combed. What response by the nurse is most therapeutic at this time? 1. "You look great today, so you must be feeling better." 2. "I see you are wearing a bright blue sweater today." 3. "Has something changed in your life this morning?" 4. "Today must be a very special occasion for you."

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 measures 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 the 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 client who is of the Jehovah's Witness faith presents to the emergency department following a traffic accident. The primary healthcare provider orders a type and cross-match for this client. It is determined that the client will benefit from two units of blood. What should the nurse do? 1. Prepare the client for the administration of blood. 2. Explain to the primary healthcare provider that the client's faith prohibits blood transfusions. 3. Explain to the client that the blood transfusions are needed for return to health. 4. Try to convince the client to accept the transfusions.

2. Correct: The nurse must serve as the client's advocate. This client's religion prohibits blood transfusions. 1. Incorrect: This action is in opposition to the client's religious beliefs. 3. Incorrect: The client has made the decision based on religious beliefs. 4. Incorrect: The client has the right to make decisions autonomously and in congruence with religious beliefs.

A client diagnosed with Alzheimer's disease becomes agitated and combative when the nurse approaches to perform a shift assessment. What would be the most appropriate first action for the nurse to take? 1. Obtain assistance to restrain the client. 2. Talk quietly to the client. 3. Administer haloperidol. 4. Leave until the family can calm the client down.

2. Correct: The nurse needs to present a calm manner and speak quietly to the client. This will convey trust and decrease tension and stress in the client. 1. Incorrect: Restraints are a last resort and can make the client more agitated. 3. Incorrect: The use of positive nursing actions can reduce the use of chemical (drug therapy) restraints. 4. Incorrect: Do not pick an answer that transfers the client away from the nurse's care.

Calculator The nurse is caring for a client who has the diagnosis of schizophrenia. The nurse enters the room to administer the morning dose of the prescribed antipsychotic medication. The client is drooling and has extreme muscular rigidity. After assessing the client for adequate respiratory effort, what is the nurse's priority? 1. Elevate HOB and give the medication as prescribed. 2. Hold the medication and call the primary healthcare provider. 3. Report the behaviors to the on-coming shift. 4. Hold the medication, and check the vital signs.

2. Correct: The nurse should hold the medication, and report the symptoms to the primary healthcare provider. The client may be experiencing neuroleptic malignant syndrome. 1. Incorrect: The client is experiencing symptoms of possible neuroleptic malignant syndrome. The nurse should not give another dose of the medication without consultating with the primary healthcare provider. 4. Incorrect: The client may be experiencing neuroleptic malignant syndrome. It is important to notify the primary healthcare provider immediately. 3. Incorrect: The symptoms that the client has are very serious and should be reported to the primary healthcare provider immediately.

The nurse is caring for a client with a fibula fracture. The primary healthcare provider makes rounds and writes prescriptions. What is the nurse's best action? Exhibit MSO4 8 mg IM now Advance diet as tolerated Hgb and Hct in AM 1. Check the prescription prior to sending it to the pharmacy. 2. Clarify the prescription with the primary healthcare provider. 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 unapproved abbreviation that presents safety concerns. MSO4 is the abbreviation for morphine sulfate. MgSO4 is the abbreviation for magnesium sulfate. Notifying the primary healthcare provider to clarify the prescription will prevent a medication error. 1. Incorrect: The prescription should not be sent to the pharmacy until after it is clarified with the primary healthcare provider. The Institute for Safe Medication Practices (ISMP) and The Joint Commission (TJC) recommend using the complete names for morphine and magnesium to eliminate confusion. 3. Incorrect: MSO4 is not an approved abbreviation. Before notifying the pharmacy, make sure you know what the prescription is for. The complete drug name should be written out. 4. Incorrect: You might be making a medication error if you assume you know what you are giving. Always seek clarification when in doubt.

A preeclampsia client is being treated with magnesium sulfate. The nursing assessment shows a respiratory rate of 10 with deep tendon reflexes of 0. What is the nurse's priority action? 1. Place client in Trendelenburg position and apply oxygen. 2. Stop magnesium and prepare to give calcium gluconate. 3. Ask another nurse to verify the deep tendon reflexes. 4. Prepare client for an emergency cesarean section.

2. Correct: The nurse's findings indicate the client's central nervous system has been overly depressed, with a respiratory rate of 10 and absent deep tendon reflexes. The nurse's priority intervention is to stop the magnesium, which is the cause of the problem, and prepare to reverse the situation with calcium gluconate. 1. Incorrect: Placing a client head down, in Trendelenburg position, is used for treating shock. No information is presented that indicates shock. Also, there is no information about oxygen saturation levels that would indicate the need for oxygen. 3. Incorrect: It is not unusual for one nurse to ask another nurse to confirm abnormal findings; however, in this situation, it would be considered a delay of treatment and transfers care of the client to someone else. The nurse's priority action must focus directly on the client. 4. Incorrect: The purpose of administering magnesium sulfate is to prevent seizures and decrease the blood pressure in a preeclampsia client. There is no information in the question that indicates that either the client or the fetus is in distress, requiring an emergency section.

The nurse is caring for a client admitted to rule out myocardial infarction. The nurse has administered sublingual nitroglycerin. What time frame should the nurse expect the earliest onset of effectiveness? 1. 15 seconds 2. 3 minutes 3. 5 minutes 4. 15 minutes

2. Correct: The onset of action for nitroglycerin sublingual is 1 to 3 minutes. So the effectiveness can be assessed 3 minutes after the drug is administered.1. Incorrect: This time frame is too short for the onset of action of nitroglycerin given sublingual.3. Incorrect: Sublingual doses of nitroglycerin can be repeated every 5 minutes. The drug would start to be effective before 5 minutes.4. Incorrect: Fifteen minutes would be to long to wait to assess the effectiveness of nitroglycerin sublingual, in a client suspected of a myocardial infarction.

The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate to the nurse that the client should not be advanced to the next level? 1. Facial flushing 2. Reports shortness of breath 3. Heart rate increase of 10 beats/min. 4. Systolic blood pressure increase of 10 mm Hg

2. Correct: The onset of shortness of breath could be an indicator that the client should not advance to the next level. The client should be instructed to stop and rest if chest pain or shortness of breath occurs. While in a rehabilitation program, it is imperative to give the client very specific guidelines for physical activity so overexertion will not occur. 1. Incorrect: Facial flushing is not life-threatening. The client can advance to the next level. 3. Incorrect: An increase in heart rate of 10 beats a minute is an expected finding with physical activity. This would not prevent the client from advancing to the next level. 4. Incorrect: An increase in systolic BP is an expected finding with physical activity.

A client with diabetes has a history of ignoring the primary healthcare provider's prescription for daily medication management of the illness. The client has been working toward a health promotion goal of increased adherence to prescribed medication regimen. Which outcome suggests that the client has met the health promotion goal? 1. Client has lost five pounds. 2. Client takes medication as prescribed. 3. Client has been hospitalized twice for complications of diabetes. 4. Client walks one mile per day.

2. Correct: The outcome directly addresses medication adherence, the major focus of the health promotion plan. 1. Incorrect: This is a positive outcome; however, the focus is on medication adherence.3. Incorrect: This outcome would indicate possible non-adherence to the medication regimen.4. Incorrect: While this is a positive outcome for anyone's health, the focus is medication adherence.

A client scheduled for a bronchoscopy and possible lung biopsy tells the nurse, "I don't know what a bronchoscopy is." Which nursing intervention should the nurse implement? 1. Explain the bronchoscopy procedure to the client and inform the client of the risks, benefits, and treatment alternatives. 2. Immediately inform the primary healthcare provider that the client requests additional information about the bronchoscopy procedure. 3. Give the client an information pamphlet on the bronchoscopy procedure, and tell the client to sign the consent after reading the pamphlet. 4. Instruct the client to sign the informed consent form. The primary healthcare provider will answer any additional questions right before the procedure is performed

2. Correct: The primary healthcare provider performing the procedure should explain the risks and benefits, recovery time, and reasonable alternatives, as well as the consequences of refusing treatment. 1. Incorrect: The nurse can explain the bronchoscopy procedure and expectations to the client, but the nurse is not performing the bronchoscopy. 3. Incorrect: Providing an information pamphlet to the client may be beneficial, but this should never be substituted for the primary healthcare provider's communication with the client. 4. Incorrect: Questions should be answered by the primary healthcare provider before the client signs the consent form.

A nurse is caring for a multipara client in active labor who received morphine 4 mg IVP for pain. Thirty minutes later, the client had a precipitous delivery. What should the nurse prepare to administer to the newborn? 1. Oxygen 2. Naloxone 3. Glucose 4. Vitamin K

2. Correct: The primary side effect of opioids is respiratory depression, which is more likely to affect the newborn. Naloxone reverses opioid-induced respiratory depression. This newborn will need naloxone to reverse the effects of the narcotic that was given to mom 30 minutes earlier. 1. Incorrect: Prepare to administer the naloxone to reverse the respiratory depression first. Then if oxygen is needed, provide it. 3. Incorrect: Glucose is not indicated in this situation. 4. Incorrect: Vitamin K is given to the newborn after delivery to prevent vitamin K dependent bleeding but it is not the priority here.

A client has delivered a set of premature twins. The neonatal intensive care unit (NICU) notifies the charge nurse on the postpartum floor the death of one infant is expected within the hour. What is the priority action by the charge nurse? 1. Sit quietly with client and allow expression of feelings. 2. Instruct UAP to take mother to the NICU immediately. 3. Request hospital clergy to visit the mother right away. 4. Notify father of the baby about the current situation.

2. Correct: The priority action is to allow the mother to be with the infant and perhaps to hold the infant prior to demise to help in the grieving process. Escorting the mother immediately to the NICU can be accomplished by the UAP while the charge nurse initiates other actions needed by this client. 1. Incorrect: While it is always important to encourage a client to express feelings, at this point the priority need is to facilitate the bonding of mother and infant. The NICU nurses will be with the client and can provide the emotional support needed by the client. 3. Incorrect: The nurse realizes the client is experiencing anticipatory grief and will need a great deal of emotional support. However, the priority need at this time is for the client to be with the dying infant. Additionally, there is no mention of the mother's religious preference, which should be considered prior to involving the hospital clergy. 4. Incorrect: If the father is not already present, the NICU would have already completed this action. However, it is also important to consider any legal issues regarding this family unit and to verify whether the client requests the presence of the father.

What action should the nurse take first for the 5 year old client brought to the urgent care clinic with a blistering sunburn? 1. Administer analgesics. 2. Apply cool water soaks. 3. Check immunization status for tetanus. 4. Educate family to avoid greasy lotions or butter on the burn.

2. Correct: The priority is to stop the burning process. This can be done by applying cool water to the burned area. 1. Incorrect: Determining pain level and administering pain medication would be the second priority. 3. Incorrect: Before the client is sent home, tetanus immunization status would need to be determined. 4. Incorrect: This would be included in discharge teaching.

The nurse is talking with the spouse of an alcoholic client. Which statement by the client's spouse is evidence of codependent behavior? 1. "I frequently tell my spuse that drinking alcohol is ruining our relationship." 2. "I go and pick my spouse up from the bar when not home by midnight." 3. "I do not go out drinking with my spouse, and will not drink at home either." 4. "I have told my spouse that I am willing to attend a counseling session when my spouse wants to stop drinking."

2. Correct: The spouse is attempting to please the alcoholic client. Codependent people are people pleasers, and they make excuses for others. The spouse is enabling the client to continue to drink. The spouse may feel keeping the client from driving while intoxicated will keep people safe. 1. Incorrect: This is a response by a person who is not codependent. This person is not afraid to show feelings and does not deny that there is a problem. 3. Incorrect: By not drinking with the client, the spouse shows that this behavior is not condoned.4. Incorrect: Again, the spouse does not deny a problem and wants to help the client quit rather than making excuses.

Which prescription by the emergency room primary healthcare provider for a client who fell from a ladder should the nurse question? 1. Record intake and output hourly. 2. Prepare the client for lumbar puncture. 3. Perform neurologic checks every 10 minutes. 4. Schedule a brain computed tomography (CT) scan.

2. Correct: The traumatic injury to the brain from the fall may result in increased intracranial pressure. The reduction of pressure in the lumbar spine during a lumbar puncture may result in the potential for herniation of the brain. A lumbar puncture should not be performed. 1. Incorrect: Brain damage can result in metabolic and hormonal dysfunctions. Brain injuries may result in disorders of sodium regulation and endocrine function. Strict intake and output are important to monitor for any fluid changes. 3. Incorrect: The client should be assessed frequently to continue to evaluate their neurological status. The Glasgow Coma Scale (GCS), corneal and gag reflexes, vital signs should be assessed for any variations. 4 Incorrect: The client experienced a blunt trauma to the head after falling off the ladder. A computed tomography of the brain is prescribed to evaluate hemorrhage and trauma to the brain.

A client is admitted to the emergency department with digoxin toxicity. Nursing assessment reveals cool skin, a slow, weak pulse, and a BP of 86/44. What initial action should the nurse take based on the assessment and cardiac rhythm strip? Exhibit brachial cardiac 1. Administer sodium nitroprusside 0.3 mcg/kg/min IV. 2. Set up for transcutaneous pacing. 3. Have client perform vagal maneuver. 4. Draw blood for potassium level.

2. Correct: This client is exhibiting symptomatic bradycardia, specifically 3rd degree heart block. Transcutaneous pacing is the treatment of choice. 1. Incorrect: Sodium nitroprusside is indicated for treatment of severe hypertension. 3. Incorrect: Vagal maneuvers are done for rapid, rather than slowed heart rates. The vagal response causes the heart rate to drop which could throw this client into asystole. 4. Incorrect: The number one concern here is that the client is unstable and needs pacing to increase the heart rate. Determining the potassium level can be done later.

The nurse is assigned a group of clients. For which client would the use of acetaminophen pose a higher risk? 1. 42 year old female who abuses cocaine. 2. 54 year old male who abuses alcohol. 3. 23 year old female who has asthma. 4. 34 year old male with sickle cell anemia.

2. Correct: The use of acetaminophen poses a higher risk for the client who abuses alcohol due to its interaction with the liver. Clients should be educated to be cautious if using acetaminophen due to the hepatotoxicity that can occur with liver dysfunction and failure. 1. Incorrect: Clients who use cocaine do not carry a higher risk of hepatotoxicity with acetaminophen use. 3. Incorrect: Clients who have a history of asthma do not carry a higher risk of hepatotoxicity with acetaminophen use. 4. Incorrect: Pain management should follow the "analgesic ladder" recommended by the World Health Organization for the treatment of cancer-related pain. The choice of analgesic and the dosage should be based on the severity of pain in the individual client. The ladder starts with nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen for mild-to-moderate pain. Because clients with sickle cell disease have varying degrees of hepatic impairment, acetaminophen may be contraindicated. So, the alcoholic client is at greatest risk.

The medical surgical nurse is admitting a client diagnosed with deep vein thrombosis (DVT) of the right leg. The client suddenly begins to report shortness of breath. Which additional early signs/symptoms indicative of a complication would the nurse need to report to the primary healthcare provider immediately? 1. Tachycardia with tachypnea. 2. Restlessness and dizziness. 3. Pain in the lower right leg. 4. A positive Homan's sign.

2. Correct: The worst complication of a DVT is the potential for a pulmonary embolism, resulting when part of the blood clot breaks free and travels to the lungs. This life-threatening complication presents with symptoms of hypoxia, including restlessness, agitation, or dizziness. The client may also develop chest pain, depending on the size of the clot. 1. Incorrect: While these symptoms may require further assessment, the question does not provide any parameters for vital signs. Individually, tachycardia and tachypnea could be attributed to pain, anxiety, or even hospitalization. There is not enough information provided to necessitate an immediate call to the Primary healthcare provider. 3. Incorrect: Pain in the affected extremity is not an unexpected finding with this diagnosis, although the nurse would need to further assess and evaluate the level and location of the pain in relation to the blood clot. This symptom is not surprising and would not require immediately alerting the primary healthcare provider. 4. Incorrect: The Homan's sign was a method formerly used to assess for the presence of a DVT and was performed by dorsiflexing the foot of the affected leg in an effort to elicit pain. However, this technique has proven to be unreliable and is no longer part of the assessment process.

A home care nurse is preparing to perform venipuncture on a client 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 is the client most likely experiencing? 1. Hyperventilation 2. Panic disorder 3. Somatization 4. Conversion disorder

2. Correct: These are all signs of panic disorder. Additional s/s include: sweating, feeling of choking, chest discomfort, abdominal distress, dizziness, lightheadedness, faintness, feelings of unreality or being detached from self, fear of losing control, fear of dying, Paresthesias, chills or hot flashes. 1. Incorrect: A client experiencing hyperventilation would exhibit rapid respiratory rate, and tingling of lips and/or hands. Hyperventilation may occur with a panic attack but the best answer is option 2. 3. Incorrect: Somatization is the process by which psychological needs or stress are expressed in the form of physical symptoms. These reports of signs and symptoms are usually several years in duration. 4. Incorrect: Conversion disorder is a psychological disorder with symptoms or deficits affecting motor or sensory function that mimic a neurological or general medical disease.

The nurse is evaluating a client for compliance to the prescribed diabetic program by checking recent lab results. Based on the lab data, what should the nurse conclude regarding the client? Exhibit Fasting Blood Glucose 90 mg/dL (4.995 mmol/L) Hemoglobin A1C 6.5% 1. At risk for developing hypoglycemia. 2. Demonstrating good control of blood glucose. 3. At risk for developing Somogyi phenomenon. 4. Demonstrating signs of insulin resistance.

2. Correct: These are normal lab values indicating good control of blood glucose. 1. Incorrect: The client is not at risk for developing hypoglycemia. Fasting glucose is currently normal. 3. Incorrect: Somogyi pnenomenon occurs when there is a rebound hyperglycemia. The client is given too much insulin and their blood glucose level drops. The body attempts to compensate and releases hormones (epinephrine) that causes glycogenolysis. This leads to a rebound increase in the blood glucose levels. The insulin dose for this client should be decreased. Dawn's phenomena occurs when there is an increase in the blood glucose in the early morning hours due to release of growth hormone and cortisol. The client's insulin dose should be increased.4. Incorrect: There are no signs of insulin resistance demonstrated from these normal values.

Which condition requires the nurse to discontinue an intravenous infusion of oxytocin to a laboring client? 1. Onset of nausea and vomiting 2. Contraction every 90 seconds lasting 70 seconds 3. Maternal blood pressure 140/90 4. Early decelerations in the fetal heart rate

2. Correct: These contractions are too long and too often. 1. Incorrect: Many laboring clients become nauseated and vomit during labor. Also, common side effects of oxytocin include nausea and vomiting. This would not require the discontinuation of oxytocin. 3. Incorrect: Maternal hypotension requires discontinuation of oxytocin. This BP is not worrisome. 4. Incorrect: Early decels are generally not harmful and happen as baby is descending through the birth canal during the later stages of labor. These are not related to the oxytocin infusion.

The nurse is caring for a client taking enoxaparin. Which group of symptoms should be reported to the primary healthcare provider? 1. AST of 12 U/L and ALT 20 U/L 2. Hematocrit of 46% decreased to 35% and blood pressure decreases from 122/78 to 108/54 3. Ecchymosis around the abdominal subcutaneous injection site and platelet count of 200,000. 4. Hemoglobin of 14.5 g/dL (2.3 mmol/L) increased to 16 g/dL (2.5 mmol/L) and increased erythemia of oral mucus membranes.

2. Correct: These values indicate a drop in hematocrit and drop in blood pressure. Both of these could represent bleeding. These would be important to report to the primary healthcare provider. 1. Incorrect: The nurse would need to watch and report any signs of liver complications due to the use of enoxaparin. The AST and ALT are two liver enzyme values that would increase with liver complications. These two values represent normal AST (8-40 U/L) and ALT (10-30 U/L) values. 3. Incorrect: Bruising (ecchymosis) at the injection site is a frequent occurrence with administration of enoxaparin. This platelet count is within the normal range. 4. Incorrect: The Hgb and color of oral mucus membranes indicate an increase in Hgb. This would not indicate bleeding.

What turning method should the nurse use to turn a client who has a spinal injury? 1. Lateral transfer 2. Slide sheet procedure 3. Logrolling 4. Mechanical lift transfer

3. Correct: Logrolling is used for the client who has a spinal injury. This technique keeps the client's body in straight alignment at all times. 1. Incorrect: Lateral transfer uses a spinal board to move the client from one bed to another. 2. Incorrect: Slide sheets enable clients to be slid up a surface or over to their side, that is, up the bed or rolled over in the bed. The difference is that all of the body may not be kept in perfect alignment as with logrolling. 4. Incorrect: A mechanical lift is used to move client from a bed to chair or chair to bed.

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 injury the UAPs back. 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.

The client with bi-polar disorder is parading around the common areas of the psychiatric unit in a sexually suggestive manner. The client then sits on the lap of one of the young male clients. What should the nurse do? 1. Tell the client that the behavior is inappropriate. 2. Accompany the client to the TV room on the unit. 3. Allow the male client to handle the situation. 4. Continue with the unit routine.

2. Correct: This behavior must be interrupted, as the rights of other clients are being jeopardized. The other clients are being exploited by the manic client. Stop the behavior by going with them to another area. Many people with bipolar disorder don't recognize the extreme changes in their moods and the effects these changes have on their lives and others. You must stop them and remove them from the situation. 1. Incorrect: This client is not able to make accurate decisions in this current state, so telling the client that this behavior is inappropriate is not likely to stop it. Hypersexual behavior is often a warning sign of a manic episode. Evaluate the clients medications because the mood stabilizing medications like lithium or valprate (Depakote®) should prevent these symptoms. 3. Incorrect: The male client has a right to a safe care environment. He should not be exploited by staff or clients. Asking a fellow client to handle an appropriate situation will never be right on the NCLEX. 4. Incorrect: The behavior must be interrupted in order to maintain the rights of other clients and to maintain the dignity of the client who is in a manic state. Ignoring the symptoms and the disruption will not fix the problem. As a nurse you always want to fix the problem.

The nurse is teaching a group of adults how to check skin lesions for signs of melanoma. What should the nurse include? Select all that apply 1. Symmetrical shape 2. Multiple colors with a lesion 3. Odd looking lesion 4. Poorly defined border of lesion 5. Diameter of lesion 6 mm

2., 3., 4., & 5. Correct: Multiple colors, varying colors from one area to another or uneven distribution of color could mean cancer. Some moles don't exactly fit the criteria for ABCDs of melanoma, but they can be cancerous nonetheless. If you see a mole that looks odd, or you see sudden changes in size, color or shape, get it checked. An irregular scalloped or poorly defined border of the growth could be a sign of melanoma. The diameter of a melanoma is usually bigger than 1/4 inch or 6 mm when diagnosed, but they can be smaller. 1. Incorrect: An asymmetrical shape can be an indicator of melanoma.

A 16 year old female student is escorted to the school nurse after fainting in gym class. The student tells the nurse, "I just got weak from running." Upon examination, the nurse notes poor skin turgor, dry mucous membranes, and erosion of tooth enamel from her front teeth. Height is 5'4" (162.56 cm) and weight is 110 lbs (50 kg). The student reports muscle pain in the legs. Based on this data, what should the nurse suspect? 1. Anorexia Nervosa 2. Bulimia Nervosa 3. Obesity 4. Physical violence

2. Correct: This client is exhibiting the signs of bulimia nervosa. Additionally, the client will binge on excess calories, and then purge through vomiting and the use of laxatives, diuretics, and enemas. Weight fluctuates: usually within normal limits or slightly under or slightly overweight. Tears in the esophageal and gastric mucosa can occur. Due to vomiting, tooth enamel can erode. 1. Incorrect: Gross distortion of body image, refusal to eat, grossly underweight and malnourished. Characteristics of anorexia nervosa. The client is at the low end of the weight range for her height, but not underweight. 3. Incorrect: Obesity occurs from eating more than the body needs. Weight is more than 20% over expected body weight. They do not purge. This client's BMI of 18.9 is normal, not obese. 4. Incorrect: There is no indication that this is physical violence. The client may report headaches, dizziness and accidents such as falls. However, this client does not have any signs and symptoms of battering such as bruises, scars or burns.

The nurse provides instructions on the proper use of crutches to a client. Which comment by the client indicates a need for additional instructions? 1. "I move the crutches 6 to 12 inches ahead prior to moving foot forward." 2. "To descend stairs I will move crutches and my unaffected leg first, followed by the affected leg." 3. "When rising from a chair, I will place crutches on my affected side, lean forward, and push off from the chair with one hand." 4. "To climb stairs I will advance my unaffected leg past crutches, then place weight on unaffected leg, and advance affected leg and the crutches to the step."

2. Correct: This client will need additional instruction. The client should place their crutches on the step below first. Then move the affected leg down to the next step. The client should follow with the unaffected leg. 1. Incorrect: This is a correct statement by the client. The crutches are to be moved 6 to 12 inches forward and then the client steps past the crutches. 3. Incorrect: The client is describing the correct steps in rising from a chair. Both crutches are placed in one hand. The client should then push off from the chair with one hand. 4. Incorrect: The client should advance their unaffected leg up to the next step and place their weight on unaffected leg. Then the affected leg and the crutches should be advanced to the next step.

An 18 month old is admitted to the unit with a diagnosis of pertussis. The mother asks the nurse, "How did my child get this disease? I didn't think anyone got that anymore." What is the appropriate response by the nurse? 1. "Pertussis is a common childhood disease since there is no vaccine." 2. "Since not all children are immunized against pertussis, the disease has reemerged." 3. "Your baby got this disease because you didn't have your child immunized." 4. "Since your child is already sick, let's just focus on getting well."

2. Correct: This is a correct statement. Therapeutic communication means providing information that will help clients make better choices.Not all parents have had their children immunized against pertussis, so this disease is being seen in clients again. DPaT should be given at 2, 4 and 6 months of age. A booster is given at 15-18 months old and then at 4-6 years old.1. Incorrect: This is not true. There is a vaccine. DPaT should be given at 2, 4, and 6 months of age. A booster is given at 15-18 months old and then at 4-6 years old. 3. Incorrect: Don't be confrontational. This puts the mother on the defensive. This is not therapeutic communication. Giving one's own opinion, evaluating, moralizing or implying one's values by using words such as "nice" "bad" "right" "wrong" "should" and "ought". "You shouldn't do that. It is wrong". Everyone who does not get immunized gets the disease. 4. Incorrect: Do not change the subject. This does not address the mother's concern. Changing the subject, or introducing new topic inappropriately, can create anxiety. The nurse needs to address the mother's question of how the child contracted the disease.

An emergency department nurse has just received report on assigned clients. Which client should the nurse assess first? 1. Client reporting back pain of 8 on a scale of 0/10 after falling down from a patch of ice. 2. Client reporting a stiff neck and has a fever of 103 ° F (39.4 ° C). 3. Client vomiting for 3 hours after eating at a restaurant. 4. Client with a history of migraines reporting a severe headache.

2. Correct: This is the most critical client of the ones assigned to this nurse. These s/s could indicate encephalitis or meningitis. 1. Incorrect: The most likely cause of this client's pain is a strain or sprain which is not life-threatening. 3. Incorrect: This client is likely to have food poisoning but is not as serious as the client with possible encephalitis or meningitis. 4. Incorrect: Clients with a history of migraines would not be a priority over the client with encephalitis or meningitis.

A client who has been prescribed zolpidem for insomnia has received medication education. Which statement by the client indicates to the nurse that education was successful? 1. "There is a high potential for tolerance with this medication." 2. "I may do things in my sleep that I will not remember the next day." 3. "Daytime drowsiness is rare when taking this medication." 4. "The most common side effects of this medication are confusion and a bitter aftertaste."

2. Correct: This is a true statement. The client may sleep drive, make phone calls, prepare food while asleep and have no memory of the activity. 1. Incorrect: This is a schedule 4 substance. There is a low potential for tolerance, dependence, or abuse with this medication. 3. Incorrect: Daytime drowsiness and dizziness are common side effects. 4. Incorrect: Daytime drowsiness and dizziness are the most common side effects. Bitter aftertaste does not occur with this medication.

The nurse overhears this client responding on the phone when their boss asks them to work an extra night shift. Which statement by the client demonstrates assertive communication? 1. "I know you are joking! I have already worked an extra night shift." 2. "I do not want to work an extra night shift. I have already worked an extra shift this week." 3. "Umm, well, okay. I guess I will work an extra night shift." 4. "Okay, I'll work an extra night shift." Then they say to another client. "The nerve of my boss to ask me to work another extra shift."

2. Correct: This is an example of assertive communication, the best response. Assertiveness is asking for what one wants or acting to get what one wants in a way that respects the rights and feelings of other people. 1. Incorrect: This response is aggressive behavior. This response is delivered in a forceful manner. 3. Incorrect: This response is nonassertive. This statement is giving into the boss, even though the client really doesn't want to work. Keywords are "umm, well and okay" 4. Incorrect: This response is Passive-Aggressive. It is the indirect expression of anger.

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

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

A client has received discharge education post extracapsular cataract surgery. Which statement made by the client indicates to the nurse that further teaching is needed? 1. "A protective eye patch will be needed for 24 hours." 2. "I will notify my primary heathcare provider for any amount of discharge, redness or scratchy feeling because these symptoms are abnormal." 3. "I will clean the surgical eye with a clean tissue, wiping once from the inner aspect of the closed eye to the outer eye." 4. "When sleeping, I will avoid lying on the same side of my affected eye."

2. Correct: This is an incorrect statement by the client. Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days." Clients are instructed to report any pain that is unrelieved, redness around the eye, nausea or vomiting to the primary healthcare provider. 1. Incorrect: This is a true statement and does not require intervention. Following surgery, the eye is covered with a patch and a metal or plastic shield for protection from light and trauma. 3. Incorrect: This is the correct way to clean the surgical eye. Cleaning from the inner to outer canthus avoids entrance of microorganisms into the lacrimal duct. 4. Incorrect: This is a correct action. Increased intraocular pressure needs to be avoided. Clients are instructed to avoid sleeping on the operative side.

A nurse has provided postpartum discharge instructions to a client who had a cesarean section. What statement by the client would indicate to the nurse that further teaching is necessary? 1. "I will relax and contract my pelvic floor muscles 10 times, eight times a day." 2. "Driving is permitted in one week if I am pain free." 3. "Lifting anything heavier than my baby is not advised." 4. "I will not cross my legs while sitting."

2. Correct: This is an incorrect statement. C-sections require a much longer recovery. The client will not have the abdominal muscles to press down on the brake pedal in an emergency. Therefore, new moms who had C-sections should wait until after the three week postpartum appointment to drive. 1. Incorrect: This would be a correct statement. The client should do Kegel exercises to prevent incontinence and strengthen the pelvic muscles. 3. Incorrect: This is a correct statement. Lifting heavy objects can cause bleeding. New moms are not able to lift anything more than the baby's weight. 4 Incorrect: This is a correct statement. Avoid sitting for prolonged periods of time with legs crossed to prevent thrombophlebitis.

The nurse has been educating a client diagnosed with general anxiety disorder (GAD). Which statement by the client indicates the need for further education? 1. "I will avoid caffeine from now on." 2. "When I feel anxious I will increase my breathing to get more oxygen to my brain." 3. "I will go for a brisk walk when I begin to feel anxious." 4. "I will keep a diary of anxiety attacks to determine what triggers them."

2. Correct: This is an incorrect statement. The client needs to slow breathing down with deep-breathing exercises. An increase in respirations can lead to respiratory alkalosis. 1. Incorrect: Caffeine can increase panic and anxiety in clients whom suffer with GAD. Caffeine is a stimulant and can produce symptoms like those of anxiety. This statement means that teaching has been effective. 3. Incorrect: Physical activities discharge excess energy in a healthful manner. Exercise produces endorphins, which promotes a sense of well-being. This statement means test teaching has been effective. 4. Incorrect: Recognition of precipitating factors is the first step in teaching a person to interrupt escalation of anxiety. Also, identifying stressors promotes future change. This statement means that teaching has been effective.

After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention? 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 both nares and 2 x 2 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 chest pain 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 chest pain.

The nurse enters a client's room to administer morning medications and notes that the client is praying aloud. What would be the nurse's best action? 1. Interrupt the client to administer the medications. 2. Wait quietly until the prayer is finished. 3. Join the client for the prayer. 4. Ask the client if you can provide a directed prayer.

2. Correct: This is the best action by the nurse as this is a private spiritual moment for the client. Prayer is a self-care strategy that provides comfort, increases hope, and promotes healing and psychological well-being. The nurse could either leave and return later or wait quietly for the client to finish. 1. Incorrect: Administering the medications can wait until the client finishes the prayer. 3. Incorrect: Do not assume that the client wants others to join in the prayer. This is a private moment for the client. 4. Incorrect: Do not assume that the client wants others to join in the prayer. Don't interrupt the client while praying.

A home health nurse is caring for a Mexican-American client who has been discharged from the hospital post myocardial infarction. While the nurse is at the house, a curandero is also at the home at the request of family members. What is the best action of the nurse? 1. Leave, and return once the curandero has left. 2. Discuss the plan of care with the client, family, and curandero. 3. Ask the curandero to leave so that the client can be assessed. 4. Explain to the family 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 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.

After discontinuing a peripherally inserted central line (PICC), it is most important for the nurse to record which information? 1. How the client tolerated the procedure. 2. The length and intactness of the central line catheter. 3. The amount of fluid left in the IV solution container. 4. That a dressing was applied to the insertion site.

2. Correct: This is the most important information that needs to be documented. This information would be important in determining if a potential safety issue/complication could occur as a result of the PICC line being removed or a portion of the line breaking off before removal. 1. Incorrect: This is not the most important information that needs to be documented. There are no client safety issues with charting the client's tolerance of the procedure. 3. Incorrect: This would be charted so the intake and output could be calculated. This is not the most important data that needs to be documented related to the removal of the PICC line. 4. Incorrect: This would need to be documented because a dressing is applied to the insertion site after removal. However, this is not the most important data that would need to be documented after this procedure.

A client who delivered a 9-pound 12-ounce (4.17 kg) baby 1 hour ago, has saturated 2 peri-pads in 15 minutes. Which nursing action should take priority? 1. Notify the primary healthcare provider. 2. Massage the fundus. 3. Obtain a blood pressure. 4. Begin an infusion of oxytocin.

2. Correct: This is the only answer that will STOP BLEEDING! The fundus is boggy! 1. Incorrect: Doesn't stop the bleeding. Since it says priority you have to say, if I could only do ONE thing. If you choose this answer you have not STOPPED THE BLEEDING. 3. Incorrect: This is good, but how will it stop the bleeding? 4. Incorrect: The most common reason for saturating 2 peri-pads is a boggy fundus. The priority is to massage the fundus and stop the bleeding! If post partum hemorrhage continues, an infusion of oxytocin may be initiated.

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

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

Several clients have reported to the charge nurse that they are not receiving pain relief when a certain RN administers their pain medication. The charge nurse has noticed that the RN has been looking unkempt in appearance and seems to be in a daze much of the time. What is the most appropriate action for the charge nurse to take? 1. Lessen the nurse's client assignment to see if things improve. 2. Discuss the concerns directly with the nurse. 3. Give the nurse a 6 month period to be observed. 4. Avoid confronting the nurse so that the client's care will not be jeopardized.

2. Correct: This may be a situation in which the charge nurse must address the issue of an impaired nurse. All nurses should be aware of the signs and symptoms of substance abuse. The best way for the charge nurse to deal with these suspicions initially is to directly discuss the concerns with the nurse. Intervention may be needed immediately to protect the safety of the clients. If deemed appropriate, the charge nurse may encourage the nurse to seek help independently. 1. Incorrect: This action will not do anything to help an impaired nurse. In fact, this could potentially put the few clients being cared for by this nurse at risk of harmful actions, and it could create an unsafe workload on the other nurses who would be picking up additional clients that this nurse was no longer caring for. 3. Incorrect: Oh my! Would we really consider allowing this impaired nurse to continue to care for clients for 6 months without intervention while we "observe" the actions of the nurse? This would not be a very good idea. Keep in mind that impaired nurses can lose their usual ability to provide safe, competent client care. Although nurses may be working under the influence of a substance, they retain accountability for their actions and cannot use impairment as a legal defense if harm occurs to a client. So we should certainly not allow the nurse to continue working without investigation and/or intervention. 4. Incorrect: I know that not jeopardizing client care sounded nice, but avoiding confrontation with the nurse will not help to fix this problem. Although it can be very difficult to suspect a co-worker of being impaired or abusing substances, especially when fear of retaliation may be present, nurses should know that they have a responsibility to report any suspicion of such activity to nursing management.

A client who must use crutches, is being taught by the nurse how to perform a three-point gait. What information should the nurse provide? 1. Move right crutch forward, then left foot. Next move left crutch forward, then right foot. 2. Move both crutches forward without bearing weight on the affected leg, then move the unaffected leg forward. 3. Move left crutch and right foot forward together, then move the right crutch and left foot forward together. 4. Move both crutches ahead together, then lift body weight by the arms and swing both legs to the crutches.

2. Correct: This method is correct for the three-point gait. Client has to bear weight on the unaffected foot and both crutches. The affected leg does not touch the ground. 1. Incorrect: This is the four-point alternate gait. This type of gait is used commonly when =both legs are weakened. 3. Incorrect: This is the two-point alternate gait. Two point requires at least partial weight bearing on each foot. 4. Incorrect: This is the swing-to gait. This gait is indicated for individuals with limited use of lower extremities and trunk instability.

A new nurse is anxious about being assigned to a a client with violent episodes. Which statement by the charge nurse would address the new nurse's anxiety? 1. "What you really mean is that you fear a client with violent episodes." 2. "Though it is difficult, the staff needs to remain relaxed, but conscious of the client's violent episodes." 3. "I will instruct the staff to monitor the client's behavior for any signs of violent behavior." 4. "You attended an in-service during orientation on dealing with the client with violent behavior."

2. Correct: This response focuses both on the client's and the staff's response to the client. This is an example of the therapeutic communication of restating. The safety of the client, other clients, and the health care team is also a priority. The aggression by the client may be physical, verbal or both. The nurse should remain calm and firm. This approach will assist the client to return to their pre-crisis state. 1.Incorrect: The charge nurse is concluding the meaning of what the new nurse is saying. This is an example of the nontherapeutic communication of interpreting. The charge nurse stated that the new nurse is scared. This response may block further discussions with the new nurse about nursing care for potentially violent clients. The client, other clients, and the healthcare team's safety can also be placed at risk. 3. Incorrect: The charge nurse is changing the subject by stating that the staff members will be directed to monitor the client for violent behavior. This nontherapeutic communication of introducing an unrelated topic allows the charge nurse to control the direction of the conversation. The new nurse is expressing her concerns about caring for a client with violent episodes. The charge nurse is not focusing on the concerns of the new nurse. 4. Incorrect: The charge nurse responds by stating the new nurse attended an in-service during orientation about dealing with a client with violent behavior. The charge nurse does not identify that the new nurse may be uncomfortable dealing with clients with violent behavior. This is the nontherapeutic communication technique of rejecting. The new nurse may stop sharing with the charge nurse because of concern over further rejection.

A teenage client with asthma reports becoming very anxious and fearful each time an asthma attack occurs. What would be the nurse's best response to the client? 1. "I understand that you feel anxious. But you must stop this behavior." 2. "The feelings that you described can occur in individuals with asthma. You may find that learning relaxation exercises may help." 3. "I am concerned that feeling anxious during an asthma attack means you need more education about asthma." 4. "Everyone with asthma experiences tough times with their symptoms. You are learning to manage your asthma."

2. Correct: This statement acknowledges the client's feelings and then provides a suggested strategy that has been found to be useful in clients with anxiety and fear associated with asthma. 1. Incorrect: The nurse states understanding but then tells the client to stop the behavior without providing any helpful suggestions. 3. Incorrect: This response is disagreeing with the client's feelings and psychosocial response by stating that more education about asthma will prevent anxiety during an asthma attack. 4. Incorrect: This response dismisses and belittles the client's feelings and psychosocial response associated with asthma. By stating "everyone with asthma", the nurse is making a stereotypical response. This does not promote expressions of feelings by the client.

The driver of a motor vehicle was driving while intoxicated with a friend in the passenger seat. Both clients are admitted to the Intensive Care Unit. The nurse is caring for the driver of the vehicle who states, "I'm so scared. What if the car accident is my fault and my friend dies?" What is the most appropriate response from the nurse? 1. "I wouldn't worry about that; everything will be all right." 2. "You are worried that you may be responsible for your friend's condition?" 3. "How come you were drinking and driving?" 4. "Let's not talk about that right now."

2. Correct: This type of therapeutic communication is called restating. By repeating the client's statement, the nurse expresses an understanding of what the client said. Restating also gives the client the chance to clarify or continue his thoughts. 1. Incorrect: This statement gives the client false reassurance. It devalues the client's feelings and may discourage the client from expressing further feelings. 3. Incorrect: This statement is probing and causes the client to feel defensive. 4. Incorrect: This statement rejects the client's ideas and feelings; this may lead to decreased interaction with the nurse due to fear of future rejection.

Which statement made by a 67 year old client who recently retired indicates to the nurse that client has developed ego integrity? 1. "I want to make my mark on the world." 2. "I am satisfied with my life so far." 3. "I wish I could go back and fix the mistakes I have made." 4. "Life is too short. I have more living to do."

2. Correct: Those who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase means looking back with few regrets and a general feeling of satisfaction. 1. Incorrect: Generativity versus stagnation is the seventh of eight stages of Erik Erikson's theory of psychosocial development. This stage takes place during middle adulthood (40 to 65). Generativity refers to "making your mark" on the world through creating or nurturing things that will outlast an individual. 3. Incorrect: Feeling regret over past decisions or mistakes can lead to despair. To reach ego integrity, the client must accept mistakes made and look at accomplishments achieved in life. 4. Incorrect: Success in this stage will lead to the virtue of wisdom. Wisdom enables a person to look back on their life with a sense of closure and completeness and accept death without fear.

A client with asthma uses a corticoid inhaler. What teaching should the nurse provide to decrease the risk of an oral fungal infection? 1. Lessen the exposure of the oral mucosa to the ICS by exhaling rapidly. 2. Rinse the mouth completely and brush teeth following the use of the ICS. 3. Use alcohol based mouth rinses with ICS. 4. Drink water prior to using the ICS.

2. Correct: Thrush, is an oral fungal infection, which is one of the most common side effects of ICS. Up to 1/3 of all clients on ICS develop this infection. Rinsing and brushing helps to remove the medication residual from the oral mucosa and upper pharyngeal area. 1. Incorrect: This is not appropriate because exhaling rapidly would result in a loss of the medication and reduce the effectiveness. 3. Incorrect: This is not accurate because alcohol based mouth rinses have not been shown to reduce the risk of thrush. Alcohol based mouth wash can be drying to the oral mucosa. 4. Incorrect: Drinking water, prior to using the ICS is not an effective means of preventing thrush.

An unresponsive client begins to vomit. What intervention by the nurse would have the highest priority? 1. Suction the client's mouth. 2. Turn the client onto their side. 3. Apply oxygen per face mask. 4. Insert an oropharyngeal airway.

2. Correct: To prevent aspiration the first thing to do is turn the client onto their side. Leaving the client in the supine position will allow vomitus to get into the lungs when the client breathes. 1. Incorrect: Suctioning can be done after you turn the client onto the side. They could aspirate while you get the suction equipment put together to suction. 3. Incorrect: Applying oxygen will not prevent aspiration. Turn onto side. 4. Incorrect: The first thing to do is to turn to the side to protect the airway. Don't waste time. The oropharyngeal airway will not prevent aspiration. It is used to maintain an open airway

A new mother asks the clinic nurse why her baby should receive recommended vaccinations. What is the best response by the nurse concerning vaccinations? 1. "Vaccinations give antibodies to your baby to protect them from disease." 2. "Vaccinations will help your baby produce antibodies against disease causing organisms." 3. "Federal law requires that your baby receive recommended vaccinations." 4. "There is no reason not to vaccinate your baby since only mild, uncomfortable reactions can occur."

2. Correct: Vaccines are suspensions of antigen preparations intended to produce a human immune response to protect the person from future encounters with the organism. 1. Incorrect: Vaccines will cause the body to produce antibodies. Vaccines give possible immunity to the baby. 3. Incorrect: Vaccines are required for admittance into public school. If a child is homeschooled, the parent may not have the child vaccinated. 4. Incorrect: It is true that the vaccination may cause a mild reaction, but this is not the best response. This answer does not address the mother's question.

A client is curious about visible appearance changes related to menopause. What menopausal changes, in general, would the nurse explain to the client? 1. Bone loss and fractures. 2. Loss of muscle mass. 3. Improved skin turgor and elasticity. 4. A reduction in waist size.

2. Correct: Visible changes associated with menopause include loss of muscle mass, increased fat tissue leading to thicker waist, dryness of the skin and vagina, hot flashes, sleep abnormalities, and mood changes. 1. Incorrect: Bone loss is dependent on bone mass, weight-bearing exercise, and nutrition. Some bone loss may occur, but may not lead to fractures. 3. Incorrect: A decrease in turgor and elasticity may occur as we grow older. 4. Incorrect: There is increased fat tissue with an increase in waist size.

A client with a history of adrenal insufficiency is placed on fludrocortisone. Which value is most important for the nurse to monitor? 1. Magnesium 2. Weight 3. Pain 4. Glucose

2. Correct: Weight is monitored daily to assess for sudden increases which would indicate fluid retention. Fludrocortisone is a man made glococorticoid and is used to treat low gloucocorticoid levels caused by diseases of the adrenal gland. Glucocorticoids are important in maintaining salt and water balance in the body and normalizing blood pressure. 1. Incorrect: No, monitor for lowered serum potassium instead of magnesium because fludrocortisone causes the body to retain sodium, and excrete calcium and potassium. 3. Incorrect: Adrenal insufficiency and steroid therapy are not precursors of pain. 4. Incorrect: Glucose may increase as a result of steroid therapy as glucocorticoids inhibit insulin. But, weight is the critical value to monitor for dosing, as treatment may be discontinued with a sudden weight increase.

The nurse is taking care of a client that has been on TPN for 5 days. Upon entering the room, the nurse observes that the TPN has been turned off. What is the nurse's priority action? 1. Flush the IV line 2. Obtain blood glucose level 3. Check written prescription 4. Restart TPN infusion

2. Correct: What have I been administering to the client? A high calorie, high glucose content solution, and then I stop it abruptly. You have the pancreas pumping out insulin to cover the glucose and then no glucose. This client could go into hypoglycemia, right? So check the blood glucose level takes priority. We are worried about hypoglycemia. 1. Incorrect: This is always good nursing but will not fix this problem. 3. Incorrect: Again, good nursing, but not fixing the problem. 4. Incorrect: The TPN is turned off, and I do need to turn it back on after I check my client for hypoglycemia.

What statement by the nurse would be most appropriate for a client who is exhibiting signs of escalating anger? 1. "You seem angry, but I can't understand why you would be upset." 2. "I notice that you are angry. Please share what you are thinking." 3. "You need to calm down. You will make the other clients upset." 4. "I am not going to be able to talk to you if you keep getting angry like this."

2. Correct: When a client appears to be angry or is demonstrating signs of escalating anger, the nurse should recognize this and verbalize to the client what is seen or heard so that the client realizes that their feelings are being considered. This statement first shows reflection of the situation and recognizes that the client is angry. By doing this, it also allows the client to feel understood. The second part of the nurse's response expresses a desire to better understand the client and express empathy. This should be kept brief by simply asking the client to share the thoughts and feelings that are being experienced during this period of anger escalation. By gaining an understanding of the client's thoughts and feelings, you will be better equipped to intervene appropriately. 1. Incorrect: You have a client whose anger is escalating. Do you want to further agitate them by devaluing them and stating that you can't understand why they would be angry? Of course not! Commenting that the client seems angry would be acceptable, but belittling their emotional response would not be therapeutic. 3. Incorrect: Although the client's anger could make other clients upset, demanding that the client calms down would not be a good approach to take with this client. The client could possibly become more upset and belligerent, which would only complicate the situation more. The nurse should first try to understand what is going on with the client. Deescalating techniques would then be used to help calm the client. 4. Incorrect: Threatening comments, such as this one, by the nurse would probably inflame the situation. The nurse should attempt to understand the client's feelings and demonstrate empathy.

The nurse is caring for a client on the post surgical unit. What should the nurse teach the client about short term treatment of post op pain? 1. There are no concerns about addiction from pain medications following surgery. 2. Pain control following surgery rarely results in addiction. 3. The opioid medications typically result in addiction. 4. The primary healthcare provider will not prescribe an addictive medication.

2. Correct: When a person is in acute pain following surgery, the risk of addiction to pain medication is rare. The key is to provide the medication over a short period of time to get the client past the initial pain of surgery. Remember the client will be ambulating early. Ambulation and nonpharmaceutical comfort measures should also be provided by the nurse to decrease the need for narcotics as client recovery continues.1. Incorrect: There are slight concerns about addiction with administration of opioids; however, it is usually not a concern for the majority of post op clients with short term use in the hospital. The nurse should use alternative methods for providing relief as well. Guided imagery, massage, gradual ambulation, are just a few examples. 3. Incorrect: Use of opioids may result in addiction; however, research shows that only a small percentage of the population is prone to addiction. The goal of postoperative pain management is to relieve pain while keeping side effects to a minimum. This is often best accomplished with a multimodal approach. 4. Incorrect: Opioids are potentially addictive; however, they serve a very useful purpose in the treatment of short-term post-op pain.

A teenager leaves class in the middle of an exam to go to the school nurse's office. The student reports difficulty sleeping for several days, increasing nervousness, irritability, and palpitations. The nurse notes flushing of the skin, and an irregular heartbeat. What would be the best question for the nurse to ask this client? 1. "Do you feel this way because you are afraid that you are failing the exam?" 2. "Have you been drinking energy drinks while studying for your exam?" 3. "What drugs are you taking?" 4. "Do you want me to call your mother?"

2. Incorrect: Caffeine is a stimulant used to keep people awake and increase energy. It is found in many OTC medications and in many soft drinks and energy drinks. The student is exhibiting all the signs/symptoms of ingesting too much caffeine. 1. Incorrect: This is not addressing the problem. These are physical symptoms of a problem. 3. Incorrect: This is confrontational and will put the student on the defensive. Caffeine is not generally thought of as a drug by clients, so might not even be considered in the first place. 4. Incorrect: This might be done later, but this question does not help to determine what is going on with the student.

In the office for a yearly physical examination, a 30-year-old client reports that the client and husband used to be very happy before the children were born. Now the client is struggling with the current situation. What should the nurse understand about this situation? 1. The client is probably having an extramarital affair. 2. The developmental task at this stage is adjusting to the needs of more than two family members. 3. A relative or close friend should be consulted for help so the client can pursue activities outside the home. 4. The client should be referred to a psychotherapist for evaluation and care.

2. Correct: When children are born or adopted into a family, the established couple must adjust to supporting the physical and emotional needs of the additional family member. Additionally, the couple is engaged in developing an attachment with the child(ren) and coping with energy depletion and lack of privacy. These requirements may lead to a sense of unhappiness and frustration on the part of one or both parents. 1. Incorrect: The answer choice that the client is having an extramarital affair is inappropriate. There is no evidence to support this assumption. 3. Incorrect: Although receiving assistance from family and friends is a good option, it is not the best answer choice. This family has to learn to adjust to being a family. 4. Incorrect: The client's feelings are normal and do not require that the client be referred to a psychotherapist.

A client is being scheduled for a cat scan (CT) of the abdomen with contrast. When considering client safety, what should be the priority action for the nurse to implement? 1. Verify that informed consent has been provided. 2. Confirm with client the accuracy of allergies listed. 3. Force fluids following procedure. 4. Monitor output following procedure.

2. Correct: When considering client safety, the nurse should confirm allergies with the client. Clients should be asked about allergies to iodine or shellfish. The radiocontrast agents in the dye contain iodine and have resulted in severe reactions and even death in a few cases. If the client is allergic to iodine, the healthcare provider should be notified before the CT is performed. The use of contrast dye for the procedure will typically be omitted to avoid the risk of a severe reaction. 1. Incorrect: It is very important that a client receive information regarding risks and benefits of a procedure before providing consent (informed consent), but assuring that the consent was provided is not the priority for client safety over the risk of a severe reaction to the dye. 3. Incorrect: Again, it is very important to implement increased fluid intake following procedures, such as this CT of the abdomen, to help flush the dye through the kidneys. However, the safety priority remains the potential for a severe reaction that should be avoided by asking about allergies to iodine. 4. Incorrect: Monitoring urine output is an important nursing action following the CT because sometimes dye can lead to kidney problems or can increase problems in clients with existing renal disease. But this is not a priority over assessing for allergies that could lead to severe reactions.

The primary healthcare provider (PHP) informs a client that cancer was identified in the large intestine, and surgery should be scheduled as soon as possible. After the PHP leaves the room, the client turns their head away from the nurse and begins to cry. Which action by the nurse is appropriate? 1. Exit the room quietly. 2. Touch the client's shoulder. 3. Notify the client's family. 4. Begin preoperative instruction

2. Correct: When the nurse touched the client's shoulder, the nurse is utilizing the therapeutic communication technique of touch. Touching the client conveys caring and is a supportive action. This is especially important for the vulnerable client who has received upsetting information. 1. Incorrect: By exiting the room the nurse is communicating nonverbally that the nurse does not desire to talk to the client. The client could also perceive that the nurse leaving is abandonment during the stress of learning about the cancer diagnosis. 3. Incorrect: Notifying the client's family about the diagnosis without permission from the client is a Health Insurance Portability and Accountability Act (HIPAA) violation. The HIPAA Privacy Rule establishes national standards to protect individuals' medical record and personal health information. This action also would not assist the client during this stressful period. 4. Incorrect: The client was just informed of the diagnosis of cancer in the large intestine. Preoperative instructions should not be communicated to the client when the client's stress level is elevated. The client will not be able to focus or retain the preoperative instructions.

An elderly client diagnosed with terminal cancer is the sole caregiver to a developmentally delayed adult child. The client is worried that the child, with a developmental age of seven years old, will need permanent placement in a long term care facility. What statement by the nurse is most accurate? 1. "Your child will need to be under constant supervision." 2. "A supervised group home would be an ideal setting." 3. "Maybe we could find someone to take in your child." 4. "We should start getting the child used to living alone."

2. Correct: With a developmental age of seven years old, group home supervision would be ideal. The adult child can complete most activities of daily living and will only need minimal assistance with such tasks as cooking, laundry or shopping. 1. Incorrect: This comment is inaccurate, based on Erikson's stages. Even a seven year old can manage most ADLs without assistance, such as bathing, dressing, and grooming. Constant supervision would not be necessary. 3. Incorrect: Take in implies the child would need a private individual to provide care round the clock in a home, which is not necessary for this individual's developmental age. There are many activities the adult child can complete without supervision, so private home placement is not needed. 4. Incorrect: An adult with a mental age of seven is not capable of living completely alone. While able to complete ADLs and many small tasks, this individual would not be able to be live independently.

A nurse is teaching a group of women about human papillomavirus (HPV). What should the nurse tell the women that human papillomavirus puts women at risk for? 1. Human immunodeficiency virus 2. Cervical cancer 3. Hepatitis B 4. Cirrhosis

2. Correct: Women who have had human papillomavirus are at increased risk for developing cervical cancer. 1. Incorrect: HPV does not increase the risk of developing HIV. HPV increases the risk for developing cervical cancer. 3. Incorrect: HPV does not contribute to Hepatitis B. HPV increases the risk for developing cervical cancer. 4. Incorrect: HPV does not contribute to Cirrhosis. HPV increases the risk for developing cervical cancer.

What does a non-stress test tell the nurse about a pregnant client? 1. That the baby is going to be a boy or girl 2. The baby is doing well and the placenta is providing enough oxygen at this time 3. That the baby's heart is healthy and there are no birth defects 4. That the mother is strong enough to undergo vaginal delivery

2. Correct: Yes, the non-stress test identifies whether an increase in the fetal heart rate (FHR) occurs when the fetus moves, indicating adequate oxygenation, a healthy neural pathway from the fetal central nervous system to the fetal heart and the ability of the fetal heart to respond to stimuli. 1. Incorrect: No, the sex is not determined by this test. 3. Incorrect: No, we can't determine birth defects from a non-stress test. 4. Incorrect: No, we can't determine if the mother is strong enough to undergo vaginal delivery from a non-stress test.

Over which locations does the nurse auscultate breath sounds? 1. Trachea and lateral areas of thoracic cage 2. Anterior and posterior aspects of all lung fields 3. The mid-section as well as the lateral section of the lungs 4. The mid-clavicular to mid-axillary lines comparing side to side

2. Correct: Yes, you must go side to side (lateral aspects) and also listen to the front and back (anterior and posterior). 1. Incorrect: Does not include anterior and posterior lung fields. Do not auscultate over trachea.3. Incorrect: Does not include anterior and posterior lung fields.4. Incorrect: Does not include the posterior lung fields.

The day shift nurse in a long-term care facility has been noticing that the adult brief on a total-care client has not been changed since the previous day's shift and perineal care has not been provided, despite the brief being full with urine and feces. The client's perineal area is becoming excoriated from the contact with excrements. The nurse has spoken with the night shift nurse on 2 occasions about the concerns and was told by the night shift nurse that she takes care of the clients and to stay out of her business. What action should the day shift nurse take next? 1. Avoid reporting the night shift nurse to prevent job loss or disciplinary actions. 2. Report the client findings and previous discussions to the charge nurse. 3. Notify the agency attorney of the breach in care being provided. 4. Tell the client's family that they should report the night shift nurse.

2. Correct: You notice in the stem that the day shift nurse has already taken the first step, which was to discuss the ethical issue with the night shift nurse involved. Since no corrective measures have been taken, the day shift nurse has an ethical obligation to the client to now report this situation to the charge nurse. 1. Incorrect: Staying silent will not protect the client, who is the one that the day shift nurse has an ethical obligation to protect. Although the day shift nurse may not want to see the night shift nurse disciplined or terminated, the focus should remain on protecting the client from harm. 3. Incorrect: Although the agency attorney may become involved at some point, the charge nurse would be the next person in the chain of command to report this situation to. 4. Incorrect: Telling the family to report the night shift nurse would be inappropriately shifting the ethical obligation of the nurse to report the situation. This could also create some legal problems that could be avoided by appropriate reporting by the nurse.

A child is being discharged home following a bone marrow transplant. When providing discharge instructions to the parents, what information is most important for the nurse to include? 1. Clean toothbrush weekly with alcohol. 2. Avoid eating raw fruits and vegetables. 3. Drink bottled water the day. 4. Apply heating pad to bruised areas of the skin.

2. Correct:The greatest risk to clients following a transplant is the chance of infection from any source since the client is severely immune-compromised for an extended period of time. There are numerous precautions necessary to avoid bacteria, but one area of concern is food storage, preparation, and consumption. Raw fruits with no skin to peel, such as strawberries, and raw vegetables like broccoli and cauliflower, present a serious risk for bacterial contamination and should not be consumed by new transplant clients. 1. Incorrect: Precise mouth care is vital following a bone marrow transplant; however, rinsing a toothbrush in alcohol is unsafe. Any residual alcohol would cause irritation and trauma to gum tissue, placing the client at risk for mouth inflammation and infection. Clients are instructed to brush teeth twice daily with a soft bristle brush, using a fluoride toothpaste. Some clients are instructed to soak the toothbrush once weekly in a special bleach solution, then rinse in hot water, while others need to replace the toothbrush weekly, based on lab test results. 3. Incorrect: Standing water of any type quickly builds up bacteria, including flower vases and vaporizers. Although bottled water may seem a safe choice, after that bottle is opened, bacteria begins to quickly build up, even if the bottle is recapped. Any water standing more than 15 minutes is considered old and must be thrown out. 4. Incorrect: With bone marrow transplant clients, it will be months before the body begins to stabilize and produce normal blood cells. Bruising and low platelet counts are to be expected for a period of time. When clients develop bruising, the approved treatment is cold compresses or ice packs applied for 15 minutes a couple times per day, and never a heating pad. Additionally, the healthcare provider should be notified so that a current platelet count can be obtained.

A client diagnosed with a deep venous thrombosis (DVT) has been prescribed warfarin. Which of the client's current medications would the nurse notify the primary healthcare provider related to the prescribed warfarin? Select all that apply 1. Metformin 2. Aspirin 3. Ginkgo 4. Amlodipine 5. Hydrochlorothiazid

2., & 3. Correct: Aspirin's chemical classification is a salicylate. One of the actions of aspirin is to reduce platelet aggregation. Aspirin's action of reducing platelet aggregation if taken with warfarin will also increase the client's risk of bleeding. Ginkgo, a herb, has properties which will increases the risk of bleeding if prescribed in conjunction with the administration of warfarin. Gingko's properties improve blood circulation. 1. incorrect: Metformin's functional classification is an oral antidiabetic medication. Metformin is not listed as a medication that causes either an increase or decrease in the actions of warfarin. 4. Incorrect: Amlodipine's functional class is a calcium channel blocker. The interaction of warfarin and amlodipine does not result in an increase or decrease in the actions of warfarin. 5. Incorrect: Hydrochlorothiazide's functional class is a thiazide diuretic. Hydrochlorothiazide does not have any properties that will interact with warfarin to decrease or increase warfarin's actions.

Where should a nurse place the stethoscope when auscultating heart sounds? Select all that apply 1. First intercostal space right of the sternum to hear sounds from the pulmonic valve area. 2. Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area. 3. Second intercostal space to the right of the sternum to hear sounds from the aortic valve area. 4. Third intercostal space in the midclavicular line to hear sounds from the mitral area. 5. Apex of the heart to hear the loudest 2nd heart sound (S2).

2., & 3. Correct: These are correct locations to listen to heart sounds. 1. Incorrect: Second intercostal space left of the sternum is where you will hear sounds from the pulmonic valve. 4. Incorrect: The fifth intercostal space in the midclavicular line is where you hear sounds in the mitral area. 5. Incorrect: This is where you will hear the loudest first heart sound (S1). You listen at the base of the heart to hear S2 the loudest.

Where should a nurse place the stethoscope when auscultating heart sounds? Select all that apply 1. First intercostal space left of the sternum to hear sounds from the pulmonic valve area. 2. Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area. 3. Second intercostal space to the right of the sternum to hear sounds from the aortic valve area. 4. Fifth intercostal space left side of sternum to hear sounds from the mitral area. 5. Apex of the heart to hear the loudest 2nd heart sound (S2).

2., & 3. Correct: These are correct locations to listen to heart sounds. 1. Incorrect: Second intercostal space left of the sternum to hear sounds from the pulmonic valve 4. Incorrect: The fifth intercostal space in the midclavicular line is where you will hear sounds in the mitral area. 5. Incorrect: This is where you will hear the loudest 1st heart sound (S1). Listen at the base to hear S2 the loudest.

A nurse is planning to teach a group who works at a local mall about proper use of automated external defibrillators (AED). Which points should the nurse emphasize? Select all that apply 1. The standard AED can be used on children over the age of 5. 2. All users of the AED must be trained in its operation. 3. CPR should be taught to users. 4. Primary healthcare provider oversight is needed to ensure proper maintenance. 5. The local EMS should be notified of the type and location of AEDs.

2., 3., 4. & 5. Correct: These are appropriate actions. 1. Incorrect: Standard AEDs can be used on children over the age of 8. For children ages 1-8, the AHA recommends the pediatric attenuated pads that are purchased separately.

The nurse is caring for a client with multiple episodes of diarrhea and suspected Clostridium Difficile (C. diff). Which interventions should be included in the plan of care? Select all that apply 1. Institute contact precautions only after confirmation of stool culture. 2. Instituting contact precautions for all who enter the client's room 3. Using alcohol based foam for hand hygiene. 4. Dedicating equipment for use only in the client's room. 5. Requesting antidiarrheal medication for the client.

2., & 4. Correct: Contact isolation will be needed to prevent the spread of infection. Also the electronic equipment for vital signs must not be used in the room. The client will need a disposable stethoscope, BP cuff and thermometer dedicated for use in that patient room.1. Incorrect: Precautions should be instituted and a stool sample sent for any client with persistent diarrhea. Isolation should be in place with suspected c. diff.3. Incorrect: Soap and water must be used to clean the hands. Alcohol based foams do not have enough alcohol in them to destroy the c diff spores. 5. Incorrect: Medications to stop diarrhea will not be prescribed with c. diff. because they cause even further irritation.

What signs/symptoms would the nurse expect to find in a client diagnosed with osteoarthritis (OA) in the knee? Select all that apply 1. Sjogren's syndrome 2. Clicking sound when knee bends 3. Fever 4. Pain that is worse after activity 5. Severe fatigue

2., & 4. Correct: Loss of cartilage between bone joints produces the clinking or cracking sound heard when the joint bends. Pain is worse after an activity involving the affected joint or toward the end of the day. 1. Incorrect: Sjogren's (SHOW-grins) syndrome is a disorder of the immune system identified by its two most common symptoms — dry eyes and a dry mouth. It is not seen in osteoarthritis. 3. Incorrect: Fever is not associated with Osteoarthritis but is associated with rheumatoid arthritis (RA). 5. Incorrect: Severe fatigue is seen with rheumatoid rather than osteoarthritis.

An unlicensed assistive personnel (UAP) reports to the charge nurse that a postoperative client's 8AM blood pressure is 200/104 and the oxygen saturation reading is 86%. What actions would be appropriate for the charge nurse to delegate? 1. Tell the LPN to assess for shortness of breath and evidence of tissue prefusion. 2. Have the LPN reinforce the use of relaxation techniques. 3. Ask the LPN to draw arterial blood gas levels. 4. Instruct the RN to administer the prescribed dose of labetalol hydrochloride IV. 5. Instruct the UAP to call the primary healthcare provider and notify of change in client's condition.

2., & 4. Correct: The LPN can reinforce teaching. The client's BP is elevated and using relaxation techniques along with the medication that is being administered may help to decrease the client's BP. Labetalol is beneficial in this situation because of its rapid onset of action (approximately 5 minutes). The charge nurse delegates this to the RN because it would be outside the scope of practice of the LPN and not in the role of the UAP to administer IV medication. 1. Incorrect: The LPN cannot assess, evaluate or teach. These are the roles of the RN and are outside the scope of practice of the LPN. 3. Incorrect: Drawing ABGs from an artery is out of the scope of practice of the LPN. 5. Incorrect. It is not in the role of the UAP to notify the primary healthcare provider of changes in the client's condition. The UAP could not receive additional prescriptions should the primary healthcare provider desire to add or change prescriptions based on the client's change in condition.

An unlicensed assistive personnel (UAP) reports to the charge nurse that a postoperative client's 8AM blood pressure is 200/104 and the oxygen saturation reading is 86%. What actions would be appropriate for the charge nurse to delegate? Select all that apply 1. Tell the LPN to assess for shortness of breath and evidence of tissue prefusion. 2. Have the LPN reinforce the use of relaxation techniques. 3. Ask the LPN to draw arterial blood gas levels. 4. Instruct the RN to administer the prescribed dose of labetalol hydrochloride IV. 5. Instruct the UAP to call the primary healthcare provider and notify of change in client's condition.

Which tasks would be appropriate for the RN to delegate to an unlicensed assistive personnel (UAP)? 1. Ask the client diagnosed with dementia memory-testing questions. 2. Monitor 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 as a fever. 5. Assess oxygen saturation on a client experiencing angina.

2., & 4. Correct: The UAP can obtain UOPs on clients and can give a tepid sponge bath to a client. 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. This is an RN task.

A nurse has taught a group of teenage girls about breast self-awareness. Which statements by the teens would indicate to the nurse that teaching was effective? Select all that apply 1. "I should have a clinical breast exam every 5 years starting at the age of 18." 2. "Doing a monthly breast self-exam will help me learn what is normal for me." 3. "It is only important to know my maternal health history." 4. "Signs I should not ignore include dimpling of the skin, and nipple discharge." 5. "Self-breast exam should be done a few days before my menstrual cycle begins."

2., & 4. Correct: The purpose of breast self-exam is to determine what is normal. This will allow the client to recognize when there is a change in breast tissue. S/S of breast cancer includes dimpling of the skin, nipple discharge, tenderness, change in appearance, retracted nipple, hard lump and itchy or scaly skin. 1. Incorrect: Clinical breast exams are recommended every 3 years starting at age 20, and every year starting at age 40. 3. Incorrect: Talk to both sides of the family to learn about your family health history. 5. Incorrect: The breast self-exam should be done after the menstrual cycle (day 7-12) for a better exam. The breasts will be too tender just prior to the period.

The nurse is assisting the client on the correct procedure for applying anti-embolism stockings. Which statement by the client indicates that the client understands the procedure? Select all that apply 1. "The stockings should be applied when my legs are swollen." 2. "I will apply the anti-embolism stockings before getting out of bed." 3. "I will apply cortisone-10 ointment to skin on both legs every day." 4. "Prior to applying the stockings, I will look for reddened areas on my skin." 5. "When pulling up the stockings, I will allow for an extra roll of the stocking at my calves."

2., & 4. Correct: To promote increased blood flow in the legs, anti-embolism stockings should be applied before getting out of bed. After keeping the legs elevated during sleeping, the legs should be less swollen. The compression of the deep venous system will be more effective if swelling is decreased prior to applying the stockings. Both legs should be assessed for any reddened skin areas prior to applying the stockings. If reddened areas are noted, the cause of the reddened areas should be evaluated and treatment initiated, if appropriate. Client's symptoms should be addressed prior to the application of the stockings. 1. Incorrect: The purpose of the anti-embolism stockings is to promote increased blood flow in the legs. To promote the increase blood flow in the legs, anti-embolitism stockings should not be applied when the legs are swollen. If the legs are swollen when applying the stockings, the compression to the deep venous system is reduced. 3. Incorrect: Unless prescribed, the stockings should not be applied over any ointment that has been applied to the legs. The legs and feet should be dry. The stockings are to be worn over an extended period. If there is a skin condition that warrants treatment, the stockings may reduce the effectiveness of the treatment. 5. Incorrect: The client's leg should be measured to ensure that the correct size of the anti-embolism stockings is applied. An extra roll of the stocking at the calves would decrease the appropriate deep venous pressure and could also cause a pressure area on the calves.

A client has been admitted with multiple severe allergies, including food and medications. The nurse knows what actions are most important to protect the client? Select all that apply 1. Assign client to a private, sterile room. 2. Place allergy alert bracelet on client. 3. Have client wear mask when in hallway. 4. Attach sign listing allergies above the bed. 5. Send list of allergies to dietary department.

2., & 5. CORRECT: It is crucial to place the facility's allergy alert bracelet on the client upon admission, generally on the same wrist as the facility ID bracelet. Each time the client's ID is verified, staff will also see the allergy bracelet. Dietary department must also be alerted of all allergies in writing as should the pharmacy. In most facilities allergy alert stickers are attached on the outside of the chart, on the medication sheet, and facility-specific areas to remind the staff caring for the client. 1. INCORRECT: A client with allergies does not have to be placed into a private room, even if the allergies are environmental. There is no such thing as a "sterile" client room, which implies a sealed location with reverse airflow system. Although operating rooms try to maintain a sterile atmosphere, the entire room itself is not sterile. 3. INCORRECT: Allergies would not require the client to wear a mask in the hallway, or when transported to another department. Even if a client allergy is airborne, such as dust, a mask does not provide significant protection. 4. INCORRECT: A sign listing exact client allergies would violate HIPAA regulations and privacy policies. In severe cases, a facility may choose to place a plain allergy sticker in the client's room, but cannot place any specific, identifying client information in public view.

What characteristics would indicate to the obstetrical nurse that a client is experiencing false labor? Select all that apply 1. Cervical dilation noted. 2. Contractions decrease with sleep. 3. Bloody show noted. 4. Contraction intensity increases with walking. 5. Contractions felt in abdomen above umbilicus.

2., & 5. Correct: False labor or Braxton Hicks contractions are mild, irregular frequency, and intermittent; decrease in frequency, duration, and intensity with walking or position changes; often stop with sleep or comfort measures such as oral hydration or emptying of the bladder. False labor contractions are typically felt as a tightening or pulling sensation of the top of the uterus. In contrast, true labor contractions are more commonly felt in the lower back and gradually sweep around to the lower abdomen. 1. Incorrect: True labor includes progressive effacement and dilation. False labor does not significantly change the cervix in effacement or dilation. 3. Incorrect: Effacement and dilation cause expulsion of the mucus plug, rupturing the small cervical capillaries in the process. False labor does not cause effacement or dilation; therefore, there will be no bloody show. 4. Incorrect: True labor contractions tend to increase with walking. False labor contractions do not change or may decrease with activity (such as walking).

The client with ulcerative colitis calls the clinic and reports increasing abdominal pain and increased frequency of loose stools. The client asks the nurse to clarify foods that can be eaten with ulcerative colitis. What foods should the nurse suggest? Select all that apply 1. Dried beans 2. Fish 3. Apples 4. Yogurt 5. Scrambled eggs

2., & 5. Correct: Fish and scrambled eggs are both high in protein and low in fiber. Foods high in fiber are irritating to the GI tract and should be avoided. A food diary is needed to determine triggers for flare-ups. 1. Incorrect: Fiber in the beans will increase motility. 3. Incorrect: Fiber in apple will increase motility. 4. Incorrect: Dairy products should be avoided in times of flare-ups as dairy is often a cause of flare ups.

What task can the nurse assign to an unlicensed assistive personnel (UAP) while caring for a client diagnosed with a stroke? Select all that apply 1. Check the client's gag reflex. 2. Assist with feeding the client. 3. Monitor the client's headache pain level. 4. Encourage client to expression frustrations. 5. Maintain the head of the bed at 25 - 30 degrees.

2., & 5. Correct: It is within the scope of practice for an UAP to maintain a designated bed position and assist with feeding a client. The nurse is responsible for setting the bed at the prescribed position and will direct the UAP to maintain this bed position. The UAP is also trained to assist clients with feeding. 1. Incorrect: Assessing the client's gag reflex is not within the scope of an UAP. A nurse would need to be trained in specific techniques to assess the client's gag reflex. 3. Incorrect: It is not within the scope of a UAP to assess the pain level of the client. The nurse must assess the location and intensity of the headache. The nurse cannot delegate assessing a client to a UAP. 4. Incorrect: The client should be encouraged to express their feelings, concerns, and needs, but he UAP is not trained in therapeutic communication and other medical and psychological client needs. Encouraging the client to express their frustrations is not within the UAP's scope of practice.

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

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

What developmental milestone does the nurse expect to see in a two month old baby? Select all that apply 1. Responds to own name. 2. Holds head up. 3. Rolls over from stomach to back. 4. Pushes down on legs when feet are on a hard surface. 5. Turns head towards sound. 6. Reaches for toy with one hand.

2., & 5. Correct: When checking the developmental milestones of a 2 month old, the nurse should expect to see the baby hold up the head and turn the head toward a sound. 1. Incorrect: A baby can respond to their own name by 6 months, not 2 months. 3. Incorrect: A baby may be able to roll over from abdomen to back by 4 months. 4. Incorrect: At 2 months the baby is not able to push down on legs when feet are on a hard surface. The nurse should expect to see this by time the baby is 4 months old. 6. Incorrect: Reaching for a toy with one hand is seen when the baby is 4 months of age.

A client is transported to the emergency department following a 20 foot fall from a ski lift. The nurse records initial assessment findings on the chart. Based on that data, what actions should the nurse implement immediately? Exhibit Vitals BP 90/40; HR 125; RR 30 and labored; + jugular venous distention (JVD) with subcutaneous emphysema noted to right shoulder area. Select all that apply 1. Apply occlusive dressing to chest. 2. Initiate large gauge IV line. 3. Prepare for chest tube placement. 4. Administer high flow oxygen. 5. Position client on right side.

2., 3. & 4. Correct: Based on the assessment data recorded by the nurse, the client most likely has a tension pneumothorax secondary to blunt force trauma from the fall. Immediate actions must focus on preventing tracheal deviation and a fatal outcome. The need for intravenous fluids and medications in any trauma requires at least one large bore IV line or more. This client will need immediate chest tube placement to relieve increasing intrathoracic pressure. While preparing the client for this procedure, high-flow oxygen should be administered via nonrebreather mask because of the client's respiratory distress. 1. Incorrect: There is no indication in the question of an open chest wound, or that a dressing is needed. The occlusive chest dressing will be placed over the insertion site of the chest tube after placement is completed. 5. Incorrect: This trauma client will be secured to a back board, most likely with a cervical collar in place, until x-rays confirm there has not been a cervical spine injury. Placing the client on the right side is counterproductive and in fact could further impair respiratory efforts.

The nurse has been working with an attractive teenage girl regarding appropriate nutrition. Which statement by the teenager would support a disturbed body image and the need for education on adequate nutrition? Select all that apply 1. "I am happy my weight is within normal limits. " 2. "I can never exercise enough to lose those saddle bags." 3. "I can always work a little harder on school work and hobbies." 4. "I try to eat only two meals a day to keep my weight down." 5. "I have been trying to include more fruits and vegetables in my diet."

2., 3. & 4. Correct: Compulsive exercising may indicate an eating disorder or a risk for developing one. Perfectionism in school, sports, and hobbies may indicate low self-esteem, which is reflected in eating disorders. Compulsive adherence to routines for weight loss or control may indicate a risk for developing an eating disorder. 1. Incorrect: This would indicate a healthy self-concept.5. Incorrect: Choosing to eat more fruits and vegetables is a positive, healthy promotion strategy for good nutrition.

As a member of the emergency preparedness planning team at the hospital, which actions should the nurse encourage the team to implement? Select all that apply 1. Developing a response plan for every potential disaster. 2. Providing education to employees on the response plan. 3. Practicing the response plan on a regular basis. 4. Evaluating the hospital's level of preparedness. 5. Assigning all client care duties to the Nursing Supervisor.

2., 3. & 4. Correct: Developing a single response plan, educating individuals to the specifics of the response plan, and practicing the plan and evaluating the facility's level of preparedness are effective means of implementing emergency preparedness. The basic principles of emergency preparedness are the same for all types of disasters. Only the response interventions vary to address the specific needs of the situation. 1. Incorrect: One good response plan, not multiple plans, should be developed. This will ensure adequate understanding of the plan and decrease confusion of roles that could occur with multiple plans. There is no feasible way for the hospital to have a response plan for every potential disaster. 5. Incorrect: All client care duties cannot safely be assigned to one caregiver. The nursing supervisor needs the help of other staff to carry out nursing care for the clients in the hospital.

A client's absolute neutrophil count (ANC) is 750/mm3. Which measures should the nurse take to protect the client? 2., 3. & 4. Correct: If a client's ANC is less than 1000/mm3, the client is at risk for infection. Instructing the client to wear a mask outside of the hospital room protects the client from infection. The soil in fresh flowers and plants can carry bacteria and fungi, which can cause infection. Performing hand hygiene is the best way to prevent the spread of infection. 1. Incorrect: Not allowing the client to shave would be an appropriate intervention for someone with a low platelet count. 5. Incorrect: Not allowing the client to floss the teeth would be an appropriate intervention for someone with a low platelet count. The client needs good oral care to prevent infections in the mouth.

2., 3. & 4. Correct: If a client's ANC is less than 1000/mm3, the client is at risk for infection. Instructing the client to wear a mask outside of the hospital room protects the client from infection. The soil in fresh flowers and plants can carry bacteria and fungi, which can cause infection. Performing hand hygiene is the best way to prevent the spread of infection. 1. Incorrect: Not allowing the client to shave would be an appropriate intervention for someone with a low platelet count. 5. Incorrect: Not allowing the client to floss the teeth would be an appropriate intervention for someone with a low platelet count. The client needs good oral care to prevent infections in the mouth.

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

2., 3. & 4. Correct: Myasthenia gravis is a chronic autoimmune disorder characterized by progressive muscle weakening and chronic fatigue. Clients become weaker throughout the day, contributing to the potential for complications. Stress reduction techniques are important since stress can contribute to a myasthenic crisis, a severe respiratory emergency. Daily tasks, including ADL's, should be completed early in the day when the client has the most energy. Medications for MG, including neostigmine and pyridostigmine, must be taken on time and prior to meals. 1. Incorrect: Clients with myasthenia gravis are instructed to include gentle daily exercise combined with periods of rest throughout the day. Weight lifting would be too strenuous and would quickly tire this client, possibly leading to a myasthenia crisis. 5. Incorrect: Because of the difficulty in chewing or swallowing, multiple small meals throughout the day are safer and more beneficial to a client with myasthenia gravis. Medications are timed in relation to meals, so consistent but smaller meals would be more beneficial for the client.

A client's absolute neutrophil count (ANC) is 750/mm3. Which measure should the nurse take to protect the client? Select all that apply 1. Prohibit the client from shaving. 2. Instruct the client to wear a mask when leaving the hospital room. 3. Remove fresh flowers and plants from the client's room. 4. Ask visitors to perform hand hygiene before entering the client's room. 5. Instruct client to avoid vigorous flossing of teeth

2., 3. & 4. Correct: Normal ANC is 2500-8000/mm3. If a client's ANC is less than 1000/mm3, the client is at risk for infection. Instructing the client to wear a mask outside of the hospital room protects the client from infection. The soil in fresh flowers and plants can carry bacteria and fungi, which can cause infection. Performing hand hygiene is the best way to prevent the spread of infection. 1. Incorrect: Not allowing the client to shave or vigorous flossing of teeth would be an appropriate intervention for someone with a low platelet count. This client has a low white cell count. 5. Incorrect: Not allowing the client to shave or vigorous flossing of teeth would be an appropriate intervention for someone with a low platelet count.

A nurse is working with community officials to decrease the incidence of violence in the community. Which primary preventive measures might the nurse suggest? Select all that apply 1. Provide a safe haven for victims of violence. 2. Provide educational programs about types of violence. 3. Form a neighborhood watch program. 4. Develop a media campaign identifying risk factors of potential abuse. 5. Provide for the immediate removal of a victim of violence from the home.

2., 3. & 4. Correct: These are all appropriate interventions for the nurse to suggest to the community. The key is prevention. The nurse is teaching ways to prevent violence before it occurs. Primary prevention is true prevention. Primary prevention aims to prevent disease or injury before it ever occurs. This is done by preventing exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury should exposure occur. Examples include: legislation and enforcement to ban or control the use of hazardous products (e.g. asbestos) or to mandate safe and healthy practices (e.g. use of seatbelts and bike helmets); education about healthy and safe habits (e.g. eating well, exercising regularly, not smoking); immunization against infectious diseases. 1. Incorrect: This is a true statement but is not a preventive measure. This does not prevent violence from occurring; it is an intervention to decrease the chance of future violence making it tertiary prevention. Tertiary prevention aims to soften the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries (e.g. chronic diseases, permanent impairments) in order to improve as much as possible their ability to function, their quality of life and their life expectancy. Examples include: cardiac or stroke rehabilitation programs, chronic disease management programs (e.g. for diabetes, arthritis, depression, etc.); support groups that allow members to share strategies for living well; vocational rehabilitation programs to retrain workers for new jobs when they have recovered as much as possible. 5. Incorrect: This is not a primary preventive measure but a secondary preventive measure. Removing the victim is not preventing primary violence but additional violence. Secondary prevention aims to reduce the impact of a disease or injury that has already occurred. This is done by detecting and treating disease or injury as soon as possible to halt or slow its progress, encouraging personal strategies to prevent re-injury or recurrence, and implementing programs to return people to their original health and function to prevent long-term problems. Examples include: regular exams and screening tests to detect disease in its earliest stages (e.g. mammograms to detect breast cancer); daily, low-dose aspirins and/or diet and exercise programs to prevent further heart attacks or strokes; suitably modified work so injured or ill workers can return safely to their jobs.

Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Which actions should be instituted by each unit's charge nurse? Select all that apply 1. Turn on local news for up-to-date information on the train derailment. 2. Prepare a list of clients who could quickly be discharged or transferred. 3. Determine which personnel could be sent to the command center. 4. Notify clients that the disaster plan has been put into effect. 5. Alert all off-duty personnel to stand by in case of call- in.

2., 3. & 5. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. However, there are some basic points which are standard among all facilities. This situation is considered an external disaster which means the hospital will be expecting multiple victims. The charge nurse on each unit needs to prepare a list of possible discharges or transfers to be given to the appropriate primary healthcare providers for further action. When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. However, each unit must have one designated representative to send to the command center, when requested, to receive and then relay, pertinent information back to the unit. These individuals are selected by the charge nurse, and do not have to be nurses. Additionally, off-duty personnel may be needed and should be alerted to stand by; however, the command center alone makes the determination whether extra personnel should be called in, or if it would put more individuals in jeopardy. 1. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. 4. Incorrect: This would unnecessarily alarm the clients. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client.

Which response by the nurse is appropriate when admitting a 5 year old child who is crying and hugging a stuffed animal? 1. "Hello, I am your nurse. I am going to show you to your room." 2. "Don't cry. Let's go to the playroom where you can meet other children." 3. "You are upset. I see you have your stuffed animal." 4. "Can I hold your stuffed animal? Then, would you like to put your stuffed animal in the bed?"

3. Correct: These statements acknowledge the child's feelings and changes focus. 1. Incorrect: This response does not acknowledge the child's feelings. 2. Incorrect: This response does not alleviate fear. 4. Incorrect: Closed-ended questions are not helpful in getting a child to express fear.

The staff nurse is caring for a 3-month old client receiving potassium IV therapy. Which actions indicate to the charge nurse that the staff nurse understands IV management? Select all that apply 1. Uses a 15 gtt factor drip chamber when changing the IV tubing. 2. Applies elbow restraints to prevent dislodgement of the IV catheter. 3. Checks the IV site for blood return hourly. 4. Instructs unlicensed assistive personnel (UAP) to count drip rate hourly. 5. Attaches a volume-controlled IV administration set to IV bag prior to beginning IV therapy.

2., 3. & 5. Correct: Young children and infants usually must be restrained to some degree to prevent accidental dislodging of the needle. Elbow restraints can prevent an infant with a scalp IV from rubbing or touching the IV site. When a foot, leg, or arm is used, limb motion must be limited. IV potassium is an irritant. When the fluid being infused is a known irritant or vesicant, the nurse should check the IV site for blood return and possible infiltration hourly. Infants and young children have a narrow range of normal fluid volume, and the risk for fluid overload is great, especially in an infant. Always use a volume-controlled IV administration set with an infant or small child. These sets hold no more than 100-150 mL of fluid, so the maximum amount that could accidentally be infused is limited.1. Incorrect: Always use microdrip tubing which is a 60 gtt chamber. Microdrip chambers are used for children and for clients who can not tolerate a fast infusion rate or large volumes. 4. Incorrect: This intervention is beyond the scope of a UAP. The UAP may assist with activities of daily living and bedside care under the supervision of a registered nurse or other healthcare professional. The nurse is responsible for monitoring the IV flow rate.

A nurse is participating in a community health fair for middle aged individuals. Which points should the nurse stress for decreasing the risk of stroke? 1. Reduce dietary intake of unsaturated fat. 2. Swim or walk most days of the week. 3. Treat obstructive sleep apnea, if present. 4. Drink five or more 8 ounce glasses of water daily. 5. Decrease smoking to less than ½ pack a day.

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

A nurse is participating in a community health fair for middle aged individuals. Which points should the nurse stress for decreasing the risk of stroke? Select all that apply 1. Reduce dietary intake of unsaturated fat. 2. Swim or walk most days of the week. 3. Treat obstructive sleep apnea, if present. 4. Drink five or more 8 ounce glasses of water daily. 5. Decrease smoking to less than ½ pack a day.

A client has been admitted to the ICU following an extensive anterior-wall myocardial infarction. What change in vital signs would alert the nurse the client may be experiencing cardiogenic shock? Select all that apply 1. Bounding pulse of 65. 2. Decreased urinary output. 3. Blood pressure of 80/40. 4. Cold and clammy skin. 5. Slowed respiratory rate.

2., 3., & 4. Correct: Cardiogenic shock is a condition in which inadequate blood flow leads to poor tissue perfusion throughout the body. This type of shock is usually the result of a diastolic dysfunction in the ventricles caused by a variety of heart issues or diseases. In shock, systolic blood pressure levels drop quickly below 100, further decreasing tissue perfusion as well as lowering level of consciousness. The resulting reduction in kidney perfusion can decrease urinary output to the point of oliguria. The body will compensate by shunting blood inward to vital organs, decreasing peripheral perfusion and resulting in cold, clammy extremities. If not treated immediately, the client can die. 1. Incorrect: In any type of shock, the pulse increases to pump existing volume throughout the body to perfuse vital organs. 5. Incorrect: The respiratory rate will increase with the heart rate since the body is not receiving enough oxygen secondary to poor perfusion.

A client diagnosed with new onset atrial fibrillation has been prescribed dabigatran. What should the nurse teach this client? Select all that apply 1. Place medication in a weekly pill organizer so that medication is not forgotten. 2. Do not take with clopidogrel. 3. Dabigatran decreases the risk of stroke associated with atrial fibrillation. 4. Take this medication with food. 5. aPTT and INR levels will be drawn monthly.

2., 3., & 4. Correct: Do not take dabigatran with any other anticoagulants, including clopidogrel due to increased bleeding risk. Dabigatran decreases the risk of stroke and systemic embolism in clients with atrial fibrillation that is not associated with a cardiac valve problem. Take this medication with food to decrease gastric side effects such as dyspepsia and gastritis. Proton pump inhibitors and histamine 2 recepter blockers may also decrease gastric side effects. 1. Incorrect: After container is opened, medication should be used within 30 days. It is sensitive to moisture and should not be stored in weekly pill organizers. To maintain efficacy, keep medication in manufacturer- supplied bottle. 5. Incorrect: This medication does not require monitoring of INR levels. However, the client should be informed about the risk of bleeding and to monitor for signs of bleeding.

The nurse is teaching a group of teenagers about decreasing the risk of developing skin cancer. What information should the nurse include? Select all that apply 1. Use sunscreen with a sun protection factor (SPF) of at least 30. 2. A self-tanning product containing dihydroxyacetone (DHA) is safe to use. 3. Put on sunscreen every day, even on days when it is cloudy. 4. Stay in the shade between 9 AM and 4 PM. 5. Tanning beds are safer than outdoor tanning.

2., 3., & 4. Correct: People of all ages should avoid tanning. If you like the look of tanned skin, choose a self-tanning product that contains the active ingredient DHA. This active ingredient has been approved by the U.S. Food and Drug Administration and is safe to use. Most are fast-acting and will give skin a darker appearance in a matter of a few hours. This "tan" will last about a week. Put on sunscreen every day, even on days when it is cloudy. UV rays from the sun can reach you on cloudy and hazy days, as well as bright and sunny days. UV rays also reflect off surfaces like water, cement, sand, and snow. The hours between 10 a.m. and 4 p.m. Daylight Saving Time (9 a.m. to 3 p.m. standard time) are the most hazardous for UV exposure outdoors in the continental United States. UV rays from sunlight are the greatest during the late spring and early summer in North America. 1. Incorrect: Use sunscreen with a SPF of 15 or higher, and both UVA and UVB (broad spectrum) protection. 5. Incorrect: Tanning beds are dangerous. Avoiding the sun but replacing it with a tanning bed does not reduce the risks that are associated with UV damage to the skin.

A client returns to the unit post scleral buckling of the right eye. Which nursing interventions should the nurse include? Select all that apply 1. Approach client from the right side. 2. Place personal items within easy reach. 3. Maintain eye patch over right eye. 4. Administer antiemetic for reports of nausea. 5. Assist client to turn, cough, and deep breathe every 2 hours. 6. Place client prone for 1 hour.

2., 3., & 4. Correct: Place all personal articles and the call light within easy reach. These measures prevent stretching and straining by the client. An eye patch or shield will prevent injury to the affected eye. We do not want the client to vomit, so administer an antiemetic for reports of nausea. Vomiting will increase intraocular pressure. 1. Incorrect: Approach the client on the unaffected side. This approach facilitates eye contact and communication. 5. Incorrect: The goal is to prevent anything that will increase intraocular pressure. That means coughing should be avoided. 6. Incorrect: Lying prone will increase intraocular pressure. After surgery for a detached retina, the client is positioned so that the detachment is dependent. For example, if the outer portion of the right retina is detached, the client is positioned on the right side. Positioning so that the detachment is inferior maintains pressure on that area of the retina, improving its contact with the choroid.

A client is admitted with abdominal pain, distention, fever, dehydration, (+) Cullen's sign and a rigid boardlike abdomen. Which interventions would help control the client's pain in the acute period? Select all that apply 1. Small frequent feedings 2. NG tube to low suction 3. Side-lying position with head elevated 4. Hydromorphone by PCA pump 5. IV isotonic solutions

2., 3., & 4. Correct: The pain is caused by inflammation of the pancreas and the autodigestive process. How do we fix the pain? Rest the pancreas and decrease the secretion of digestive enzymes or better known as...empty and dry. The NG tube will keep the stomach empty and dry. Side-lying with head elevated decreases tension on the abdomen and may ease pain. The hydromorphone is an analgesic and will help with the pain. 1. Incorrect: We want them NPO. If you selected this option, then you are telling the NCLEX Lady that you are going to constantly stimulate the release of digestive enzymes with frequent feedings and keep the pancreas inflamed, inflamed, inflamed! Pain! 5. Incorrect: IV solutions will keep them hydrated and correct electrolyte disturbances but not relieve pain.

A client arrives to the emergency department with reports of palpitations, chest discomfort, and light-headedness. The nurse connects the client to a cardiac monitor and notes a weak, thready pulse, and a BP of 90/50. What actions should the nurse take? Exhibit 1. Administer Lidocaine 50 mg intravenous push (IVP). 2. Initiate oxygen at 2 liters per nasal cannula. 3. Apply oxygen saturation monitor to client. 4. Prepare for immediate synchronized cardioversion. 5. Perform carotid massage. 6. Begin cardiopulmonary resuscitation.

2., 3., & 4. Correct: This client has a rapid heart rate of 188/min. The actual rhythm is atrial tachycardia but can also be identified as supraventricular tachycardia because the heartrate is greater than 150/min. This client is considered unstable so requires oxygen therapy, with O2 saturation monitoring, and synchronized cardioversion. 1. Incorrect: Lidocaine is not indicated for an atrial or supraventricular dysrhythmia. 5. Incorrect: Carotid massage is not within the scope of practice of the nurse. Asystole could result. 6. Incorrect: This client has a pulse, so CPR is not needed at this time.

What interventions should the nurse plan to implement when admitting a client diagnosed with measles? Select all that apply 1. Admit to a semi-private room with a client diagnosed with tuberculosis (TB). 2. Place a surgical mask on the client when transferring to x-ray. 3. Initiate airborne precautions. 4. Wear surgical mask when entering the client's room. 5. Assign a nurse who has received the measles vaccine to take care of this client.

2., 3., & 5. Correct: If the client must leave the room, a surgical mask should be worn to prevent transmission to others. Measles can be transmitted via contact, droplet, and airborne methods, so airborne precautions are needed. Healthcare providers who are not immune to measles should not care for a client with measles. 1. Incorrect: The client should be placed in a private room with negative air pressure when airborne precautions are necessary. TB and measles are not like illnesses and should not be placed in the same room. 4. Incorrect: A particulate or N95 respirators should be worn by staff entering the room of a client on airborne precautions. N95 respirators filter particles that you may inhale. A surgical mask prevents the spread of particles during exhalations.

The client shares that her husband died 2 months ago. She stays at home at least 3 times per week and cries most of the day. Which interventions for dealing with loss would the nurse initiate? Select all that apply 1. Resume previous social activities right away. 2. Establish a structure of daily activities. 3. Reinforce that dreaming about the loved one is positive. 4. Recommend immediate professional assistance. 5. Encourage communicating feelings during grief process.

2., 3., & 5 Correct: Organizing specific daily activities will give the client a sense of control of their lives. This action will assist the client through the day and promotes self-confidence. Dreaming about the deceased is a symptom of the normal grief process. The client is compensating for the loss by experiencing dreams that include her husband. The stages of grief do not proceed in a systematic process. The client may stay in one stage for a while, skip a stage, or begin the stages again from the beginning. The client should express their feeling as they move through the grief stages. Grief is an individualized process. 1. Incorrect: Due to the change in the marital status of the client, the client may not be comfortable resuming previous activities. The nurse could discuss prior social activities with client utilizing therapeutic communication techniques such as open ended questions to assist the client in deciding which social activities to resume at this time. 4. Incorrect: The client is exhibiting normal grief actions/symptoms. The assessment of the client does not warrant the professional assistance at this time. The word immediate means prompt or rapid. The stem does not indicate a need for immediate action.

Which finding would the nurse expect to see in a client diagnosed with pneumocystis carinii pneumonia (PCP)? Select all that apply 1. Hemoptysis 2. Fever 3. Dyspnea 4. CD4 count of 500 cells/cubic millimeter 5. Wheezing

2., 3., & 5. At first, PCP may cause only mild symptoms or none. Common signs/symptoms include fever (usually low-grade if with HIV), dry cough or wheezing, shortness of breath or dyspnea on exertion, fatigue, and pleuritic pain on inspiration. 1. Incorrect: Clients with pneumocystis pneumonia have a nonproductive cough. Hemoptysis is a late sign of lung cancer or tuberculosis. 4. Incorrect: The CD4 count is a test that measures how many CD4 cells are in the blood. These are a type of white blood cells, called T-cells, that move throughout the body to find and destroy bacteria, viruses, and other invading germs. A normal CD4 count is from 500 to 1,400 cells per cubic millimeter of blood. CD4 counts decrease over time in persons who are not receiving antiretroviral therapy. At levels below 200 cells per cubic millimeter, clients become susceptible to a wide variety of opportunistic infections, many of which can be fatal.

What interventions should the nurse initiate while caring for a client who has a cooling blanket in place? Select all that apply 1. Assess temperature every hour. 2. Perform comparison check with another thermometer periodically. 3. Assess client skin condition hourly. 4. Turn blanket off when temperature is at goal temperature. 5. Observe for signs of chilling.

2., 3., & 5. Correct. Perform comparison check with another thermometer periodically to ensure there is no problem associated with equipment failure. For cooling treatments, extended periods of cooling can cause areas of decreased perfusion, skin burns, and tissue injury. Chilling can increase metabolism and body needs. 1. Incorrect: Check the client's temperature every 15 minutes. If the client is cooled too quickly, chilling, increased metabolism, and adverse reactions may occur. 4. Incorrect: The blanket will not immediately return to room temperature and will continue to cool the client even after it is turned off. Turning it off shortly before the goal temperature is achieved will prevent altering the client's core temperature beyond the desired outcome.

What signs/symptoms would the nurse expect to assess in a client diagnosed with acute pericarditis? Select all that apply 1. Petechiae on trunk 2. Muffled heart sounds 3. Pericardial friction rub 4. Pulsus paradoxus 5. Chest pain on deep inspiration

2., 3., & 5. Correct: Muffled heart sounds are indicative of pericarditis. Fluid is between the heart and the chest wall; heart sounds are lowered and distant. A pericardial friction rub is a classic symptom of acute pericarditis. Chest pain is the most common symptoms of pericarditis, and is aggravated by deep inspiration, coughing, position change, and swallowing. 1. Incorrect: Petechiae on the trunk, conjunctiva, and mucous membranes are indicative of endocarditis. 4. Incorrect: Pulsus paradoxus is an exaggerated decrease of systolic blood pressure during inspiration exceeding 12 mm Hg. It is the hallmark of cardiac tamponade.

The nurse is teaching a client, recovering from a myocardial infarction (MI), about the prescribed diet of low sodium, low saturated fat, and low cholesterol. Which statements, if made by the client, would indicate to the nurse that teaching has been successful? Select all that apply 1. "I should drink fruit juices rather than soft drinks." 2. "A good snack to eat would be unsalted popcorn." 3. "When making homemade tomato sauce, I should not add salt." 4. "I should use 2% milk when cooking." 5. "There is no restriction on egg white consumption.

2., 3., & 5. Correct: Popcorn without salt is a healthy snack choice for clients on a low sodium, low saturated fat, and low cholesterol diet. Homemade tomato sauce can be made without adding salt. The American Heart Association no longer makes recommendations on how many egg yolks to eat or not to eat. A good, general guideline is to eat no more than 1 egg yolk a day, up to 5 total a week. There is no restriction on egg whites (including those used in baking and cooking). 1. Incorrect: Consume whole vegetables and fruits rather than fruit juices. Fruit juices have added sugars and lack fiber. 4. Incorrect: Use skim or 1% milk rather than 2% or whole milk.

The charge nurse is observing a new nurse administer a Mantoux test. The new nurse demonstrates accurate knowledge of the procedure by completing what steps? You answered this question Incorrectly 1. Administers 0.1 ml of PPD to upper outer arm. 2. Inserts needle under dermis with the bevel up. 3. Uses tuberculin syringe with 27-gauge needle. 4. Wraps site with gauze to prevent leaking. 5. Assesses the injection site after 48 hours.

2., 3., & 5. Correct: The Mantoux test is standardly used to test individuals for immunity to tuberculosis by giving an intradermal injection of tuberculin. This intradermal test uses 0.1 millimeter of solution given with a tuberculin syringe and 27 gauge needle, injected with bevel pointed upward into the inner surface of the forearm. The test must be read between 48 and 72 hours for accuracy. 1. Incorrect: PPD stands for "purified protein derivative", which is the solution injected for this test. The upper outer surface of the arm is just below the deltoid muscle area and is not suitable for an intradermal injection. 4. Incorrect: If the solution is injected properly, a small wheal, or bubble, will appear on the skin which should not be compressed in anyway, particularly with gauze wrap.

Which response by the nurse is appropriate when responding to a client who reports eliminating all dairy foods from their diet because of lactose intolerance? 1. "Take calcium tablets since they can be used as a total supplement for dairy products." 2. "You can take lactose enzymes which will eliminate the effects of lactose intolerance." 3. "Valuable nutrients found in milk include calcium and protein." 4. "Consume more leafy green vegetables to maintain calcium levels."

3. Correct: Milk contains both calcium and high-quality protein. 1. Incorrect: Dairy products provide for both calcium and protein. 2. Incorrect: Lactose enzymes may help but will not eliminate the problem. 4. Incorrect: People generally do not eat enough green leafy vegetables to get enough protein.

The nurse is cleaning and dressing a foot ulcer of a diabetic client. Which actions are appropriate? Select all that apply 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!

Which assignment by the charge nurse would be most appropriate for a general pediatric nurse being reassigned to the hematology/oncology pediatric unit? Select all that apply 1. Child dying with leukemia who has been on the hematology/oncology unit for two weeks. 2. Teenager with sickle cell disease in for pain management. 3. Child admitted following a bicycle accident that has idiopathic thrombocytopenic purpura (ITP). 4. New admit scheduled for bone marrow transplant. 5. Child diagnosed with leukemia admitted for stomatitis.

2., 3., & 5. Correct: The nurse should be given an assignment similar to the type of clients and skill level the nurse is accustomed to on the general pediatric unit. Therefore, the choices should be these three clients. Even though one of the clients has leukemia, the child is being treated for stomatitis, not the leukemia. Sickle cell clients are frequently cared for on general pediatric units. The reassigned nurse has the knowledge and skills needed to meet the clients needs for pain management and treatment for the sickle cell disease. The general pediatric nurse should be competent in caring for children with low platelet counts, so the child with ITP could be assigned to this nurse. The nurse would be familiar with bleeding precautions, monitoring for bleeding, and associated care. 1. Incorrect: This client is dying with leukemia and needs consistency in the staff assigned to care for them. Although the general pediatric nurse could competently care for a dying child, the focus should be on the client. This child needs and deserves consistent care and care by those that are familiar to this child. 4. Incorrect: A child who is to receive a bone marrow transplant would not be the best assignment, since the nurse must have special preparation and an understanding of the protocol with a bone marrow transplant client. This is not something that a general pediatric nurse would typically do. Therefore, this client would need to be cared for by the nurses on the hematology/oncology unit who has this special training and/or knowledge.

What should a nurse teach a group of teenage boys who admit to using smokeless tobacco? Select all that apply 1. Smokeless tobacco increases risk for lung cancer. 2. Inspect mouth frequently for lesions. 3. White patches in mouth should be reported to healthcare provider. 4. Risk for stomach cancer can be decreased by not swallowing smokeless tobacco juice. 5. Report decreased saliva to primary healthcare provider. 6. Smoking cessation.

2., 3., & 6. Correct: The mouth should be inspected frequently for painless lesions that do not heal. This may be a sign of oral cancer and should be reported to the primary heathcare provider. White patches (leukoplakia) is a sign of potential oral cancer as well. Nicotine is addictive and is found in smokeless tobacco. Clients using smokeless tobacco can benefit from smoking cessation information/classes. 1. Incorrect: Use of smokeless tobacco increases the risk developing of esophageal cancer, cancers of the mouth, throat, cheek, gums, lips, tongue, pancreatic cancer, stomach cancer, kidney cancer. 4. Incorrect: This is an incorrect statement. Some amount of tobacco juice will be swallowed and can lead to esophagus and stomach cancer. 5. Incorrect: Decreased saliva is not associated with oral cancer.

A client who has Parkinson's disease has a new prescription for benztropine. What should the nurse include when teaching the client and spouse about this medication? Select all that apply 1. This medication blocks dopamine in the brain to decrease tremors and muscle stiffness. 2. Notify your primary healthcare provider if you develop urinary retention. 3. Benztropine can reduce the ability to sweat, so do not become overheated. 4. No lab tests are needed while taking this medication. 5. Sit up or stand up slowly to prevent lightheadedness.

2., 3., & 5. Correct: Urinary retention is a side effect of benztropine. Benztropine can reduce the ability to sweat and cause the body to overheat. Do not become overheated in hot weather or while you are being active because heatstroke may occur. Benztropine may cause dizziness, lightheadedness, or fainting. Alcohol, hot weather, exercise, or fever may increase these effects. To prevent these negative effects, sit up or stand slowly, especially in the morning. Sit or lie down at the first sign of any of these effects. 1. Incorrect: Benztropine is an anticholinergic. It works by decreasing the effects of acetylcholine, a chemical in the brain. This results in decreased tremors or muscle stiffness, and helps improve walking ability for clients with Parkinson's disease. 4. Incorrect: Lab tests, including liver function, kidney function, lung function, blood pressure, fasting blood glucose, and blood cholesterol, may be performed while using benztropine. These tests may be used to monitor the client's condition or check for side effects.

The nurse should wear gloves when administering which medication? 1. Lorazepam 1mg orally. 2. Nitroglycerin ointment 2% 0.5 inch to chest. 3. Ceftriaxone 250mg intramuscularly. 4. Metronidazole 500mg intravenous piggyback. 5. Humalog 8 units subcutaneously.

2., 3., & 5. Correct: You do not want to get nitroglycerin on your hands. The medication would be absorbed into your skin. When giving a medication intramuscularly or subcutaneously, there is a chance of being exposed to blood. Remember to wear gloves when there is a chance for you to encounter body fluids. 1. Incorrect: Gloves are not needed when administering oral medications unless contact with client's mucous membranes is anticipated or the medication is hazardous. 4. Incorrect: Gloves are not needed when preparing antibiotics such as ceftriaxone by IV piggyback.

An elderly client living in a long-term care facility fell 8 hours ago causing a laceration on the occipital area of the skull and steri-strips were applied for closure. Which signs/symptoms would indicate to the nurse that the client should be transferred to the emergency department? Select all that apply 1. Purposeful movement. 2. Sudden emotional outbursts. 3. Client report of blurred vision. 4. Pupils equal, react to light, and accommodation. 5. Bright red blood oozing from the wound. 6. Headache unrelieved by acetaminophen.

2., 3., & 6. Correct: Signs/symptoms of increased ICP include: excessive sleepiness, inattention, difficulty concentrating, impaired memory, faulty judgment, depression, irritability, emotional outbursts, disturbed sleep, diminished libido, difficulty switching between two tasks, and slowed thinking. Abnormalities in vision and extraocular movements occur in the early stages of increased ICP. A headache that is unrelieved by acetaminophen would warrant further investigation. 1. Incorrect: This is a normal response and does not warrant further investigation. 4. Incorrect: This is a normal response and does not warrant further investigation. 5. Incorrect: The scalp is very vascular and oozing would be expected. Apply pressure to stop bleeding.

Eight hours after a cholecystectomy a male client has tried unsuccessfully to urinate using a urinal in bed. Which nursing interventions would the nurse implement? Select all that apply 1. Insert a straight catheter. 2. Administer the prescribed PRN analgesic. 3. Assist the client to stand at the bedside to void. 4. Emphasize that the client must void within 2 hours. 5. Encourage the client to increase fluid intake to 500 mL/hr. 6. Assist the client to the bathroom and turn on running water.

2., 3., & 6. Correct: The pain level of the client should be assessed. When the client is experiencing pain, the client's anxiety level will increase. The prescribed PRN analgesic should be administered to decrease the client's pain and anxiety levels. Though there is no posture-related differences when men void in the lying position versus the standing position, the male client sometimes prefers voiding in the standing position. The sound of the water can stimulate the central nervous system to facilitate the voiding process. 1. Incorrect: In and out catheter will not assist the client to void. 4. Incorrect: Giving the client a time limit to void is a not a helpful technique. The nurse is telling the client what to do. This will increase client's anxiety which will decrease the client's ability to void. 5 Incorrect: Increasing the intake amount will cause the bladder to expand further, but the client is having difficulty initiating the voluntary opening of the sphincter.

What should the nurse teach the client following a right knee arthroscopy? Select all that apply 1. Apply ice to right knee continuously for the first 24 hours. 2. Elevate the right knee when sitting. 3. Notify the primary healthcare provider of tingling in the right leg. 4. Gradually start an exercise program to prevent scarring. 5. Place a plastic bag over wound when showering.

2., 3., 4. & 5. Correct: Elevating the joint for several days will reduce swelling and pain. Tingling to the extremity could mean nerves have been damaged. Exercise is gradually started to strengthen muscles surrounding the joint and prevent scarring of surrounding soft tissues. The client needs to keep the site as clean and dry as possible. 1. Incorrect: Continuous ice can cause tissue damage.

The home care nurse, working with an infant in the home, is concerned about the infant developing diaper rash from wearing cloth diapers. Which strategies should the nurse teach to the parents to prevent skin irritation? Select all that apply 1. Change diapers every four hours. 2. Wash diapers with hypoallergenic detergent. 3. Rinse diapers twice when washing. 4. Apply a protective ointment to diaper area with each diaper change. 5. Check infant at least hourly for wet or soiled diapers.

2., 3., 4. & 5. Correct: Hypoallergenic detergent will remove skin bacteria as well as urine from the diaper. Detergents can be irritating to the skin and may cause dryness; therefore, adequate rinsing is important. Double rinse the diapers in cold water to remove traces of chemicals and soap. A protective ointment is even more important to use with cloth diapers, as they do not have the same wicking properties of the disposable diapers. Frequently checking the diaper for wetness and soiling will limit the contact time for urine or feces to be in contact with the skin. Whether using cloth diapers, disposables or both kinds, always change the baby as soon as possible after wetting or soiling the diaper to keep the bottom as clean and dry as possible. 1. Incorrect: The child should be checked more frequently to prevent irritation to the skin from soiling. At least every 2 hours is recommended.

The nurse is talking with the mom of a preschooler at the well-child visit. The mom reports that her 3 year old has a lot of energy and sleeps 9 hours per night. What assessment questions should the nurse ask in response to this comment? 1. Nothing, as this is normal for preschoolers. 2. Does your child take naps during the day? 3. Does your child wake up spontaneously or do you wake her? 4. Does your child appear rested upon awakening? 5. Does your child have trouble settling down for sleep?

2., 3., 4. & 5. Correct: Preschoolers typically require 11 - 13 hours of sleep per day. The child may be supplementing nighttime sleep with long naps. It is important to determine if the child has to be awakened after nine hours or if the child awakens spontaneously. The child may have to be awakened due to mom's work schedule. The adequacy of rest should be determined, as the child is sleeping less than is typical. The nurse should determine if the child has difficulty falling asleep. If so, perhaps more restful nighttime rituals should be implemented.1. Incorrect: Preschoolers typically require 11-13 hours of sleep per day. Nine hours is not enough.

The nurse is talking with the mom of a preschooler at the well-child visit. The mom reports that her 3 year old has a lot of energy and sleeps 9 hours per night. What assessment questions should the nurse ask in response to this comment? Select all that apply 1. Nothing, as this is normal for preschoolers. 2. Does your child take naps during the day? 3. Does your child wake up spontaneously or do you wake her? 4. Does your child appear rested upon awakening? 5. Does your child have trouble settling down for sleep?

What should a nurse include when preparing to educate a female client on how to prevent recurrent cystitis? Select all that apply 1. Drink at least eight, 4 ounce glasses of water per day. 2. Urinate as soon as the urge occurs. 3. Avoid irritating perineum with harsh soap. 4. Empty your bladder post coitus. 5. Avoid use of a diaphragm.

2., 3., 4. & 5. Correct: The client should void as soon as the urge occurs and completely empty the bladder. The client should not use excessive soap or harsh soap to minimize irritation of the urethra. Women should void immediately after sexual intercourse. This helps prevent bacteria from moving into the urethra. Pressure on the urethra may cause irritation and urinary tract infections in women who use diaphragms. 1. Incorrect: A client with normal renal function and who does not have heart or kidney disease needs to drink 2200 to 2700 mL of fluid daily. Increasing fluid intake helps flush out solutes or particles that collect in the urinary system.

The nurse is making a home assessment for the purpose of preventing injury for a visually impaired elderly client who also has diabetes. Which findings are important for the nurse to include in this assessment? 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 to know 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. Depression assessment should be performed on all elderly clients.

The nurse is making a home assessment for the purpose of preventing injury for a visually impaired elderly client who also has diabetes. Which findings are important for the nurse to include in this assessment? Select all that apply 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

A client has been admitted to the psychiatric unit with a diagnosis of schizophrenia. Which client behaviors does the nurse anticipate? Select all that apply 1. Abstract reasoning 2. Waxy flexibility 3. Grandiose delusions 4. Anxiety 5. Agitated behavior

2., 3., 4. & 5. Correct: Waxy flexibility describes a condition in which the client allows body parts to be placed in bizarre or uncomfortable positions for long periods of time. Delusions of grandiosity like believing they are a famous person or religious figure is a false fixed belief experienced by the client. If the client is in the acute phase of schizophrenia, the person may be overwhelmed by anxiety and is not able to distinguish thoughts from reality. It is thought that delusions may develop to cope with the anxiety. Agitated behavior like running about and going from one location to another can lead to exhaustion in this client. 1. Incorrect: This client has concrete thinking which implies over emphasis on specific details and an impairment in the ability to use abstract concepts. For example, during the nursing history you may ask the client what brought them to the hospital and the answer will be "a cab".

A nurse is helping a client to maintain normal voiding habits while recovering from a cesarean section. What methods should the nurse initiate? Select all that apply 1. Have the client recline slightly while using bedside commode. 2. Encourage the client to push over the pubic area with hands. 3. Suggest the client read or listen to music. 4. Pour warm water over the perineum. 5. Stay and talk with client while waiting for urge to void.

2., 3., 4. Correct: Encourage the client to push over the pubic area with the hands or lean forward to increase intraabdominal pressure and external pressure on the bladder. Reading or listening to music will help to decrease anxiety and tension. Pouring warm water over the perineum promotes muscle relaxation. 1. Incorrect: Assist the client to a normal position for voiding. For males, standing. For females, squatting or leaning slightly forward when sitting. These positions enhance movement of urine through the tract by gravity. 5. Incorrect: Provide privacy. Many people cannot void in the presence of another person.

A nurse, who has been assigned to the Emergency Response Team, is beginning to work on the agency's disaster response plan. What would be the nurse's role in this disaster response plan? Select all that apply 1. Perform duties specific to the area of expertise only. 2. Identify the individual in charge of a given client area. 3. Remain alert to potential security issues. 4. Consider ethical conflicts that may impact care. 5. Provide emotional support and make referrals to mental health resources.

2., 3., 4., & 5 Correct: The role of the nurse in disasters can vary greatly. However, it is imperative that there is clarity regarding the individual (nurse, primary healthcare provider, etc.) that will be in charge of a particular client care area and what activities each nurse may or may not perform. Disasters can bring unique security issues. Nurses should be acutely aware of these and plan for ways to manage identified issues. Ethical conflicts in a disaster can involve a discrepancy between client/victim needs and the available resources. Nurses have to be prepared to make decisions regarding resource management. Other ethical issues that nurses may face involve issues such as confidentiality, consents, end of life care, ineffective therapy, requests for assisted suicide, and needing to meet the needs of many more victims than physical resources allow. There are so many responses that nurses may encounter from clients involved in a disaster. Anxiety levels may be high, clients may demonstrate depression, and a strong emotional impact can be experienced. Many various behavioral issues are often noted. Nurses play a vital role in meeting behavioral needs by providing active listening and emotional support. The behavioral and emotional needs may be greater than the nurse can handle on a short term basis. Therefore, it is important for the nurse to know when to refer clients or families to available mental health resources. 1. Incorrect: Nurses can take on many different roles during a disaster. Nurses should realize that they may be asked to "step out of their comfort zone" and not only perform duties that are outside of their area of expertise, but also may be expected to take on some responsibilities that are typically carried out by primary healthcare providers and advanced practice nurses.

What preoperative education should the nurse provide to a client scheduled for a transsphenoidal hypophysectomy? Select all that apply 1. There will be a large dressing covering the forehead. 2. Avoid drinking from a straw. 3. The head of the bed will be elevated 30 degrees. 4. After surgery, your urinary output will be monitored. 5. Use a sponge when doing oral care.

2., 3., 4., & 5. Correct. Drinking from a straw can damage the surgical area, so the client should not use a straw until approved by the primary care provider. The client will return from surgery with the head of the bed elevated to about 30 degrees. This will allow for gravity to assist with draining of any cerebrospinal fluid. Surgery can damage the posterior lobe of the pituitary gland, which makes the client urinate frequently and feel thirsty. This is diabetes insipidus. If the client puts out too much urine, then fluid volume deficit or shock can occur. The incision is just above the gumline, so the client should not brush the front teeth. Oral care is best performed using a sponge until the incision heals. 1. Incorrect: Pituitary surgery can be removed through traditional microscopic or endoscopic technique. So, there is no dressing on the forehead.

What should a nurse include when teaching a client diagnosed with shigellosis regarding how to prevent the spread of the infection to others? Select all that apply 1. Wash hands three times a day with alcohol. 2. Do not return to work until authorized by local health department. 3. Do not prepare food for others while you are sick. 4. Avoid swimming until fully recovered. 5. No sex until several days after diarrhea has stopped.

2., 3., 4., & 5. Correct. These are correct actions to prevent the spread of infection. Shigella germs are present in the stools of infected persons while they have diarrhea and for up to a week or two after the diarrhea has gone away. Shigella is very contagious; exposure to even a tiny amount of contaminated fecal matter—too small to see-- can cause infection. Transmission of Shigella occurs when people put something in their mouths or swallow something that has come into contact with stool of a person infected with Shigella. 1. Incorrect. Wash your hands with soap carefully and frequently, especially after using the toilet.

The nurse is caring for a trauma client who is receiving a unit of whole blood. The client begins to experience lower back pain. What actions should the nurse take? Select all that apply 1. Administer diphenhydramine. 2. Collect a urine specimen. 3. Stop the transfusion. 4. Take the client's vital signs. 5. Change the IV tubing

2., 3., 4., & 5. Correct: Assume the worst, and stop the transfusion first, then continue with the assessment. Low back pain is a sign of an acute hemolytic reaction. This is the most dangerous and potentially life-threatening type of transfusion reaction. It occurs when the donor blood is incompatible with that of the recipient. Get lab tests such as a urinalysis to check for presence of hemoglobin, which indicates hemolytic reaction. Take vital signs. Change IV tubing to remove all blood and maintain the IV line with normal saline solution, with new IV tubing, at a slow rate. 1. Incorrect: Diphenhydramine is indicated for an allergic reaction to the blood component being transfused. It is not indicated for a hemolytic reaction.

The nurse is educating a group of teenagers who have expressed an interest in using electronic cigarettes (e-cigarettes). What information about electronic cigarettes should the nurse include? 1. Electronic cigarettes are a safe alternative to smoking. 2. It is difficult for consumers to know what electronic cigarette products contain. 3. Nicotine can harm adolescent brain development. 4. Electronic cigarette aerosol generally contains fewer toxic chemicals than the smoke from regular cigarettes. 5. Defective electronic cigarette batteries can cause fires and explosions.

2., 3., 4., & 5. Correct: It is difficult for consumers to know what e-cigarette products contain. For example, some e-cigarettes marketed as containing zero percent nicotine have been found to contain nicotine. Nicotine can harm adolescent brain development, which continues into the early to mid-20s. E-cigarette aerosol generally contains fewer toxic chemicals than the deadly mix of 7,000 chemicals in smoke from regular cigarettes. However, e-cigarette aerosol is not harmless. It can contain harmful and potentially harmful substances, including nicotine, heavy metals like lead, volatile organic compounds, and cancer-causing agents. E-cigarettes can cause unintended injuries. Defective e-cigarette batteries have caused fires and explosions, some of which have resulted in serious injuries. In addition, acute nicotine exposure can be toxic. Children and adults have been poisoned by swallowing, breathing, or absorbing e-cigarette liquid. 1. Incorrect: Teens need to be aware that electronic cigarettes are not a safe alternative to smoking. Nicotine, which is highly addictive, and other harmful chemicals are still absorbed through the lungs and into the body with the use of electronic cigarettes.

The nurse is educating a group of teenagers who have expressed an interest in using electronic cigarettes (e-cigarettes). What information about electronic cigarettes should the nurse include? Select all that apply 1. Electronic cigarettes are a safe alternative to smoking. 2. It is difficult for consumers to know what electronic cigarette products contain. 3. Nicotine can harm adolescent brain development. 4. Electronic cigarette aerosol generally contains fewer toxic chemicals than the smoke from regular cigarettes. 5. Defective electronic cigarette batteries can cause fires and explosions.

The nurse is teaching a group of adults how to check skin lesions for signs of melanoma. What should the nurse include? 1. Symmetrical shape 2. Multiple colors with a lesion 3. Odd looking lesion 4. Poorly defined border of lesion 5. Diameter of lesion 6 mm

At a well-baby check, the parents of a 14 month old report how the child is doing and then excitedly share that they have purchased and are moving into a "fixer-up" home that was built in the mid-1960s. Based on the parent's report, what would be the priority concern for the nurse to address with the parents? 1. Fall risk due to increased mobility 2. Increased anxiety due to change in the environment 3. Speech consisting of only 4 words 4. Potential for lead poisoning

4. Correct: Since the home that they are moving into was built before 1978, there is a high likelihood that it has lead-based paint. One of the most common causes of lead poisoning is lead from paint, including dust that is contaminated with lead. Lead-based paint that is peeling, chipping, cracking, or damaged is a hazard that requires immediate attention. Young children, such as this 14 month old, are at high risk for lead poisoning as they may chew on painted surfaces or may come in contact with painted surfaces that often have areas of wear-and-tear such as window sills, door frames, railings, etc. In addition, remodeling or renovating activities as well as scraping old paint can create toxic lead dust. The reason that this is the priority concern is that even low levels of lead in the blood in children could result in learning and behavior problems, delayed growth, anemia, hearing problems, hyperactivity, and lower IQ. In more severe cases, lead ingestion can cause seizures, coma, and possibly death. 1. Incorrect: Yes, 14 month old children are likely to experience some tumbles and bumps. This is normal for this age child as depth perception and coordination are not fully developed and they are learning the skills of increased mobility. However, these are not generally of great concern under normal circumstances and certainly do not take priority over the concern for lead poisoning. 2. Incorrect: Toddlers tend to do better with routines that are predictable. Changes in the routine can cause the toddler to become anxious. Moving to a new home would be very disruptive to this 14 month old's routine. This anxiety could be manifested by increased clinginess, regression, decreased appetite, and other unusual behaviors such as increased aggressive behaviors, shyness, and anxious habits (twirling hair, clinging to and rubbing favorite blanket, etc.). Even though these behaviors may be concerning and would need to be addressed, they would not be a priority over the effects that lead poisoning could cause. 3. Incorrect: The speech of the 14 month old is still early in the developmental process and can vary from child to child. A 14 month old's vocabulary normally consists of about three to five words. So, this 14 month old with a vocabulary of 4 words is not abnormal and would not be of concern to the nurse.

The nurse should assess for what signs of toxicity in a child who is admitted with salicylate overdose? Select all that apply 1. Hypoventilation 2. Vomiting 3. Tinnitus 4. Diaphoresis 5. Dehydration 6. Hypothermia

2., 3., 4., & 5. Correct: Nausea and vomiting are the most common toxic effects. This can be caused by CNS toxicity or by direct damage to the gastric mucosa. Salicylates can be neurotoxic, and this is manifested by ringing in the ears. Ototoxicity can also lead to hearing loss. Diaphoresis results in the early phase of toxicity. Serious dehydration can result from insensible losses due to hyperventilation and fever, as well as active losses due to vomiting. 1. Incorrect: The first phase of salicylate toxicity is characterized by hyperventilation due to stimulation of the respiratory center in the brain. This is a key feature of salicylate toxicity. 6. Incorrect: Hyperpyrexia is an indication of severe toxicity, especially in younger children.

What teaching points should the nurse include when educating a client how to prevent a venous stasis ulcer? Select all that apply 1. Elevate legs above heart for 5 minutes, twice a day. 2. Perform leg exercises regularly. 3. Wear graduated compression stockings. 4. Treat itching with prescribed topical corticosteroids. 5. Minimize stationary standing.

2., 3., 4., & 5. Correct: Regular leg exercises improve calf muscle function. Wearing graduated compression stockings will help prevent dilation of lower extremity veins, pain, and a heavy sensation in the legs that typically worsens as the day progresses. Itching can cause the client to scratch, which leads to skin breakdown. Topical corticosteroids can decrease itching and should be used as prescribed. Minimize stationary standing as much as possible to decrease pooling of blood in the lower extremities. 1. Incorrect: Elevate legs above heart for 30 minutes three times a day will minimize edema and reduce intraabdominal pressure.

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

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

What electrolyte imbalance should the nurse monitor for when caring for a client diagnosed with chronic alcoholism? 1. Hypochloremia 2. Hypokalemia 3. Hypophosphatemia 4. Hypomagnesemia 5. Hypocalcemia

2., 3., 4., & 5. Correct: The number one way of getting rid of potassium is through the kidneys. What does alcohol make you do? Diuresis. Acute hypophosphatemia is seen in up to 50% of patients over the first 2-3 days after they are hospitalized for alcohol overuse. Hypophosphatemia is manifested as rhabdomyolysis (muscle breakdown) and weakness of the skeletal muscles. Magnesium deficiency occurs due to that increase in diuresis as well. Hypomagnesemia is often accompanied by hypocalcemia, or lowered calcium levels, which may be aggravated by a deficiency of vitamin D. 1. Incorrect: Hypochloremia is usually caused by excess use of loop diuretics, nasogastric suction, vomiting or diarrhea due to small bowel abnormalities, and loss of fluids through the skin occurring because of trauma such as burns.

A nurse receives a client in the post anesthesia care unit following application of a long leg cast to the left leg due to a fractured tibia and fibula. Which interventions should the nurse initiate? Select all that apply 1. Elevate foot of bed 30 degrees. 2. Palpate bilateral pedal pulses. 3. Apply ice packs to fracture site. 4. Mark break through bleeding. 5. Assess client's ability to move toes

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

What interventions should the nurse include when planning care for a client post heart transplant? Select all that apply 1. Place on airborne precautions. 2. Instruct visitors to wash hands prior to entering the room. 3. Maintain strict aseptic technique. 4. Initiate pulmonary hygiene measures. 5. Provide for early ambulation.

2., 3., 4., & 5. Correct: The transplant recipient is at high risk for infection due to the suppression of the body's normal defense mechanisms. All of these interventions decrease the incidence of the client developing an infection. The heart transplant client is prescribed medications to reduce the risk of organ rejection by inhibiting or suppressing the immune system. Handwashing is the main defense against infection. Pulmonary hygiene measures are are implemented to maintain open airways and prevent respiratory infections. The pulmonary measures can include oral hygiene, deep breathing exercises, mucus-controlling agents, and intermittent positive-pressure breathing. Pulmonary hygiene helps to decrease the development of pneumonia. Early ambulation helps increase general strength and lung expansion. Also ambulation increases circulation,peristalisis,and joint mobility, Emotionally ambulation improves self-esteem and feelings of independence. 1. Incorrect: The client needs to be protected from everyone else so a private room and protective isolation are needed. All persons entering the room must wash hands well and wear a mask and gloves. The client must wear a mask when leaving the room.

A nurse is planning an educational session on fluticasone/salmeterol for a group of clients who have been prescribed this medication. What teaching points should the nurse include? Select all that apply 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 HandiHaler DPI, 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 also decrease mouth and throat irritation. Medication should be taken every day as directed, even on days when 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 for long term control and maintenance treatment for the prevention of bronchospasm and airway inflammation associated with asthma, chronic bronchitis, and COPD. 1. Incorrect: Medication must be taken with an inhaler. Capsules and tablets are not to be swallowe

The nurse is teaching a newly diagnosed diabetic client about self-injection of insulin. Which statement made by the client indicates to the nurse that teaching has been effective? Select all that apply 1. "The abdominal site is best because it is closest to the pancreas." 2. "I can reach my thigh the best, so I will use different areas of the same thigh." 3. "By rotating the sites within one area, my chances of having tissue changes are less." 4. "If I change injection sites from the thigh to the arm, the rate of absorption will be different." 5. "I should inject at least 1-2 inches away from the last injection site."

2., 3., 4., & 5. Correct: To promote consistency in insulin absorption, the client should systematically rotate injection sites within an anatomic area to prevent lipodystrophy. Four main areas for injection are the abdomen, upper arms, thighs and hips. The client should try not to use the exact same site more than once in 2 to 3 weeks. If insulin is injected where there is more fat underneath the skin, insulin may be absorbed more slowly. Also, insulin should not be injected into the limb that will be exercised; absorption will be faster, increasing risk of hypoglycemia. The client should avoid using the exact same site more than once in 2 to 3 weeks.1. Incorrect: The diabetic client should rotate sites within the same area before moving to a new area. This will assist in preventing lipodystrophy. Use of the abdominal site has nothing to do with being close to the pancreas. The abdomen is the preferred site because it provides the most rapid insulin absorption.

A nurse is participating in a cancer risk screening program. Which signs/symptoms would indicate to the nurse that a client needs further investigation? Select all that apply 1. Unexplained weight gain of 10 pounds 2. Leukoplakia 3. Prolonged hoarseness 4. Hematuria 5. Persistent abdominal bloating

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

What signs/symptoms would the nurse expect to find in a client diagnosed with pernicious anemia? Select all that apply 1. Pain 2. Smooth, red tongue 3. Burning feeling in feet 4. Lightheadedness 5. Dyspnea on exertion

2., 3., 4., & 5. Pernicious anemia symptoms could include a smooth tongue that is red in color rather than a healthy pink. And neurological problems such as a burning feeling in the feet, slow reflexes, and disorientation. Light headedness, dyspnea on exertion, fatigue, and breathlessness are anemia symptoms that clients often report. 1. Incorrect. Pain is a symptom seen in sickle cell anemia.

Which interventions should the nurse include for a client with sickle cell crisis who is experiencing pain? Select all that apply 1. Apply cold compresses to affected joints. 2. Massage affected areas gently. 3. Support and elevate swollen joints. 4. Monitor pain level by looking for BP, respiratory, and heart rate elevation. 5. Place client on Nothing By Mouth (NPO) status. 6. Administer Normal Saline (NS) at 125 mL/hour.

2., 3., 4., & 6. Correct: Apply local massage gently to affected areas to help reduce muscle tension. Massage also warms the area and promotes vasodilation. Supporting and elevating affected joints will decrease swelling, thus decreasing pain. Physiological manifestations of vital signs aid in evaluation of pain and effectiveness since pain is unique to every person. The nurse should also assess pain with an objective scale by having the client rate the pain 1-10. The NS provides hydration and is appropriate in sickle cell crisis. Hydrating the client makes it easier for the abnormally formed RBCs to pass through vessels. 1. Incorrect: Apply warm, moist compresses to affected joints or other painful areas. Avoid use of ice or cold compresses. Warmth causes vasodilation and increases circulation to hypoxic areas. Cold causes vasoconstriction and compounds the crisis.5. Incorrect: The sickle cell client should not be kept from eating or drinking. Hydration is an important component of therapy. Dehydration promotes sickling process.

What developmental milestone does the nurse expect to see in a four month old baby? 1. Responds to own name. 2. Pushes up to elbows, when lying on stomach. 3. Rolls over from stomach to back. 4. Pushes down on legs when feet are on a hard surface. 5. Watches the path of something as it falls. 6. Reaches for toy with one hand.

2., 3., 4., & 6. Correct: By the age of four months, the nurse would expect the baby to be able to push up to the elbows when lying prone. A baby may be able to roll over from abdomen to back by 4 months. At 4 months the baby should be able to push down on legs when feet are on a hard surface. Reaching for a toy with one hand is seen when the baby is 4 months of age. 1. Incorrect: A baby can respond to their own name by 6 months, not 4 months. 5. Incorrect: When checking the developmental milestones of a 9 month old, the nurse should expect to see the baby watch the path of something as it falls.

Which signs/symptoms noted by the nurse would support a client history of chronic emphysema? Select all that apply 1. Atelectasis. 2. Increased anteroposterior (AP) diameter. 3. Breathlessness. 4. Use of accessory muscles with respiration. 5. Leans backwards to breathe. 6. Clubbing of fingernails

2., 3., 4., & 6. Correct: Emphysema is described as a permanent hyperinflation of lung beyond the bronchioles with destruction of alveolar walls. Airway resistance is increased, especially on expiration. Inspection reveals dyspnea on exertion, barrel chest (anteroposterior diameter is equal to transverse diameter), tachypnea, and use of accessory muscles with respiration. Clubbing of fingernails is due to chronically decreased oxygen levels. 1. Incorrect: Atelectasis is collapse of alveolar lung tissue, and findings reflect presence of a small, airless lung. This condition is caused by complete obstruction of a draining bronchus by a tumor, thick secretions, or an aspirated foreign body, or by compression of lung.

The nurse is talking with a group of teenagers who have expressed an interest in getting a tattoo. What information about tattoos should the nurse provide? Select all that apply 1. Apply a moisturizer to the tattooed skin once a day. 2. Carefully consider the tattoo location as weight gain can distort the image. 3. Bloodborne risks of tattooing include Hepatitis and HIV. 4. Tattoo dyes can cause allergic skin reactions. 5. Tattoos can be inexpensively removed with little discomfort. 6. Make sure the tattoo artist removes the needle and tubes from sealed packages.

2., 3., 4., & 6. Correct: Weight gain, including pregnancy weight gain, might distort the tattoo or affect its appearance. If the equipment is contaminated with infected blood, the client can contract various bloodborne diseases, hepatitis B, hepatitis C, and HIV. Tattoo dyes, especially red, green, yellow and blue dyes, can cause allergic skin reactions, such as an itchy rash at the tattoo site. Make sure the tattoo artist removes the needle and tubes from sealed packages before the procedure begins. This decreases the risk of a bloodborne disease. 1. Incorrect: Apply a mild moisturizer to the tattooed skin several times a day. The tattoo needs to remain moist to prevent scab formation. 5. Incorrect: For most people, tattoos should be considered permanent. New procedures for removal are painful and expensive.

A client with leukemia receiving high dose chemotherapy is being evaluated for the development of tumor lysis syndrome. Which lab value should the nurse recognize as being a hallmark sign of the tumor lysis syndrome? 1. Thrombocytopenia 2. Hyperkalemia 3. Hypocalcemia 4. Hyperuricemia 5. Hypomagnesemia 6. Hyperphosphatemia

2., 3., 4., & 6. Correct: When the cells are destroyed or lyse from the chemotherapy, there is a release of potassium and phosphates from the cells. Therefore, hyperkalemia and hyperphosphatemia are direct results of the cellular destruction. Purines are also released during cellular destruction. The purines are metabolized and converted to uric acid, which leads to hyperuricemia. So why is hypocalcemia correct? Do you remember that phosphorus and calcium have inverse relationships? So, if the phosphorus is high, the calcium will be low. That is why the client will have hypocalcemia. 1. Incorrect: Although clients who are on chemotherapy often have thrombocytopenia, or low platelet counts, this is not a hallmark sign of tumor lysis syndrome. 5. Incorrect: Hypomagnesemia is not a hallmark sign of the tumor lysis syndrome. However, as uric acid levels increase from the cellular lysis, the uric acid crystals can create a mechanical obstruction in the renal tubules of the kidneys and lead to acute kidney injury. If the kidneys are not working properly, will magnesium be excreted properly? No! Therefore, a later finding of the kidney injury could be hypermagnesemia, not hypomagnesemia

A client from Indonesia is being admitted to the Labor and Delivery unit. Her spouse brought her to the hospital. She is 39 weeks gestation, her contractions are 4 minutes apart, and she experienced spontaneous rupture of the membranes at home. She does not speak English, but a hospital-based interpreter is present. Which questions by the nurse would be appropriate to ask the client when performing the admission assessment? Select all that apply 1. Are there any odd cultural practices that we need to be aware of in caring for you during labor and delivery? 2. In your culture, are fathers generally present for the delivery? 3. Are there any foods that are not permitted or are requested based on your culture or religion? 4. Do you have any personal beliefs or customs prohibiting physical activity during pregnancy, birth and the postpartum period that you will be observing? 5. Will you be observing any special or culturally accepted way for expression of pain? 6. Are there any special considerations that need to be observed for newborn care?

2., 3., 4., 5., & 6 Correct: The nurse should never assume that the husband will be present for the delivery. For example, in some cultures, the husband is generally not present during labor and delivery because the woman is considered "unclean" during this time. In some cultures, rather than the husband/partner being present for the delivery, the husband's mother or sister often attends to the woman during labor and delivery. Additionally, in some cultures, women often prefer that their own mothers accompany them while in labor and during delivery. If it is determined that the fathers are generally present, the nurse could then question if the woman's husband wishes to be present or if she wishes to have another family member or support person present. Although laboring clients are not generally provided food during labor, the client may be allowed to eat soon after delivery. The nurse should assess for dietary or nutritional considerations that may vary by culture. For example, some cultures practice a system of hot/cold body balance. Since pregnancy is believed to be a hot condition, it is believed that foods that they consider hot should be restricted. Numerous foods that are high in protein are considered to be hot in these cultures and are therefore avoided by the clients. The basis for avoiding these foods is that the body is already considered to be out of balance and they do not want to exacerbate the condition. The client may continue this practice after delivery as well. In some cultures, the food is sent from home for the woman after delivery. Activity is another factor that the nurse should assess. In some cultures, the women prefer to sit or squat during delivery and in other cultures, the women try to remain as still as possible. Following delivery, some cultures have established time frames that the mother should remain inactive or when she should be up moving. The way that women express pain can vary by cultures. For example, some cultures value stoicism. They believe that a woman must experience pain and discomfort as part of the childbirth experience. However some women in other cultures express pain in very loud and expressive ways. It is equally as important for the nurse to assess cultural differences and attitudes toward the use of pain-relief strategies. The nurse should assess how the woman handles pain and if she prefers the use of specific rituals, treatments, or methods when in pain rather than the use of traditional pain medications. Some cultures, such as the Chinese, are taught self-restraint. The laboring woman may refuse pain medication the first time she is asked because her culture considers it impolite to accept something the first time it is offered. Therefore, the nurse may need to be culturally sensitive the first time the pain medication is offered, while making sure to follow up to see if the woman desires pain medication on a subsequent offer. Newborn care must be considered from a cultural standpoint as well. Many cultures have practices surrounding newborn care that the mother may desire to follow. One such example is that Vietnamese and Thai women may believe that the head of the infant is the site of the soul and it should not be touched. There may be other cultural practices that the nurse should be aware of when caring for the woman during labor and delivery, such as with the placenta, circumcision of the infant, and feeding methods. 1. Incorrect: Although assessment of cultural practices to be aware of when providing care is a very important part of nursing care, the nurse should be very careful not to label these practices as "odd", "unusual" or "strange".

A client diagnosed with primary pulmonary hypertension is admitted to the hospital. What does the nurse expect the client to mention when reviewing the client's current treatment regimen? Select all that apply 1. Aminoglycosides 2. Calcium channel blockers 3. Digoxin 4. Diuretics 5. Oxygen 6. Vasodilators

2., 3., 4., 5., & 6. Correct: Calcium channel blockers are given to help relax the muscles in the walls of the blood vessels. Digoxin can help the heart beat stronger and pump more blood. It can help control the heart rate if dysrhythmias are experienced. Diuretics are prescribed to eliminate excess fluid from the body. Oxygen therapy may be prescribed to treat pulmonary hypertension, especially if the client lives at a high altitude or has sleep apnea. Vasodilators are used to open narrowed blood vessels. 1. Incorrect: Aminoglycosides are antibiotics used to treat infections.

What assessments would be appropriate for the school nurse to perform related to school safety practices and emergency preparedness? Select all that apply 1. Teach about gun control laws. 2. Observe for gaps or changes in levels of sidewalks. 3. Identify which students have special healthcare needs. 4. Locate all entrances and exits to buildings. 5. Identify threats and hazards in the school and surrounding community. 6. Perform a check of all fire extinguishers.

2., 3., 4., 5., & 6. Correct: One of the first things that a school nurse should do is to assess where an accident might happen. Observing for gaps or changes in the level of sidewalks is an example of this assessment. The school nurse should assess for special healthcare needs in the event that the school enters a time of extended lockdown. Some students would require attention during the time of lockdown, such as diabetics who could not wait to receive insulin or have food available. All entrances to the schools must be identified to know where a potential entry for intruder might could occur. Some access points may need to be changed to reduce risk to students. Becoming familiar with all exits is crucial to planning timely and safe evacuation of students if needed. The school nurse can draw upon a wealth of information that exists regarding threats or events that have occurred in the past at the school or in the local community in order to plan for possible future events. Fire extinguishers should be checked on a regular schedule for assessment of access, date of expiration, and functionality. 1. Incorrect: Teaching about laws on gun control is not an assessment, but rather an intervention that can be done. Teaching is not the initial step of the nursing process. Assessment comes first.

The nurse is caring for a client who has aphasia. What interventions should the nurse include in the plan of care to improve communication with this client? Select all that apply 1. Increase speaking volume and tone. 2. Present one thought at a time. 3. Use and encourage use of gestures. 4. Do not push communication if client is tired. 5. Give client time to generate a response. 6. Ask questions that can be answered with "Yes" or "No".

2., 3., 4., 5., & 6. Correct: These interventions will help to improve communication. Don't overwhelm the client with multiple thoughts or pushing communication on a tired or anxious client. Gestures such as pointing to something or asking the client to point to what they want will help to increase communication. Using a communication board for the client to point to commonly needed things is helpful. Give extra time to comprehend and respond to communication. Keep questions easy to answer and communication simple. 1. Incorrect: Don't yell at the client. The problem is not inability to hear. Asphasia is loss of ability to understand or express speech caused by brain injury.

A nurse manager has recognized that nurses on one shift do not seem to be working well together and, on occasions, refuse to help each other when needed. What strategy could the nurse manager use that would help with team building? Select all that apply 1. Avoid discussing conflicts to build a positive work environment. 2. Model behaviors that create a caring environment and promote trust. 3. Create a shared vision of the unit and agency mission and purpose. 4. Recognize nurses who demonstrate commitment to team efforts. 5. Make nurses aware of the messages that their behaviors send to the team. 6. Have nurses agree upon roles, responsibilities, and proper lines of communication.

2., 3., 4., 5., and 6. Correct: The nurse manager needs to incorporate strategies that are effective in team building. One important thing that a nurse manager can do when trying to get nurses to work as a team is to actually model behaviors that promote trust and create a caring environment for not only the clients, but also the nurses and other staff as well. Trust is a cornerstone when trying to build team relationships. In order for nurses to recognize a need for teamwork and reduce conflict, they should have a clear understanding of the unit and agency mission and purpose. The unit manager should assure that this is clearly documented and articulated to the nurses and staff on the unit. The nurse manager should help each nurse and staff member understand how they fit into the overall purpose and goals of the unit and agency. We all know that recognition tends to foster positive behaviors. The nurse manager should recognize nurses who demonstrate commitment to team efforts. This can be done with tangible or nontangible rewards. So, why should nurses be made aware of the messages being sent to the other team members by their behaviors? These nurses may not realize how their unwillingness to work as a team negatively impacts the healthcare team as a whole. They may think that as long as they take care of their clients the way that they want to, everything should be fine. Nurse managers can help nurses to see how their behaviors affect client care and team relations. Once the nurses have agreed upon the roles and responsibilities as part of the healthcare team and understand the lines of communication, they are more likely to follow through with these. Communication by the nurse manager will be crucial in carrying out this team building strategy where all team members agree upon what needs to be accomplished and who to communicate with along the way. 1. Incorrect: It is the nurse manager's responsibility to address the conflict and issues that arise. Failure of the nurse manager to address conflicts within the workplace often fuels more conflict. In addition, the team members often lose respect for the nurse manager who does not discuss and help to resolve the issues. Conflict avoidance can have long term effects on the nursing unit and the agency and can stifle productivity and success of the unit.

A community health nurse is presenting a seminar to a group of senior citizens on ways to reduce the risks of peripheral artery disease (PAD). What topics should the nurse include? Select all that apply 1. Anti-embolic stockings 2. Smoking cessation 3. Moderate exercise 4. Application of heat 5. Low cholesterol diet 6. Decrease blood pressure

2., 3., 5. & 6. Correct: Senior clients are at increased risk for peripheral artery disease for a variety of reasons, though many erroneously believe that this process is an unavoidable part of the aging process. Educating clients on preventative activities will help reduce incidence of atherosclerosis and improved mobility along with quality of life. Smoking is a major risk factor in developing PAD by contributing to arterial constriction. Clients can increase collateral circulation with a moderate exercise program of at least 30 minutes three times a week. A low cholesterol, heart healthy diet with more fruits and vegetables helps reduce cholesterol while decreasing blood pressure, both important goals towards controlling PAD. 1. Incorrect: Increasing arterial blood flow is important in the prevention or management of peripheral artery disease; however, anti-embolic stockings are designed to improve venous return in clients with decreased mobility. The use of these stockings would actually hinder arterial flow in lower extremities. 4. Incorrect: Clients with PAD often complain of cold extremities secondary to decreased arterial blood flow. But the application of heat such as use of a heating pad is unsafe and is always contraindicated in the elderly with PAD. Inability to sense temperature extremes may result in serious burns to lower extremities. Additionally, clients with PAD do not heal as well from injuries or wounds.

A nurse manager is monitoring staff nurse compliance with regulatory guidelines regarding administration of controlled substances. Which actions by the staff nurses indicate to the nurse manager compliance is being maintained? Select all that apply 1. Removes meperidine from computer controlled dispensing system and places in client medication drawer for later use. 2. Second nurse verifies and signs as a witness to morphine 2 mg wasted according to facility protocol. 3. Verification is made of the number of narcotics available against the inventory record prior to narcotic removal. 4. Second nurse provides verifying signature for removal of hydromorphone from the computer controlled dispensing system. 5. Narcotic discrepancy in the computer controlled dispensing system is reported to the primary healthcare provider.

2., 3., Correct: These are all correct actions to meet compliance with regulatory guidelines regarding administration of controlled substances. When controlled substances must be wasted, the disposal must be witnessed by two healthcare providers who are licensed to dispense drugs and documented by signing of both healthcare providers. These substances are controlled due to the potential for abuse. 1. Incorrect: Controlled substances must remain under a locked system. When removed, the medication should be administered at that time. 4. Incorrect. A second nurse is not needed when the narcotic is removed from a computerized machine, as it keeps up with the medications. 5. Incorrect: Narcotic discrepancy would be reported to pharmacy and the nursing supervisor, not the primary healthcare provider.

An elderly client diagnosed with Stage 4 cancer is anxiously awaiting the primary healthcare provider to discuss possible care options. What is the appropriate way for the nurse to assist the client? Select all that apply 1. Assure the client that the healthcare provider will present all the best options. 2. Assist client to make list of questions to ask prior to the discussion. 3. Offer to remain with the client during healthcare provider's visit. 4. Suggest the presence of a family member could be helpful to client. 5. Provide written information to client about cancer treatments.

2., 3., and 4. CORRECT: Consider this client has been diagnosed with Stage 4 cancer. The thought of cancer can quickly overwhelm a client, making it difficult to hear and focus on information. It will be very helpful for the nurse to assist the client to create a list of questions which may otherwise be forgotten when the primary healthcare provider arrives. It will also be useful to have the nurse present during the discussion since the client may need some clarification after the fact. Though there is no indication the client has family, it would be beneficial if the client would allow family to be present during the discussion. The emotional support is often extremely positive to help the client cope with the information. 1. INCORRECT: This false reassurance does not provide any details that may be helpful for client. Also, the nurse is assuming the healthcare provider is aware of all possible cancer treatments that exist. 5. INCORRECT: While some clients benefit from written information, handing brochures to an anxious client is not one of the most appropriate ways to assist the client. The nurse is not focusing directly on the client's emotional needs at this point.

The nurse is discussing appropriate toys for toddlers with a group of parents. What toys should the nurse include? Select all that apply 1. Board games 2. Finger paint 3. Swing set 4. Water squirting toys 5. Play telephone 6. Wooden spoons

2., 4., 5., & 6. Correct: Finger painting, water squirting toys, play phones, and wooden spoons are appropriate toys for the toddler. 1. Incorrect: Simple board games are appropriate for the preschooler. It is too soon to introduce board games to a toddler. 3. Incorrect: A swing set is appropriate for the preschooler if they are supervised.

When explaining to caregivers how to reduce the risk of falls in their elderly parent, the nurse should educate about which measure? Select all that apply 1. Allow the parent to wear shoes that are most comfortable. 2. Assure there is adequate lighting with minimal glare. 3. Use sharply contrasting colors at edges of stairs. 4. Install grab bars beside the shower, tub, and toilet. 5. Encourage the parent to have an inside pet for comfort. 6. Rearrange the furniture for the parent to prevent stagnation.

2., 3., and 4. Correct: Adequate lighting with minimal glare is best to assure there is the amount of illumination needed for safe mobility. Marking the edges of stairs with sharply contrasted colors can help to reduce falls by alerting the elderly client of the change in the elevation of the walkway. The risk of falls in the bathroom can be diminished by installing grab bars to help stabilize the elderly client as they make position changes or transition from the tub, shower, or toilet. 1. Incorrect: Just because the shoes are the most comfortable does mean that they are safe to wear. They may have slick soles, be loose fitting, or have other unsafe issues. Improperly fitting shoes can create a hazard and increase the risk of falls. Unsafe footwear is one of the more common, treatable causes of falls in the elderly. 5. Incorrect: Pets often get in the path of individuals when walking and can create a tripping hazard. Having pets in the home is another one of the more common, treatable causes of falls in the elderly. 6. Incorrect: Elderly individuals manage better when the surroundings are familiar and are kept in the same arrangement. Changes in the environment can increase the risk of falls when objects are no longer where the older adult is accustomed to them being placed.

he nurse is preparing a seminar for a group of clients diagnosed with irritable bowel syndrome. Which point should the nurse include? Select all that apply 1. Teach about a low fiber diet. 2. Schedule meals at regular times. 3. Fluid should be taken with meals. 4. Become active in yoga classes. 5. Keep a food diary for 2 weeks.

2., 4. & 5. Correct: Eating at regular intervals and chewing foods slowly and thoroughly will help to manage symptoms. Additional strategies include maintaining good dietary habits with avoidance of food triggers. Stress management via relaxation techniques, yoga, or exercise are recommended. Identify irritating foods by keeping a food diary for 1-2 weeks. 1. Incorrect: This client needs a high soluble fiber diet to help control diarrhea and constipation. Dietary fiber and bulk help the client by establishing regular bowel elimination patterns with soft, bulky stools. 3. Incorrect: Although adequate fluid intake is necessary, fluid should not be taken with meals because this results in abdominal distention.

A client arrives to the emergency department after an altercation resulting in a knife wound to the abdomen. The nurse makes the following observation. Which intervention should the nurse perform? 1. Place the client in trendelenburg position. 2. Instruct the client to lie quietly in a low Fowler's position. 3. Apply abdominal binder to gently place the intestines back in the abdominal cavity. 4. Cover exposed intestine with sterile dressings moistened with sterile saline. 5. Notify the surgeon at once.

2., 4. & 5. Correct: Low Fowler's position and staying calm and quiet help to minimize protrusion of body tissues. Cover exposed intestines with sterile dressings moistened with sterile saline solution. Have someone notify the surgeon at once and you stay with the client and stay calm. 1. Incorrect: The client should be placed in the low Fowler's position and instructed to lie quietly. These actions minimize protrusion of body tissues. 3. Incorrect: Never push eviscerated abdominal contents back! And do not apply pressure with an abdominal binder. This client needs to go back to surgery.

What interventions should the nurse include when teaching a client how to prevent and treat fungal infections of the feet? Select all that apply 1. Apply cornstarch to the feet after bathing. 2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 3. Wear socks at all times until infection has cleared up. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe.

2., 4. 5, & 6. Correct: Athlete's foot is treated with topical antifungal in most cases. Severe cases may require oral drugs. The feet must be washed daily with soap and water and dried thoroughly since the fungus thrives in moist environments.Steps to prevent athlete's foot include wearing shower sandals in public showering areas and wearing shoes that allow the feet to breathe. 1. Incorrect: Clients with fungal skin infections should avoid the use of cornstarch. The carbohydrates in cornstarch may provide nutrition to fungal infections and should be avoided. 3. Incorrect: Allow feet to have exposure to the air. The feet must be kept clean and dry since fungus thrives in moist environments. Keeping the feet covered all the time causes a dark, moist environment for the fungus to thrive.

A client at 28 weeks gestation reports swollen hands and feet during her prenatal visit. Which additional signs/symptoms would be of concern to the nurse? Select all that apply 1. Decreased deep tendon reflexes 2. Blurred vision 3. Blood glucose 120mg/dL (6.7 mmol/L) 4. Muscle spasms 5. Headache

2., 4., & 5 Correct: Muscle spasms indicating nerve/muscle irritation. Headache and blurred vision are indicators of increasing blood pressure. This client is going into preeclampsia. 1. Incorrect: No, the deep tendon reflexes will be hyperactive (increased) with preeclampsia. 3. Incorrect: Mild blood sugar elevation is not related to preeclampsia.

Which nursing actions should the nurse initiate for a client with signs of increased intracranial pressure (ICP)? 1. Encourage coughing and deep-breathing. 2. Administer corticosteroids. 3. Position client in the prone position. 4. Determine ability to swallow prior to administering po fluids. 5. Maintain head in neutral alignment.

2., 4., & 5. Correct: Administer corticosteroids to reduce inflammatory response seen in acute brain injury. If I have increased ICP, my reflexes could be suppressed, so check my swallowing. Maintain head in neutral alignment to prevent decrease in venous flow which would increase the ICP. 1. Incorrect: Coughing and deep breathing make the ICP go up. 3. Incorrect: This position makes the ICP go up.

The nurse is preparing to educate a group of clients on how to decrease the risk of developing recurrent renal calculi. What topics should the nurse include? Select all that apply 1. High-purine foods to consume 2. Discuss diuretic use to prevent urinary stasis 3. Straining urine with each void 4. Maintaining a daily water intake of at least 2 liters 5. Foods low in calcium

2., 4., & 5. Correct: Diuretics are often used to prevent urinary stasis and further calculus formation. Thiazides decrease calcium excretion into the urine. Daily fluid intake should be 2-3 liters per day to ensure good renal function. Most stones are calcium stones, so decrease calcium in the diet to reduce the chance of calcium stones.

A nurse is caring for a client who has been prescribed metoprolol. What education should the nurse provide to the client? 1. Information on skin turgor. 2. Check for edema in lower extremities. 3. Take medication 30 minutes prior to a meal. 4. Do not use over the counter (OTC) nasal decongestants. 5. Notify primary healthcare provider if the pulse is < 60 beats per minute.

2., 4., & 5. Correct: Heart failure is one of the diagnoses that is an indication for the prescription on metoprolol. If the client is experiencing swelling of the lower extremities, the primary healthcare provider should be notified to evaluate the prescription of metoprolol. The client should avoid taking over the counter (OTC) nasal decongestants because they contain alpha-adrenergic stimulants, when metoprolol is prescribed. The combination of taking both medications can increase the client's risk for orthostatic hypertension. The primary healthcare provider should be notified if the client's pulse rate is < 60 beats per minute. Bradycardia is a cardiovascular side effect of metoprolol. 1. Incorrect: Skin turgor reflects the presence of dehydration. Since dehydration is not a side effect of metoprolol, the technique of monitoring skin turgor is not included in the client's medication education. 3. Incorrect: Metoprolol should be taken right after meals, and not taken prior to the meal. There is a decreased absorption rate of metoprolol with increased stomach contents .

The nurse is providing care to a client who is post laparoscopic cholecystectomy. Which finding would be of concern? Select all that apply 1. Right upper quadrant abdominal discomfort 2. Clay colored stool 3. Light yellow urine 4. Pruritus 5. Icteric sclera

2., 4., & 5. Correct: Injury to nearby structures, such as the bile duct, liver and small intestine can occur after this surgery. Clay colored stools and jaundice of the sclera are caused by recurring stricture or stone of the common bile duct. Pruritus occurs when bile reaches the skin.

Which statements made by a client diagnosed with Addison's disease indicates to the nurse that the client understands fludrocortisone therapy? Select all that apply 1. "Taking my medicine at night will help me sleep." 2. "It is important to wear a medical alert bracelet all of the time." 3. "I will limit my sodium intake to 200 mg per day." 4. "My medication dose will change based on my daily weight." 5. "I may need more medication if I feel weak or dizzy."

2., 4., & 5. Correct: Medical alert bracelet is an excellent way of informing healthcare providers of a life threatening condition if the client is unable to verbalize that information. Steroid therapy is adjusted according to the client's weight and signs of fluid volume status. Signs of being undermedicated include weakness, fatigue, and dizziness. The client will need to report these symptoms, so more medication can be given to the client. 1. Incorrect: Steroids can cause insomnia so the client does not need to take the medication prior to going to bed. 3. Incorrect: This client needs a high sodium diet as they are losing sodium and retaining potassium.

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

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

Which assessment finding by the nurse is likely to be the result of long-term corticosteroid use in a client? Select all that apply 1. Occasional nausea that occurs after eating the evening meal. 2. A wound that is slow to heal. 3. Weight loss of 15 pounds (6.8 kg) over a 6 week period. 4. The appearance of acne on the forehead and cheeks. 5. Vertebral compression fracture.

2., 4., & 5. Correct: Suppression of the immune system occurs with long-term steroid use. This leads to slow wound healing. Acne is sometimes seen with steroid use due to oily skin and overproduction of the acne bacterium. Osteoporosis risk is increased with long-term use of steroids. Remember steroids pull calcium from the bone and place it in the blood. 1. Incorrect: Nausea is not commonly seen with steroid use. 3. Incorrect: Changes in metabolism usually lead to weigh gain, not weight loss.

What should the nurse include when planning discharge teaching for a client post scleral buckling of the right eye? 1. Redness, tenderness and swelling should be gone within 2 days. 2. Teach to report seeing flashes of light immediately. 3. Place eye drops onto the cornea of the affected eye. 4. Wear eye shield during naps, and at night. 5. Have client demonstrate the correct technique for instilling eye drops.

2., 4., & 5. Correct: The client should be taught the signs/symptoms of retinal detachment, such as seeing flashes of light, floating spots or blurred, "sooty" vision, or a veil-like curtain obscuring parts of the visual field. The client should wear either an eye shield or glasses during the day, during naps, and at night. The client will need to instill eye drops into the affected eye appropriately to avoid injury and infection.

A nurse is teaching a group of expectant parents about epidural anesthesia. What information should the nurse include? Select all that apply 1. Contraindications for an epidural include a previous cesarean section. 2. Post procedure position should be side lying. 3. Headache is a post procedure side effect. 4. The major complication is hypotension. 5. Usually administered at 3-4 cm dilation.

2., 4., & 5. Correct: The client should not lie supine but should position self in a side-lying position. This will prevent compression on the vena cava. The major complication of epidural anesthesia is hypotension and supine position increases the risk. If this occurs, a bolus with 1000 mL of NS or LR to increase blood pressure by increasing vascular volume. Epidurals are usually placed during stage 1 at 3-4 cm dilation. 1. Incorrect: Previous C-sections do not eliminate the ability to have an epidural. Epidurals are commonly utilized for anesthesia during a cesarean birth. 3. Incorrect: A sterile guide needle and a small epidural catheter is placed between the spinal cord and the outer membrane. There is usually no headache since the needle does not enter the spinal column but rather the epidural space.

The post-operative craniotomy client's urinary output suddenly increases to 325 mL in 30 minutes. Which nursing action takes priority? 1. Check urine specific gravity 2. Measure ICP level 3. Obtain blood pressure 4. Monitor CVP

A client arrives to the after hours clinic with reports of palpitations and skipping heart beats. The nurse notes the client to be alert and oriented with a BP of 124/76, HR irregular at 95 beats per minute, respirations at 18 breaths per minute, and is afebrile. Cardiac monitoring is initiated. Based on this data, what questions should the nurse ask the client? Exhibit Select all that apply 1. "Have you been prescribed a tricyclic antidepressant?" 2. "Have you been experiencing more stress than usual in your life?" 3. "Does this generally begin when you are having a bowel movement?" 4. "How many cups of coffee do you drink each day?" 5. "What over the counter medications do you take?" 6. "Have you been running a fever?"

2., 4., & 5. Correct: This rhythm strip is showing that the client has normal sinus rhythm with premature atrial contractions (PACs). Common causes of PACs include stress and excess caffeine intake from coffee, tea, colas, and over the counter medications that contain caffeine. 1. Incorrect: Tricyclic antidepressants can result in a client developing premature ventricular contractions (PVCs) due to sedation and decreased oxygenation. 3. Incorrect: When the vagus nerve is stimulated, it can cause bradycardia and sinus arrest rather than premature atrial contractions. 6. Incorrect: Fever tends to increase the heart rate so that sinus tachycardia would be seen.

An elderly widower has been admitted to a psychiatric crisis unit with a diagnosis of major depression with agitation. What behaviors would the nurse expect to observe during an initial assessment? Select all that apply 1. Memory loss 2. Difficulty focusing 3. Excessive sleepiness 4. Short-tempered 5. Hand-wringing

2., 4., & 5. Correct: This type of depression is characterized by the added component of agitation. The client experiences difficulty focusing because of racing thoughts and restlessness. Other symptoms include incessant talking along with short-tempered outbursts of anger towards everyone. The inability to sit still is commonly accompanied by fidgeting or hand-wringing, which would be apparent to the nurse during an initial assessment. 1. Incorrect: Despite the client's agitation, racing thoughts and difficulty focusing, there is no actual memory loss at any point during this activity. 3. Incorrect: While excessive sleepiness may be typical of depression, the agitation which accompanies this disorder makes it very difficult to relax or sleep at all.

An elderly client who lives alone is being discharged home following a total hip replacement. The home care nurse is completing a safety assessment of the home environment prior to the client's arrival. Which conditions would require modifications to ensure client safety? Select all that apply 1. Wall-to-wall carpeting 2. Entrance throw rugs 3. Downstairs bathroom 4. Rail-free porch stairs 5. Step stool in kitchen

2., 4., & 5. Correct: Throw rugs are loose fall hazards that should be removed or tacked down to prevent tripping, particularly for a client whose mobility is impaired by hip surgery. Both inside and outside stairs should have hand rails to provide stability when in use. The presence of a step stool in the kitchen indicates that some items in the cupboards are out of reach for the client. Rearranging frequently used items to within the client's reach would be much safer than using a step stool. 1. Incorrect: Wall to wall carpeting does not generally present safety issues since it is attached to the floor on all four sides and does not move even if the client were shuffling on the surface of the carpet or using a walker. 3. Incorrect: The existence of a downstairs bathroom is a positive feature that alleviates the need for the client to climb stairs frequently during the day. Stairs are challenging for elderly adults, plus this client also has limited mobility following a total hip replacement.

The nurse is caring for a heart failure client taking spironolactone. Which snack choices would indicate to the nurse that the client understands proper dietary choices while on this medication? Select all that apply 1. Bananas 2. Cheese and crackers 3. Apples 4. Sweet potatoes 5. Grapes

3. & 5. Correct: Apples and grapes are low in sodium and potassium. Spironolactone is a potassium sparing diuretic. The client with heart failure needs to limit sodium and potassium. 1. Incorrect: The action of spironolactone is to inhibit the reabsorption of sodium in the kidney while saving potassium. It is a diuretic so the client will lose water. Bananas are high in potassium.2. Incorrect: Cheese and crackers are high in sodium. Spironolactone is given to lower BP and decrease fluid. Foods high in sodium should be limited. 4. Incorrect: The action of spironolactone is to inhibit the reabsorption of sodium in the kidney while saving potassium. It is a diuretic so the client will lose water. Sweet potatoes are high in potassium.

The nurse is assisting a client with right-sided weakness to transfer from the hospital bed to a wheelchair. The client has an IV attached to an IV pole on the right side of the bed. How should the nurse complete this transfer? Select all that apply 1. Place the wheelchair on the left side of the bed. 2. Place the wheelchair on the right side of the bed. 3. Face the wheelchair toward the foot of the bed. 4. Face the wheelchair toward the head of the bed. 5. Have client grab the wheelchair with the right arm. 6. Have client grab the wheelchair with the left arm.

2., 4., & 6. Correct: The wheelchair should be placed on the right side of the bed where the equipment is located. It needs to face the head of the bed so the client can reach the chair with the strong left arm to help with the transfer. The client should grab the wheelchair arm with the strong left arm. 1. Incorrect: Since the IV and IV pole are on the right side of the bed, the wheelchair should be placed on the right side rather than the left side of the bed. There would not be enough slack in the IV tubing to get out on the left side. 3. Incorrect: If the wheelchair faces the foot of the bed, then the client would not be able to reach with the wheelchair arm with the strong left arm. The client needs to be able to use the left arm for stability. 5. Incorrect: The client should grab the wheelchair arm with the strong left arm. The right side is weak and grabbing with this side puts the client at an increased risk for falls and injury.

Which signs/symptoms should the nurse assess for when caring for a client diagnosed with bulimia nervosa? Select all that apply 1. Increased thirst 2. Muscle cramps 3. Blurred vision 4. Tingling of lips 5. Constipation

2., 4., 5. Correct: The typical abnormalities associated with bulimia are hypokalemia and metabolic alkalosis because of the binging and purging process. This leads to muscle cramps, weakness, fatigue, constipation, and arrhythmias are all symptoms of this electrolyte and acid-base imbalance. Hypokalemia leads to metabolic alkalosis.1. Incorrect: Increased thirst is a sign of hyperglycemia and would not be the concern with someone that is purging. This client would be more likely to be hypoglycemic instead. 3. Incorrect: Blurred vision is a sign of hyperglycemia because of the effect of too much glucose in the small vessels of the eye. Microvascular damage is one of the biggest concerns with hyperglycemia; the bulemic client would be hypoglycemic.

The nurse is discussing appropriate toys for toddlers with a group of parents. What toys should the nurse include? 1. Board games 2. Finger paint 3. Swing set 4. Water squirting toys 5. Play telephone 6. Wooden spoons

2., and 5. CORRECT: The nurse is evaluating client safety at home following a stroke, observing for any actions that might be unsafe. With right arm weakness and instability of the right leg, pouring boiling water directly from a pan into a cup is dangerous. Pouring liquid from an open pan could easily spill or splash hot water on the client. Additionally, placing a large, filled casserole into a hot oven could throw the client off balance, again leading to burns. 1. INCORRECT: The nurse would not be concerned about the client using skid-proof shoes, particularly in a kitchen where there could be food or liquids on the floor. This is safe action when cooking food. 3. INCORRECT: Because of physical disabilities, it is safer for the client to use a microwave than the oven. The microwave has a small opening and no overwhelming heat when the door is opened. The smaller plates or bowls used are easier and safer for the client to handle. 4. INCORRECT: An electric chopper is far safer than trying to manage a knife with a weakened hand. Placing vegetables into the chopper and closing the lid prevents the client from being exposed to an open knife blade.

The nurse is making an initial homecare visit to a client following a stroke. The client has right arm weakness and a limp in the right leg. While evaluating the client's ability to prepare food, the nurse is most concerned about what actions? Select all that apply 1. Uses skid-proof shoes when walking in kitchen. 2. Pours boiling water from pan into cup of tea. 3. Heats food in microwave instead of the oven. 4. Uses electric chopper to dice up vegetables. 5. Prepares and cooks large casserole in oven.

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? ______mL. 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

The nurse admits a client with a cspine injury to the neuro intensive care unit (ICU). The admission assessment is completed. What is the nurse's priority intervention? Client reports blurred vision and a headache rated 9/10. BP 200/110, pulse 55. 1. Monitor BP every 15 minutes 2. Loosen tight clothing 3. Elevate the head of the bed to high fowlers 4. Administer hydralazine

A client admitted to a long-term care facility is legally blind and partially deaf. How would the nurse best provide for the client's safety in the event of an emergency? Select all that apply 1. Have roommate lead client out of the room to safety area. 2. Assign a specific UAP every shift to escort client to safety. 3. Research established protocols utilized by emergency groups. 4. Discuss best communication methods with client and family. 5. Plan for the supervisor to be responsible for evacuating the client.

3 & 4. Correct: When faced with a new or challenging situation involving client safety, the nurse manager should employ the Nursing Process to assess needs and collect contributing data. Asking for input from emergency preparedness groups, such as the Red Cross or FEMA, could provide ideas about assisting individuals with sensory deficits. Secondly, the nurse should discuss the situation with both client and family to determine appropriate methods of communicating with client, particularly in an emergency situation. 1. Incorrect: The responsibility for client safety should never be placed on a roommate or even family members. Staff should be accountable for client safety at all times. 2. Incorrect: Assigning a specific UAP each shift to locate and escort client to a safe area would be confusing. Changing protocols every shift creates a hazardous situation for staff and clients. 5. Incorrect: The facility supervisor is responsible for all aspects of an emergency, including activation of alarms, coordinating evacuation of staff and clients, and initiating facility emergency protocols such as closing fire doors or turning off oxygen valves. It would not be safe for the supervisor to also be responsible for a single individual.

A homecare nurse is attempting to visit clients isolated during the pandemic. Upon arriving at one small rural home, the nurse discoveries the client is almost out of food, has no wood for heating and has a broken water faucet. The client is alert, oriented and refuses to leave the home. There is no family to help the client. How could the nurse best assist the client to remain home at this time? Select all that apply 1. Call local ambulance crew to transport client to the hospital. 2. Ask the healthcare provider to order emergency placement. 3. Request immediate evaluation by senior protective services. 4. Run to the local store to obtain food and water for the client. 5. Develop a plan of care with client, based on present needs.

3 & 5. Correct: In such an unstable environment, the nurse should not leave this client. Attempts should be made to correct client needs as quickly as possible. Senior services are available in most areas and have extensive resources which can readily provide the help needed, including food, heating and even repairs for the plumbing. In the meantime, the nurse could evaluate what supplies the client may have on the premise and create temporary solutions for the current issues. The important point is the nurse should remain with the client until the situation is stable, with at least the basic needs of food and water corrected, and possibly providing heat from alternative sources. 1. Incorrect: The client has no physical or psychologic issues requiring transport to an emergency room. Ambulance personnel cannot force an individual to go to the hospital, and insisting the client do so could be considered harassment or even assault. 2. Incorrect: The client is of sound mind and cannot be forced to leave the home, even with an order from the healthcare provider. This is not a psychological emergency. 4. Incorrect: While obtaining food and water is a basic need for the client, the nurse realizes it is not appropriate to leave the client to do so. It is better to remain with the client until the situation is stabilized and use the phone to request whatever may be needed.

The house supervisor has sent an LPN to assist on a busy medical-surgical unit. Which client could the charge nurse assign to the LPN? Select all that apply 1. Being discharged with a new Hickman port. 2. With a deep vein thrombosis (DVT) on a heparin infusion. 3. Two-days post gastric bypass taking clear liquids. 4. With Alzheimer's disease awaiting transfer to nursing home. 5. New transfer from post-anesthesia care unit (PACU) following a mastectom

3 and 4. CORRECT: An LPN should be assigned stable clients who do not require initial teaching or frequent assessments. The client who is two days post gastric bypass has already advanced to clear liquids and would be appropriate for an LPN. Also, a client who has Alzheimer's disease awaiting transfer would have needs that could be addressed by an LPN, and therefore is a suitable assignment. 1. INCORRECT: This client has a new Hickman port which is an implanted access device used for chemotherapy or medications given long term. There is a great deal of teaching necessary regarding the care of this port. This client should be assigned to an RN. 2. INCORRECT: This client will need frequent assessment of circulation in the area of the DVT and monitoring for evidence of bleeding complications. Additionally, PTT levels will be drawn every 6 hours that may require the nurse to adjust the heparin infusion rate. This client is not appropriate for an LPN. 5. INCORRECT: This fresh post-op client will require frequent vitals and assessment of the surgical dressing following this surgery. This client would be assigned to an RN.

A nurse is planning to teach a group of adult males in their 40's about health care promotion recommendations. Which recommendations should the nurse include? Select all that apply 1. Do bi-annual skin self-exam to check for new moles or changes in moles. 2. Comprehensive eye exam every 5 years starting at age 45. 3. Limit alcohol intake to no more than two drinks per day. 4. Yearly physical exam from a health care provider. 5. Get at least 30 minutes of moderate physical exercise on most days of the week.

3, & 5. Correct: If a client must drink alcohol, they should do so only in moderation. For men, that means up to two drinks a day for men age 65 or younger and one drink a day for men over age 65. The risk of various types of cancer, such as liver cancer, appears to increase with the amount of alcohol ingested and the length of time that one has regularly been drinking. Too much alcohol can also raise blood pressure. Physical exercise can go a long way toward managing stress and controlling weight. Controlling stress and obesity can decrease the risk of many health risks such as heart disease, diabetes, and stroke. 1. Incorrect: Do monthly skin self-exam to check for new moles or changes in moles. 2. Incorrect: Comprehensive eye exam every 2 years is recommended. Changes in vision is a relatively common problem for people in their 40s. They may find that glasses are needed for the first time in their life. They may need glasses to see at a distance or for reading. 4. Incorrect: Physical exam every 2-3 years when no health issues exist including height, weight, and BMI. Routine blood tests, urinalysis and mental health screening is conducted at this time.

What measures should the school nurse implement for a child diagnosed with peanut allergies? Select all that apply 1. Keep a lidocaine auto-injector readily available. 2. Obtain assessment data about visual acuity, and health conditions that might affect food allergy management. 3. Maintain contact information for parents and primary healthcare provider. 4. Review history of known food allergens and the severity of previous reactions. 5. Train designated personnel to administer prescribed medication in an anaphylaxis emergency.

3, 4, & 5. CORRECT: Schools should maintain parent/legal guardian and primary healthcare provider contact information, including a prescribed emergency plan of care for all students with known food allergies. Food allergy information should be completed for every child identified with a food allergy and maintained in the student health record. A licensed health care professional such as a registered nurse, doctor, or allergist should train, evaluate, and supervise unlicensed assistive personnel or delegated non-health professionals. This training should teach staff how to recognize the signs and symptoms of a reaction, administer epinephrine, contact EMS, and understand state and local laws and regulations related to giving medication to students. 1. INCORRECT: Injectable lidocaine is a local anesthetic used for local or regional anesthesia. It is not a recommended or effective treatment for anaphylaxis. 2: INCORRECT. Allergic reactions can cause the eyes to become red, itchy, burning and watery, along with swollen eyelids. They pose no threat to eyesight, other than possible temporary blurriness.

The nurse is reinforcing the dietary discharge instruction for a client prescribed warfarin. Which food choices should be avoided on the warfarin dietary instruction plan? Select all that apply 1. Corn 2. Carrot 3. Spinach 4. Broccoli 5. Watermelon

3. & 4. Correct: Clients prescribed warfarin will need to reduce the intake of food sources with high levels of vitamin K. High levels of vitamin K interfere with warfarin by decreasing the effectiveness of warfarin to prevent blood clots. The vitamin K level of 1 cup of raw spinach is 144.87 mcg. The vitamin K level of 1 cup of raw broccoli is 92.46 mcg. Because spinach and broccoli are high in vitamin K, the client should eat sparingly or refrain from eating spinach, and broccoli. 1. Incorrect: There is 0.31 mcg of Vitamin K in 1.0 ear, medium (6-3/4" to 7-1/2" long) of corn. This level of vitamin K in the corn can be consumed with warfarin. The vitamin K level of corn will not interfere with the action of warfarin. 2. Incorrect: The level of vitamin K in a cup of raw carrots is 16.9 mcg. Carrots will not reduce the action of warfarin, due to the low level of vitamin K in corn. 5. Incorrect: The content of vitamin K in a cup of watermelon is 0.15 mcg. Due to the low level of vitamin K in watermelon. Watermelon will not lower the effectiveness of warfarin.

Which signs and symptoms will the nurse include when teaching a client about indicators of recurrent nephrotic syndrome? Select all that apply 1. Dysuria 2. Hematuria 3. Foamy urine 4. Periorbital edema 5. Weight loss

3. & 4. Correct: Foamy urine, which may be caused by excess protein in the urine, is seen with nephrotic syndrome. Swelling (edema), particularly around the eyes (periorbital) and in the ankles and feet, is a symptom.1. Incorrect: Dysuria would be a symptom of disorders such as kidney stone or UTI, rather than nephrotic syndrome.2. Incorrect: Proteinuria rather than hematuria is seen.5. Incorrect: Weight gain is seen with renal disorders due to poor renal function and increased fluid volume.

A client is being discharged with halo traction. What should the nurse teach about home care of this traction? Select all that apply 1. Showering is permitted. 2. Apply baby powder under the halo vest to prevent irritation. 3. Never pull on any part of the halo traction. 4. Clean around pins at least twice a day using sterile technique. 5. Driving is allowed after discharge.

3. & 4. Correct: Never pull on any part of the halo traction. It can damage or loosen the traction. Pin care is done to prevent infection. Clean around pins at least twice daily with sterile q-tip applicator. Use a new sterile q-tip for each pin site to decrease contamination from one pin site to another. Do not use ointments or antiseptics unless prescribed. 1. Incorrect: Client should never attempt a shower since there is no reliable way to keep vest liner dry. Take sponge baths or sit in a bathtub with about 2-3 inches of water. Use towels or plastic to keep vest from getting wet. 2. Incorrect: Do not use soaps, creams, lotions or powders beneath the vest as these may irritate the skin. 5. Incorrect: Absolutely no operating a motor vehicle until the primary healthcare provider allows this activity: field of vision and movement is narrowed and/or diminished. The client is an impaired driver and could cause an accident.

The nurse is caring for a client with body dysmorphic disorder. The client tells the nurse, "My ugly ears make everyone sick!" Which defense mechanism is this client utilizing? Select all that apply 1. Sublimation 2. Somatization 3. Symbolism 4. Projection 5. Conversion

3. & 4. Correct: Symbolism and projection are the correct answers. Symbolism is the unconscious process by which one object or idea comes to represent another. The client's ears symbolize everything distasteful and unacceptable to her/him. Projection is the unconscious process by which an individual attributes one's own intolerable wishes, emotions, or motivations to another person. The client states that others are horrified by the ears, but actually the client is horrified by them. 1. Incorrect: Sublimation is the unconscious process of substituting acceptable impulses for unacceptable ones. Sublimation is not shown in this scenario. 2. Incorrect: Somatization has significant functional impairment as recurrent medical symptoms appear, but no physical cause can be identified. This is not shown in this scenario. 5. Incorrect: Conversion is marked by deficits in voluntary motor or sensory function. Conversion is not shown in this scenario.

The charge nurse on the pediatric unit has several tasks that need to be completed. What tasks can be assigned to the unlicensed assistive personnel (UAP)? Select all that apply 1. Obtain a urine sample from an infant. 2. Empty a nasogastric (NG) canister for client with ileus. 3. Feed a child with bilateral burns of hands. 4. Change an ostomy appliance on child with stoma. 5. Ambulate an adolescent two days post appendectomy.

3. & 5. CORRECT: A UAP can perform any activities of daily living (ADL), including transfers in or out of bed and ambulation. Feeding clients is considered an ADL which can be performed by a UAP, so feeding a child whose hands are bandaged is an appropriate task. Also, ambulating the adolescent is definitely within the scope of duties for the UAP. 1. INCORRECT: Obtaining a urine sample from an infant is too complex for a UAP. The two methods used for collecting this urine sample is either straight catheterization of the infant or use a "wee bag". Neither of these methods can be performed by a UAP. 2. INCORRECT: Emptying containers can be within the realm of duties for a UAP. However, that does not include a NG canister. A nurse must assess the color, consistency, and amount of drainage in the canister in addition to location and position of the NG tube. This particular action should be completed by a nurse. 4. INCORRECT: Changing an ostomy appliance is a complex task. A nurse needs to assess the skin for evidence of skin breakdown or excoriation that needs treated before another flange is applied. The nurse must also assess the condition of the stoma. This is not a task appropriate for a UAP, although emptying the ostomy bag would be appropriate.

The nurse is assigned five clients on a medical floor. When planning care, the nurse recognizes which clients to be at greatest risk for ineffective oral hygiene? Select all that apply 1. A client who has just had knee surgery taking opioids for pain. 2. A right handed client who had a stroke affecting the right hemisphere of the brain. 3. A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. 4. An elderly client experiencing loss of appetite. 5. A client who takes phenytoin for partial seizures.

3. & 5. Correct: A client with severe nausea and vomiting after chemotherapy is at an increased risk for ineffective oral hygiene problems due to vomiting, decreased oral intake, and the effects of the chemotherapy on the oral mucosa. Phenytoin causes gingival overgrowth, swelling and bleeding of the gums. This can make oral hygiene more difficult. 1. Incorrect: This client can perform oral hygiene with minimal assistance. Knee surgery and opioid pain medication do not interfere with oral hygiene. 2. Incorrect: Movement for one side of the body is controlled by the opposite side of the brain. If stroke affects the right side of the brain, then you will have trouble with the left side of your body. Since this client is right handed and his left side is affected, the client can perform oral hygiene. 4. Incorrect: This client can perform oral hygiene with minimal assistance. There is no information in this option that would put this client at risk for ineffective oral hygiene.

The RN, LPN, and unlicensed assistive personnel (UAP) are providing care for clients on the nursing unit. Which tasks could be completed only by the RN? Select all that apply 1. Administration of routine medications. 2. Dressing changes. 3. Assessment of newly admitted clients. 4. Calling the primary healthcare provider about lab results. 5. Teaching the diabetic client foot care.

3. & 5. Correct: Admission assessments and teaching must be performed by the RN. The nursing process, along with teaching are outside the scope of practice of the LPN. These are tasks that must be performed by the RN. The LPN can reinforce teaching. 1. Incorrect: Medication administration is within the LPN scope of practice and can be completed by the LPN. 2. Incorrect: Dressing changes may be delegated to the LPN as this is within the LPN scope of practice. 4. Incorrect: The LPN may call lab results to the primary healthcare provider because this is within the scope of practice for the LPN. If any additional prescriptions are required, the LPN can take these prescriptions over the phone.

The charge nurse at a long-term care facility is discussing restraint policies with new staff members. The nurse explains that the use of restraints are only appropriate for what reasons? Select all that apply 1. Reduce wandering throughout the night shift. 2. Prevent confused client from exiting the building. 3. Keep combative clients from injuring staff or clients. 4. Eliminate any falls when the client is sitting in a chair. 5. Decrease potential for pulling out I.V.'s or dressings.

3. & 5. Correct: Restraints are always considered a last resort when other methods have failed. The appropriate situations for using restraints are those in which the client may cause injury to self or others because of confusion or combativeness. Certain situations in which a client has an adverse reaction to drugs and medication, resulting in violent or combative behavior, would necessitate temporary use of restraints. Also, a confused, agitated client intubated on a ventilator, with invasive lines or dressings, might also need to be restrained to prevent injury from pulling out tubes, lines, or dressings. 1. Incorrect: Restraints may not be used for staff convenience or during low staffing periods, such as the night shift. Other methods should be utilized, such as moving the wandering client closer to the nursing station or perhaps using a Geri-chair for short periods of time. 2. Incorrect: Clients with dementia often experience greater confusion later in the day and evening, increasing the risk of wandering. Such clients should be checked on more frequently to verify safety and mental status. The nurse may employ other methods, such as encouraging family to visit, to deter client wandering. 4. Incorrect: Restraining a client while seated often increases agitation and enhances the potential for accidents. A client pulling against vest or wrist restraints could cause severe injuries while trying to resist those restrictions.

A client reports dizziness and weakness while walking down the hall. The nurse notes the client's cardiac rhythm displayed on the telemetry monitor. What actions should the nurse take? Exhibit Select all that apply 1. Have client ambulate back to bed. 2. Initiate 100% oxygen per nonrebreather mask. 3. Obtain client's blood pressure. 4. Prepare for cardioversion. 5. Auscultate lung sounds. 6. Administer nitroglycerin 1 tab SL.

3. & 5. Correct: The client is dizzy and weak. This client is at risk for falling, so think safety and get the client back in bed. Use a wheelchair to accomplish this. Then obtain the client's BP. It may be low indicating poor tissue perfusion to the vital organs. One cause of premature ventricular contractions (PVCs) includes heart failure, so assess the lungs for adventitious sounds. 1. Incorrect: This client is dizzy and weak. Having the client ambulate back to the bed is a safety risk. The client could fall. 2. Incorrect: Oxygen may abate the PVCs; however, it should be initiated at 2 liters/NC rather than at 100%. Start with the least amount of oxygen that could relieve symptoms. 4. Incorrect: Cardioversion is not indicated with an underlying rhythm that is normal (NSR) with PVCs. Oxygen may decrease the PVCs. If not, medication can be administered to decrease the rate of the PVCs. 6. Incorrect: Nitroglycerin would be given if the client is experiencing chest pain or is suspected of having an MI. Get the client back in bed and provide the client with oxygen at 2 L/NC first.

A nurse walks into the medication area of a long-term care facility and sees a colleague taking a pill from a resident's supply of narcotics. The nurse says, "Please don't say anything. I need my job and I have a migraine." What actions should the nurse take? Select all that apply 1. Reassure the colleague that she won't tell this time. 2. Insist that the colleague get some help. 3. Report what was seen to the supervisor. 4. Send the colleague home. 5. Follow procedure to return medication to the resident's supply.

3. & 5. Correct: The nurse should follow the procedure to return the narcotic, and then the nurse should report the observation to the supervisor. The nurse must serve as client advocate by reporting a nurse who may be impaired. 1. Incorrect: This may be the first observation; however, it is unlikely that it is the first incidence. The impaired nurse must be reported. You are responsible to the clients on the unit, not to the staff member. 2. Incorrect: The supervisor is the one to provide information on obtaining help. The hospital or long term care facility will have a policy for the supervisor to follow. Usually this policy also includes rehabilitation. 4. Incorrect: The nurse should leave if she is taking narcotics. The supervisor will be the one to send the nurse home. The supervisor needs to determine if the degree of impairment would interfere with the ability to drive home safely.

The nurse is admitting an adolescent reporting severe depression and amenorrhea. What additional assessment findings by the nurse would suggest the client may develop anorexia nervosa? Select all that apply 1. Tight fitting clothes 2. Oily, elastic skin 3. Brittle, dry nails 4. Gingival infections 5. Low blood pressure

3. & 5. Correct: This client is reporting symptoms consistent with anorexia nervosa, a serious and potentially life-threatening eating disorder that develops secondary to the type of family or social stress experienced in adolescence. In addition to severe depression and amenorrhea, the nurse has identified brittle, dry nails, and a low blood pressure secondary to weight loss as additional indications of anorexia nervosa. 1. Incorrect: Despite the fact that anorexic clients experience severe weight loss, they continue to view themselves as heavy and generally wear loose fitting clothing to hide what they perceive as an overweight body. 2. Incorrect: Because of skeletal muscle atrophy and poor nutritional intake, anorexic clients display sallow, dry skin with brittle nails and hair. Oily, non-elastic skin would not be noted in a client with anorexia nervosa. 4. Incorrect: Gingival infections and dental caries are typical of clients with bulimia, another eating disorder in which stomach acid from frequent vomiting causes gum infections or dental caries. This is not common in anorexics

The nurse is admitting an adolescent reporting severe depression and amenorrhea. What additional assessment findings by the nurse would suggest the client may develop anorexia nervosa? 1. Tight fitting clothes 2. Oily, elastic skin 3. Brittle, dry nails 4. Gingival infections 5. Low blood pressure

A client reporting right thigh pain is admitted to a local hospital with a diagnosis of deep vein thrombosis (DVT). During the admission assessment, the client develops new signs/symptoms. The nurse would be most concerned about what sign/symptom? You answered this question Incorrectly 1. Swelling along vein of leg 2. Right foot begins to tingle 3. Restlessness 4. Warmth over affected area

3. CORRECT. A change in client's behavior or level of consciousness indicates possible decreased oxygenation to the brain. When there is a known DVT, the nurse would be concerned about a potential stroke from a clot that has broken off from the main thrombus. 1. INCORRECT. The client has just been diagnosed with a right thigh DVT; therefore, symptoms are still evolving. It is not unusual for edema to continue to increase, though the nurse should observe carefully for additional issues. 2. INCORRECT. Tingling of the foot on the affected side is expected since the affected thigh edema and the clot are compressing the circulation and nerves that extend into the foot. The nurse must monitor the situation carefully to prevent further complications. 4. INCORRECT. Pain and warmth are typical early signs of a DVT. Additionally, the tissue becomes red and inflamed from the internal edema. The nurse is aware some of the client's symptoms are still evolving, so this sign is not the most alarming at this time.

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

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

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

3. CORRECT. An Upper GI involves the ingestion of a barium based contrast under fluoroscopy to view the esophagus, stomach, and small intestine. Following such a procedure, it is vital for the client to pass all the barium before a blockage occurs. The client is encouraged to drink large amounts of fluid and is administered an over the counter laxative, such as milk of magnesia, to remove barium. 1. INCORRECT. The client's gag reflex was not inactivated. The reflex must remain intact in order for the client to drink the barium based contrast during the test. 2. INCORRECT. The barium would not yet have reached the colon following the Upper GI and therefore a cleansing enema would not be effective. If the client had received a lower GI, an enema may have been ordered. 4. INCORRECT. The client is fully awake and conscious during the entire procedure. No medications were administered that would alter the vital signs; therefore, every 10 minute vital signs are not necessary.

The homecare nurse is visiting a client who recently had a miscarriage at 22 weeks. When is the most appropriate time for the nurse to discuss the topic of another pregnancy? 1. The topic should wait until the nurse builds rapport with the client. 2. Another pregnancy should not be discussed for at least six months. 3. Wait until the client initiates the topic of future pregnancies. 4. Discussion should begin immediately upon the first home visit.

3. CORRECT: A mother who has had a miscarriage will experience all, or some, of the Kübler-Ross's stages of death and dying, and therefore, each individual will have a unique response to the loss of a fetus. The best course of action by the nurse is to utilize therapeutic communication techniques and approach the client with open-ended statements. This allows the client to initiate the topic at whatever point is most appropriate for her own situation. 1.INCORRECT: Building rapport with a new client is an important aspect of establishing therapeutic communication. While each nurse/client relationship is unique, it is expected that rapport will begin to be established during the first visit. However, even after establishing rapport, the nurse must follow the client's lead when discussing the topic of another pregnancy. 2. INCORRECT: When dealing with a client who has suffered loss, there are no hard and fast rules for discussing the topic. Deciding that the topic should not be discussed for a specific length of time, like six months, is inappropriate. Whether the client can safely get pregnant should be discussed with the primary healthcare provider. However, the nurse should take cues from the client about the topic of another pregnancy. 4. INCORRECT: The client has just experienced the loss of a pregnancy and will need the time to come to terms with that situation. Each client grieves in a unique time frame when dealing with such a loss. Unlike teaching that is initiated upon admission, the discussion of another pregnancy is not appropriate at the first visit, unless the client broaches the subject.

A pregnant client's initial blood work shows a negative rubella titer. The nurse is aware this result indicates what important course of action? 1. Client needs to be isolated until delivery. 2. Client is immune to rubella currently. 3. Client should be given rubella vaccine after delivery. 4. Client has never been exposed to rubella.

3. CORRECT: A negative titer indicates the client has no rubella antibodies present currently. But because the rubella vaccine contains a live virus, the client cannot be safely vaccinated until after delivery. 1. INCORRECT: Although the client may be cautioned about being around groups of children until after delivery, there is no need for total isolation for the duration of the pregnancy. 2. INCORRECT: If the client were immune to rubella, the titer would have been positive, indicating the presence of rubella antibodies. This client is not immune currently. 4. INCORRECT: Whether the client has ever been exposed to rubella cannot be determined from the information presented in this question.

A gunshot victim is brought by ambulance to the emergency room with an open pneumothorax. A bio-occlusive dressing to the chest. The nurse then notes increased dyspnea and sub-q emphysema in the client. What is the nurse's priority action? 1. Prepare client for insertion of chest tube. 2. Apply a non-rebreather with 100% oxygen. 3. Loosen one side of the bio-occlusive dressing. 4. Obtain a tracheostomy kit and call the surgeon.

3. CORRECT: An open pneumothorax, also referred to as a sucking chest would, allows outside air to rush into the chest cavity. Because outside air has greater pressure than intrathoracic air, the pressure builds up quickly creating a mediastinal shift that collapses all structures in the thoracic cavity. This is referred to as a tension pneumothorax and can be caused by securing all four sides of the bio-occlusive dressing. The nurse should check to see that the dressing is loose on one side. If it is not, one side of the dressing must be released to allow the air to escape from the chest. 1. INCORRECT: Although this client will ultimately need a chest tube to remove the air that entered the chest cavity, this is not the nurse's priority action. 2. INCORRECT: A dyspneic client may certainly need supplemental oxygen; however, there are not enough parameters provided to determine whether the client is truly hypoxic. 4. INCORRECT: An emergency tracheostomy is not the initial treatment for dyspnea or sub-q emphysema. Such an invasive procedure would be used only in a life-threatening situation.

The nurse in the pediatric intensive care unit (PICU) is caring for a preschool child three days after open heart surgery. What assessment finding should the nurse report immediately to the primary healthcare provider? 1. Increased episodes of fussy crying. 2. A hacking, non-productive cough. 3. Oral temperature of 100.9°F (38.3°C). 4. Chest tube draining 30 mL per shift.

3. CORRECT: An oral temperature of 100.9°F (38.3°C) is considered too elevated for 3 days post-op. An oral body temperature greater than 100.5°F (38.1°C) indicates the potential for infection. Although no other vital signs are given in the scenario, a temperature this elevated would need to be reported immediately by the nurse to the primary healthcare provider. 1. INCORRECT: Increasing episodes of crying could indicate many things in a preschool child, including pain, fear, loneliness, or even elevated body temperature. While this change in the client's status will need to be investigated further, the nurse would not need to report this behavior at this time. 2. INCORRECT: A hacking, non-productive cough, even several days after open heart surgery, could be attributed to the effects of intubation, anesthesia, or even certain cardiac medications. Clients are always encouraged to cough and deep breathe in order to prevent pulmonary complications. If the cough becomes productive or breathing becomes labored, the nurse would need to report this to the primary healthcare provider. This is not an urgent concern for the nurse. 4. INCORRECT: Chest tube drainage is common following open-heart surgery, even three days later. It is impossible to evaluate whether 30 mL in one shift is a change since there are no parameters to compare the previous shift's output. The nurse would not need to report this drainage at this time.

The nurse is working with the interdisciplinary team in developing a plan of care focused on weight gain for an anorexic client. What intervention would be ineffective for reaching that outcome? 1. Refrain from being critical of client during meals. 2. Permit client to make own food selections on menu. 3. Reward the client with private time for a meal completely eaten. 4. Provide positive reinforcement for each pound gained.

3. CORRECT: Anorexic clients believe they are grossly overweight, regardless of their current physical appearance. Therefore, the individual will attempt to get rid of food ingested at a meal by any means necessary, including aggressive exercise and induced vomiting. Rewarding the client time alone would NOT be effective in reaching the goal of weight gain. 1. INCORRECT: Negative comments at any time are counter-productive for clients with low self-esteem, particularly individuals with body dysmorphia. Refraining from critical comments during a meal is a positive action toward the weight-gain goal. However, the scenario asks for a negative goal. 2. INCORRECT: Permitting a client to participate in food selection demonstrates confidence in the individual and encourages personal responsibility for self-care. This action is a positive step toward reaching the client goal. 4. INCORRECT: The ultimate goal for an anorexic client is weight gain. Positive reinforcement is vital for clients with poor self-image. Gaining even one pound is a great achievement for the client and the nurse should acknowledge the effort toward reaching the ultimate goal.

A nurse is attempting to assess lung sounds on a 3 year old with a history of asthma. Which indicates the best method to encourage the hospitalized child to take a deep breath? 1. Allow the child to blow out a lighted candle. 2. Encourage child to blow bubbles from a wand. 3. Teach child to blow cotton balls off the table. 4. Instruct child on using an incentive spirometer.

3. CORRECT: Assessing lung sounds requires a client to inhale and exhale while the nurse auscultates. The most efficient method is to have the child participate in a game that requires breathing in and out. Blowing a cotton ball across a table is an appropriate activity which can be easily understood by a 3 year old child and mimics a game that will encourage participation. 1. INCORRECT: An open flame, even on a small candle, is a safety violation and contraindicated in all types of health facilities. Additionally, since the child will need to breathe in and out multiple times, it would be both risky and inconvenient to keep relighting a candle. 2. INCORRECT: While it might be easier, and even enjoyable, for the child try to blow bubbles from a bubble wand, consider the safety aspect. Bubbles are made from soap, which would make floors slippery. Additionally, children usually want to chase bubbles, and having the child remain still for auscultation would be a challenge. 4. INCORRECT: The purpose of using an incentive spirometer is to encourage clients to cough and deep breath. Instructing a 3 year old on the spirometer would be challenging and does not help the nurse to assess lung sounds.

An elderly client diagnosed with Alzheimer's disease has become combative, restless and wanders at night. The nurse contacts the primary healthcare provider for medication to help the client rest. The nurse knows the best choice for this client is what medication? 1. Chlorpromazine 2. Hydroxyzine 3. Haloperidol 4. Diazepam

3. CORRECT: Haloperidol is a mild antipsychotic used to treat either mental or mood disorders, including uncontrollable movements and emotional outbursts. This drug is relatively safe for elderly clients and can be used at bedtime to enhance rest. 1. INCORRECT: Chlorpromazine is a low-potency, antipsychotic medication with both sedative and anticholinergic properties. However, this drug works best with consistent multiple daily doses rather than a once time dose and has too many side effects for this elderly client. 2. INCORRECT: Hydroxyzine is an antihistamine occasionally used as an antianxiety or for sedation; however, hydroxyzine has no real effect on combative or agitated behavior. 4. INCORRECT: Diazepam is an antianxiety medication but is not appropriate for elderly clients because of the potential for paradoxical response, such as excitation or delirium.

An adolescent is being instructed on the proper way to use crutches following knee surgery. The nurse knows that teaching has been successful when the client makes what statement? 1. "The weight of the crutches should be on my shoulders." 2. "It's ok to lean against the crutches if I am standing still." 3. "If going up the stairs, my non-operative leg goes up first." 4. "When sitting down, first lean crutches against the wall."

3. CORRECT: It is evident that the client has understood the nurse's instructions with this statement. When going up stairs with crutches, the unaffected (non-operative) leg goes up first. The strong leg bears the body weight and therefore provides a solid base while the client lifts up the weaker leg. 1. INCORRECT: The correct position for crutches should be about 2 inches below the axilla and never directly up into the arm pit. Body weight is carried by the hands on the hand-grips, which means the force to push comes from the forearms and biceps, not the shoulders. Bearing weight in the axilla can cause severe damage to the axillary nerves and muscles. 2. INCORRECT: Crutches are an ambulatory aid only and, if not used correctly, can actually be a safety hazard. Even if the client is standing still, it is unsafe to use crutches as a leaning support. Additionally, even resting on the crutches can cause trauma to the axillary area. 4. INCORRECT: When sitting in a chair, the client should back up to the chair until the back of the knees gently touches the chair seat. The client should then reach back and grab the arm of the chair while holding both crutches in the other hand. Once seated, the client can then lean the crutches upright nearby. They will balance better if stood upside down.

A client admitted in the manic phase of bipolar disorder approaches the nursing station in the middle of the night, demanding the therapist be called immediately. What response by the nurse is appropriate? 1. "Calm down first, and then I will call your therapist." 2. "It's against the rules to call in the middle of the night." 3. "You must be distressed to want to talk at this late hour." 4. "That's a valid request, but it must wait until morning.

3. CORRECT: Regardless of the client's request, the nurse's response should focus on the client's feelings. Rather than reciting the rules or why the phone call cannot be placed, this therapeutic acknowledgement by the nurse clearly addresses the client's emotional state. 1. INCORRECT: Bargaining with a client for behavioral compliance is neither supportive nor appropriate by the nurse. In the manic phase, the client is unlikely to be able to comply, even if the goal is something desired by that individual. This is a non-therapeutic approach by the nurse. 2. INCORRECT: The nurse is focusing on facility rules rather than the client's emotional state or feelings. Such a response by the nurse would not resolve the issue here and is certainly not a therapeutic response. The client is likely to become more agitated. 4. INCORRECT: Even though the nurse is acknowledging the client's request, the response focuses on the phone call rather than the client's emotional state. This statement by the nurse may be true but will not resolve the situation.

The nursing supervisor is reviewing several instances in which restraints have been used. The nurse is aware the only acceptable use of restraints is what? 1. An elderly male had a chest restraint applied after crawling over bed rails several times. 2. An Alzheimer client's room door is closed to prevent wandering during shift change. 3. A confused client with a closed head injury had hand mitts applied after pulling out IV 4. A dementia client with sundowners is placed in Geri-chair with lap belt at nurse's station.

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

A client arrives at the emergency room with active gastrointestinal bleeding. What is the most important nursing action? 1. Treat the cause of the bleeding. 2. Record the amount of blood loss. 3. Initiate an intravenous access line. 4. Prepare client for stat endoscopy.

3. CORRECT: The client has active gastrointestinal bleeding, which can quickly lead to hypovolemic shock. Active bleeding would be treated with fluids, and in certain cases, blood products. Establishing an IV site allows for immediate initiation of treatment before veins vasoconstrict and become too difficult to access secondary to shock. 1. INCORRECT: While it is crucial to find and treat the cause of the bleeding, diagnosing is the responsibility of the primary healthcare provider. Because this client is experiencing internal bleeding, further tests may be needed to determine the source of the hemorrhage. 2. INCORRECT: Gastrointestinal bleeding is very difficult to measure since there is no effective way to collect the fluid. The primary healthcare provider could order a hemoglobin and hematocrit but that does not precisely measure the actual amount of blood loss. 4. INCORRECT: An endoscopy is an internal examination of a portion of the gastric system. However, proper preparation requires the client to be NPO for hours in order to properly visualize that system. This is not the most important nursing action.

A client had an open cholecystectomy several days ago. What finding by the nurse should be reported to the primary healthcare provider immediately? 1. Respiratory rate of 30 2. Blood pressure reading of 104/50 3. Incisional pain with foul, green drainage 4. Urinary output of 75 mL straw colored urine

3. CORRECT: The client is having incisional pain, which by itself could be expected following an open cholecystectomy. However, there should never be any foul, green drainage from an incision, as this indicates a post-operative infection. The nurse should report this immediately to the primary healthcare provider. 1. INCORRECT: Although this respiratory rate seems slightly on the elevated side, this client has had recent surgery and is now having some complications. Combined with the pain, this rapid respiratory rate would be expected. 2. INCORRECT: There is no baseline data provided regarding this blood pressure data. Without a reference to a client's previous blood pressure, it is impossible to form any opinion about this reading. We worry about a systolic BP of 90. 4. INCORRECT: The information provided in the question does not give any parameters by which to evaluate the urine. Straw colored urine is a normal finding; however, there is no indication regarding the length of time it took to accumulate 75 mL of urine. Therefore, no decision can be formed about this finding

A client is given an intramuscular injection of morphine following a laparoscopic cholecystectomy four hours ago. What client data would best indicate to the nurse that the medication has been effective? 1. Rates pain as 6 on 1-10 scale. 2. Heart rate is within normal limits. 3. Ambulates with assistance of one. 4. Voided 250 mL in 4 hours.

3. CORRECT: The client's ability to ambulate with one assistant indicates that pain is controlled enough to get out of bed. Even a laparoscopic procedure can cause extreme discomfort in the immediate post-op period. This action is the best indicator the client has experienced some pain relief. 1. INCORRECT: Although a baseline pain measurement is not noted, a level of 6 on the 1-10 scale is still very elevated. This client response indicates the morphine was not effective. 2. INCORRECT: Many clients do become tachycardic in response to pain; however, with no baseline to compare, a heart rate within normal levels is not the best indicator of effective pain medication. 4. INCORRECT: The amount and ability to void does not provide evidence of successful pain control. The voiding instinct is rarely affected by pain.

A client being discharged home following hip surgery is prescribed to use a walker. While observing the client walk across the room, the nurse is most concerned when the client does what? 1. Applies shoes securely before ambulating with walker. 2. Checks walker to be certain the legs are securely locked. 3. Slides walker slowly forward when walking across the room. 4. Places walker to right of the chair after sitting down in chair.

3. CORRECT: The nurse is observing the client ambulate with a walker prior to discharge, to determine whether the client is using the assistive device safely. The nurse becomes concerned upon noting the client sliding the walker during ambulating. The correct use of a walker involves the client lifting and placing the walker approximately one-foot length ahead, then stepping into the non-moving walker. It is important for the walker to remain stationary when the client takes a step forward. 1. INCORRECT: This action by the client is appropriate. Proper, gripping footwear should be worn by the client at all times when ambulating. This prevents the possibility of slipping and falling. There is no cause for concern with this action. 2. INCORRECT: Another smart move is to verify the cross bars are securely locked before ambulating. When a walker is folded for storage, the locks are unlatched. When the walker is open, the locks must click into place to verify the device is safe for ambulating. No concerns here. 4. INCORRECT: When a client sits down, the walker can be placed to either side of the chair. The most important factor is for the client to use the walker to safely maneuver into the chair rather than placing the walker aside before sitting down. Placing the walker next to the chair after being seated is appropriate.

A client diagnosed with human immunodeficiency virus (HIV) is to be sent home today. The nurse has initiated discharge instructions on the proper handling of blood and body fluid at home. The nurse knows the teaching is successful when the client makes what statement? 1. "As long as it's my home, I can use normal cleaning methods." 2. "I must scrub with hot, soapy water and allow it to air dry." 3. "I should clean area with a 10% mixture of bleach and water." 4. "I must sterilize with isopropyl alcohol and rinse with ammonia."

3. CORRECT: The proper method to clean spills of blood or body fluids at home is to use a 10% solution of household bleach, which means 9 parts of water to 1 part bleach. It is recommended to leave the bleach solution on the contaminated area for 10 to 20 minutes, and then rinse with hot water. Any towels or cloths used to clean the area should be double bagged and discarded. 1. INCORRECT: This demonstrates a false sense of security. Even in a home environment, visitors and family could become contaminated with the HIV virus. Microscopic amounts of blood or body fluids could contaminate others, and therefore proper cleaning methods must be followed even at home. 2. INCORRECT: Hot, soapy water will not kill the HIV virus on hard surfaces, regardless of the type of soap or the temperature of the water. Additionally, air drying will not decrease the virulence of the virus. 4. INCORRECT: Isopropyl alcohol, or rubbing alcohol, does not inactivate the HIV virus, even if rinsed with ammonia. Also, mixing household chemical cleaners, such as bleach with ammonia, can create dangerous fumes that are toxic to humans.

A factory employee is brought to the emergency room on first shift with a severe hand laceration occurring at work. The employee is quite upset, indicating previous competency on the machine. When reviewing medications, the nurse notes the client has recently started alprazolam at bedtime. What vital information about this medication should the nurse provide to the client? 1. Consider getting new glasses. 2. Stand up slowly when sitting. 3. Do not operate dangerous machines. 4. Instructions for taking medication appropriately.

3. CORRECT: The vital information provided when a client starts any benzodiazepine includes no driving and no operating heavy machinery. The major side effects of this category of drugs include trouble concentrating, impaired coordination, drowsiness and fatigue, all of which may have contributed to this client's accident. The fact the client uses this drug for sleep and then goes to work indicates a lack of comprehension about side effects. 1. INCORRECT: There is no indication the client even wears glasses; however, glasses would not address the problem of slowed reflexes or poor coordination when working around even familiar machinery. 2. INCORRECT: Although standing up slowly is an important safety issue of which the client should be aware, this is not the most vital teaching the nurse should present. 4. INCORRECT: The question does not indicate the client's present dose of alprazolam nor the frequency. It is impossible to determine whether the client is taking the medication correctly.

A toddler with a malfunctioning ventriculoperitoneal (VP) shunt has returned from surgery following new shunt placement. Which post-op assessment finding should the nurse report to the primary healthcare provider immediately? 1. Blood pressure of 90/45 with pulse of 100 2. Urinary output of 30 mL over two hours 3. Sleeping soundly and difficult to arouse 4. Respirations deep and shallow at 20/min

3. CORRECT: Though the toddler is recovering from anesthesia, the nurse should be able to arouse and awaken the client, even expecting some crying. Difficulty arousing this client is one sign of increased intracranial pressure and should be reported immediately. 1. INCORRECT: These vital signs are well within normal limits for the toddler age-group, even post-op. No concerns for the nurse here. 2. INCORRECT: An output of 30 milliliters may seem a bit low, but the toddler is still recovering from surgery and anesthesia, with IV fluids still infusing to rehydrate. Additionally, two hours is not long enough to establish a consistent pattern. 4. INCORRECT: The respiratory rate is within normal limits for this client now. However, with potential changes in the neurological status of this client, the nurse would monitor for any decrease in respirations.

A psychiatric nurse is completing an assessment on an elderly client being started on a tricyclic antidepressant. The nurse is aware the most crucial aspect of this assessment is evaluating what body system? 1. Endocrine 2. Nervous 3. Circulatory 4. Digestive

3. CORRECT: Tricyclic antidepressants can cause arrhythmias, changes in heart rate, and blood pressure fluctuations including orthostatic hypotension. A client's cardiovascular status should always be evaluated prior to starting this category of medication to determine the presence of pre-existing cardiac conditions. 1. INCORRECT: Blood glucose levels may become elevated while using this category of antidepressants, but hyperglycemia can be treated and controlled if the client responds well to the medication. This is not of greatest concern to the nurse. 2. INCORRECT: Tricyclics increase body levels of norepinephrine and serotonin, and the client may experience drowsiness or even blurred vision. The nurse will teach the client about safety precautions prior to discharge, but this is not the chief concern. 4. INCORRECT: Although tricyclic antidepressant medication may increase appetite, cause constipation and weight gain, these are expected side effects and not of major concern.

A client has been admitted to the med-surg floor with lower abdominal pain and bloating, fever, chills, and vomiting. Following a Cat scan, a diagnosis of diverticulitis is made. What action by the nurse is most appropriate after the initial assessment? 1. Obtain a stool specimen for ova and parasites. 2. Prepare client for emergency exploratory surgery. 3. Notify dietary the client will need a clear liquid diet. 4. Give client a heating pad to ease abdominal pain.

3. CORRECT: When diverticulum become severely inflamed or infected, an individual may need treatment in a hospital setting with intravenous antibiotics, antispasmodics and rest. In order to allow the inflammation in the gastrointestinal tract to heal, it is most important for the client to be placed on clear liquids for several days. 1. INCORRECT: Diverticulitis is inflammation within the colon caused by food particles becoming lodged in the diverticulum (out-pouching). This is generally diagnosed with a CBC, Cat scan and possibly a colonoscopy. A stool specimen is ordered when the presence of ova (eggs) and parasites are suspected in the bowel, which are not present in diverticulitis. 2. INCORRECT: Clients who experience an exacerbation of diverticulitis are treated medically with dietary modifications, liquids, bed rest, antibiotics and even antispasmodics. Surgery is rarely needed unless a diverticulum ruptures, causing an abscess, peritonitis or severe bleeding. 4. INCORRECT: Although warmth may help to ease some mild abdominal discomfort, the use of a heating pad is never acceptable in a hospital setting. This is a safety issue for clients, with the potential for burns or electric shock. Additionally, warmth should not be utilized for lower abdominal discomfort unless specifically ordered by the primary healthcare provider.

Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 1. Check the bladder for distension in the client who had a 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 assess and evaluate.Checking the bladder for distension is an assessment that requires the nurse's attention. 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. The nurse should assess the client. 4. Incorrect. The nurse cannot delegate an assessment or evaluation task to the UAP. This is beyond the scope of practice for the UAP.

A 70 year old client was admitted to the unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's blood pressure is 198/94 mm Hg. 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. Administering the client's blood pressure medicines are aimed at correcting the hypertension. The therapeutic action of furosemide is diuresis which will lower the blood pressure. Enalapril is an angiotensin converting enzyme (ACE) that treats hypertension. These medications can be administered within 30 minutes of 0900. 1. Incorrect. Assisting the client back to bed is appropriate, but does not address the problem of lowering the client's BP. Administration of furosemide and enalapril will benefit the client with hypertension. 2. Incorrect. Retaking the BP in the opposite arm is within the scope of practice of an UAP, but does not address the problem of lowering the client's blood pressure. Additionally this should be completed prior to 15 minutes time. The priority is to get the BP down by giving the prescribed medications for hypertension. 4. Incorrect. The LPN can ask the client if they have chest pain. The client does have a BP of 198/94 which could lead to chest pain. The priority is to get the BP down to decrease the risk of complications associated with hypertension, such as MI, and stroke.

A client is to undergo an endoscopy in the client's room. The gastroenterologist gives a verbal prescription to the general floor nurse to prepare and administer propofol 10 mL slow IVP until sedation is achieved. What action should the nurse take? 1. Administer the propofol as prescribed. 2. Draw up the propofol and give it to the gastroenterologist to administer. 3. Inform the gastroenterologist that giving propofol is outside the nurse's scope of practice. 4. Request the gastrointerologist write the prescription.

3. Correct. Propofol administration is outside the scope of practice for general floor nurses. The gastroenterologist cannot monitor the client adequately while performing the procedure. A nurse anesthetist or anesthesiologist should be present. 1. Incorrect. Propofol administration is outside the scope of practice for general floor nurses. 2. Incorrect. The nurse should not draw up a medication and hand it to someone else to administer. Additionally, propofol should not be administered on a general unit without an anesthesiologist, or nurse anesthetist in attendance. 4. Incorrect. Prescriptions should be written rather than given verbally. However, the RN cannot administer propofol.

The nurse is teaching a client diagnosed with salmonellosis about how to decrease the transmission to others. Which statement by the nurse would require follow up? 1. "I will wash my hands after feeding pets." 2. "I will use a meat thermometer to cook food to safe temperature." 3. "I will clean my hands with water before handling food." 4. "I will use disposable dishes until infection free."

3. Correct. Salmonellosis is caused by the bacteria salmonella. Hands should be washed with soap and warm water. Only washing with water is not correct and requires the nurse to do further teaching with the client. 1. Incorrect: This statement indicates the patient understands teaching. The client should wash hands after contact with animals, their food or treats, and their living environment. 2. Incorrect: A meat thermometer should be used to ensure foods are cooked properly. Undercooked meat and unpasteurized milk is a source for the organism. 4. Incorrect: Disposable dishes help prevent the spread of infection. It prevents the organism from being transferred on dirty dishes.

Which meal is most appropriate for a client during an acute manic episode? 1. Steak, salad, banana 2. Beef and vegetable stew, bread, vanilla pudding 3. Chicken leg, corn on the cob, apple 4. Fish fillets, cubed avocado, cake

3. Correct: They can hold these items in their hand and eat while walking around. 1. Incorrect: Steak requires cutting up with a knife and is time consuming. Do you also see a safety issue here? Knife? Not while the client is manic. They need something that they can eat with their hands because they don't sit long enough to eat. 2. Incorrect: It's hard to walk around and eat beef stew and pudding. 4. Incorrect: It's hard to walk around and eat fish and cubed avocado.

While completing the admission history on an elderly client diagnosed with advancing Alzheimer's disease, the client's spouse begins to sob and states, "After all these years, we won't be together anymore." What would be the best response by the nurse? 1. "You can come to visit anytime you want to." 2. "Would you like to see the room and facilities?" 3. "Let's find a quiet place to sit and talk awhile." 4. "You did the best you could in this situation."

3. Correct. The nurse recognizes that the client's spouse is emotionally distraught at this moment, and is most in need of the nurse's focus at this time. Major life events have affected this family unit, including the client's terminal diagnosis and separation to a new living environment. This spouse is understandably overwhelmed by the changes occurring and, while the nurse will need to complete the admission paperwork, family needs must be met. Focusing on the spouse's emotional needs and allowing time to verbalize feelings could positively affect the client's adaptation to the situation. 1. Incorrect. Although this statement may be factual, it is a closed-ended statement, which belittles the spouse's expression of distress by presuming that unlimited visitation will rectify the situation. Though the spouse is verbalizing sadness because of physical separation, the grief may be a reflection of deeper concerns, considering the client's diagnosis. 2. Incorrect. This response focuses on the facility surroundings, rather than the spouse's distress and expression of sorrow. Changing the topic both ignores and belittles the client's grief. The nurse must address the needs of family as well as those of the client. 4. Incorrect. Though this response may seem encouraging, a closed-ended statement does not allow the openly distressed spouse an opportunity to verbalize further feelings. Family dynamics can significantly impact the client's well-being and potential to adapt to new surroundings.

A nurse has received report on a client to be admitted from the surgical suite following an unexpected amputation of the right arm because of a tractor accident. Which action by the nurse would best help the client upon arrival to the unit? 1. Notify hospital social services about adaptive equipment needs. 2. Prepare to change the dressing so the client can see the stump. 3. Ask client's family and hospital chaplain to be present in room. 4. Advise dietary that client will need food precut in small pieces.

3. Correct. This client will be awake from surgery to face the unexpected amputation of an arm, which has long-term physical, psychological, emotional and financial implication. Even clients facing a scheduled limb removal experience distress, anger or depression. Anticipating that the client will need a great deal of emotional support, the nurse is aware that having family and/or the hospital chaplain present after surgery may help the client cope with the bad news. 1. Incorrect. Losing an extremity involves relearning how to complete ADL's in an alternative manner and usually requires using adaptive equipment. This client may be introduced to specialty equipment prior to discharge, and social services will arrange for any home care needs. However, this action is not of primary concern at the time of the clients arrival in the unit. 2. Incorrect. The loss of a limb, particularly unexpectedly, can overwhelm a client and result in feelings of shock, anger, or even denial. Clients can experience a range of emotional responses based on age, beliefs, values or social support. One common behavior among new amputees is the hesitancy to look at the stump. Forcing the client to visualize the wound before being psychologically ready can hinder or delay adaptation. Additionally, the surgeon generally removes the original surgical dressing. 4. Incorrect. This client will need to learn many adaptive skills once the surgical site has healed. However, having food precut into small pieces diminishes self-esteem and discourages client independence, which is important to recovery. An occupational therapist will be consulted regarding special eating utensils and techniques but usually there is little alteration in the preparation of food.

A nurse is caring for a client who is diagnosed with diabetic ketoacidosis (DKA). Which primary healthcare provider prescription is appropriate during the first 24 hours of treatment for this client? 1. 0.45% saline solution (NaCl) at 50 mL/hr 2. 3% saline solution (NaCl) at 125 mL/hr 3. 0.9% saline solution (NaCl) at 1,000 mL/hr times 2 4. Dextrose 5% in lactated Ringer's solution at 150 mL/hr

3. Correct: 0.9% saline solution should be infused at a rate of at 1,000 mL/hr times 2, up to a total of 10 L in the first 24 hours of treatment. This client will be in a fluid volume deficit or shock and fluid replacement is essential. 1. Incorrect. 0.45% saline would not be administered at 50 mL/hr because the first goal of fluid therapy in DKA is to restore volume in a severely volume depleted client, thus we need normal saline at a faster rate to replace fluid volume. 2. Incorrect. 3% saline solution would be contraindicated in this client because it is a hypertonic solution that would worsen the client's dehydration. 4. Incorrect. Dextrose 5% in lactated Ringer's solution at 150 mL/hr is inappropriate because the blood sugar is too high for infusion of a dextrose containing solution.

Based on expected growth and development for a 7 month old infant, what would the nurse anticipate that the mother would report at the infant's well-baby visit? 1. Has slight head lag when pulled to sitting position. 2. Walks holding onto furniture. 3. Able to sit, leaning forward on both hands. 4. Has neat pincer grasp.

3. Correct: A 7 month old is not expected to be able to sit fully unsupported but is able to sit by leaning forward on both hands. 1. Incorrect: No head lag should be seen when pulled to a sitting position. Head lag should end around 5 months of age. 2. Incorrect: The 7 month old is expected to be able to bear full weight on feet but generally does not walk holding onto furniture until around 11 months of age. 4. Incorrect: A neat pincer grasp does not usually develop until around 11 months of age. A 7 month old would only be expected to rake small objects with the fingers.

When making assignments for an LPN on the Labor and Delivery unit, the charge nurse is aware the most appropriate clients should meet what criteria? 1. Clients requiring close monitoring. 2. Post-vaginal delivery clients only. 3. Clients with a predictable outcome. 4. Non-routine clients in early labor.

3. Correct: A client with a predictable outcome is stable enough to be assigned to the licensed practical nurse (LPN). If complications should arise, the LPN would report this to the registered nurse. 1. Incorrect: Clients requiring close monitoring indicate an unstable or unpredictable status, which is not an appropriate assignment for the LPN. These clients should be assigned to a registered nurse. 2. Incorrect: The manner of delivery a client experienced does not dictate which staff personnel are able to provide care. More important factors would focus on whether the client had a non-eventful delivery or suffered any unexpected complications. 4. Incorrect: The term "non-routine" immediately indicates an unstable client with potential problems that need frequent assessment. An LPN should only be assigned to those stable clients with expected or predictable outcomes.

The nurse is caring for a client with acute renal failure. The morning assessment findings indicate the client has become confused and irritable. Which finding is most likely responsible for the change in behavior? 1. Hyperkalemia 2. Hypernatremia 3. Elevated blood urea nitrogen (BUN) 4. Limited fluid intake

3. Correct: A client with acute renal failure will have an increased (BUN). Significant elevation in BUN may result in nausea, vomiting, lethargy, fatigue, impaired thought processes, and headache. 1. Incorrect: Hyperkalemia can result from acute renal failure. Symptoms of hyperkalemia do not include confusion and irritability. Hyperkalemia may cause muscle weakness, muscle twitching, and flaccid paralysis. 2. Incorrect: Clients with renal failure retain fluid and are at risk for dilutional hyponatremia. Increased or decreased sodium levels can cause confusion, but this client is not at risk for hypernatremia.4. Incorrect: Clients in acute renal failure should have limited fluid intake. This will not lead to confusion.

A client is admitted to the emergency department after sustaining burns to the chest and legs during a house fire. Which assessment should the nurse perform immediately? 1. Respiratory 2. Cardiac 3. Airway 4. Neurological

3. Correct: A fire in an enclosed area causes concern for carbon monoxide poisoning. In addition to the burns to the chest, there is the added potential for airway damage. 1. Incorrect: Important to assess respiratory status but not before airway. 2. Incorrect: Important to assess cardiac, but not #1. 4. Incorrect: This assessment would be done, but not #1.

Which lab value on a client who is one day postpartum should the nurse report to the primary healthcare provider immediately? 1. Hemoglobin of 11 g/dL (110 g/L) (6.8266 mmol/L) 2. White Blood Cell count of 22,000 mm3 3. Hematocrit of 18% 4. Serum glucose of 80 mg/dL (4.44 mmol/L)

3. Correct: A hematocrit in postpartum women can drop as low as 20% (0.2) and not require transfusion in the absence of symptoms of hypovolemia. A hematocrit of 18% and lower should be reported even in the absence of dizziness, lightheadedness, shortness of breath with exertion, and syncope. 1. Incorrect: A hemoglobin of 11 g/dl (110 g/L) (6.8266 mmol/L) is considered to be normal for pregnancy and postpartum.2. Incorrect: It is not unusual for a postpartum woman to have a WBC up to 25,000 mm3 without infection because of the healing process of the reproductive system. 4. Incorrect: Serum glucose of 80 m/dL (4.44 mmol/L) is within the normal range of glycemic control.

A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. The nurse considers various ideas submitted by team members. What proposal would the nurse determine to best meet the needs of families and clients in long term care? 1. Plan all care to be completed in early morning to allow afternoon for visitation. 2. Schedule visiting times in two-hour increments so clients are not overwhelmed. 3. Encourage clients and families to develop mutually appropriate visitation times. 4. Allow families unlimited visitation around the clock to meet their schedules.

3. Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. Because facilities generally prefer some type of consistent schedule for staffing purposes, older visitation policies were often very restrictive. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. 1. Incorrect: This is not completely practical for everyone. Though it may benefit staff to have one particular goal, some clients cannot tolerate to have everything performed at one time, and instead need short rest periods during personal care. This schedule may leave some clients too exhausted to visit with family. 2. Incorrect: Restricting visitation to two hours is not appropriate, particularly for families traveling long distances to visit a client. Those residing in long term care facilities benefit greatly from time spent with family or even older friends. A two-hour limit on visits discourages quality time. 4. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility.

A nurse is caring for a client who had a total hip replacement 2 days ago. What assessment finding 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 new nurse should assess this client first because we are worried about hemorrhage. If the fundus is boggy, a fundal massage will need to be done. Assess vital signs for hemorrhage. 1. Incorrect: Clots smaller than a silver dollar are normal. However, do not ignore any bleeding. Always assess the client with any signs of bleeding to determine that 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.

After drawing up insulin for subcutaneous administration, the nurse receives a return phone call from a primary healthcare provider who wants to give prescription orders on a new admit. The nurse asks a new nurse to administer the insulin dose. What action should the new nurse take? 1. Administer the insulin dose to the client. 2. Consult with the charge nurse about administering the insulin dose to the client. 3. Tell the nurse that whoever draws up the medication has to administer that medication. 4. Offer to take the call from the primary healthcare provider so the nurse can administer the insulin.

3. Correct: A nurse can only administer medication that has been drawn up by that nurse. It is not acceptable practice to administer a medication drawn up by another nurse. 1. Incorrect: The nurse who gives this medication does not really know what was drawn up. It could be the wrong medication, the wrong dose, the wrong time. A nurse can only administer medication that has been drawn up by that nurse. 2. Incorrect: There is no need to consult the charge nurse because the new nurse should not administer the medication that has been drawn up by another nurse. 4. Incorrect: The nurse should first take the return phone call from the primary healthcare provider and then administer the insulin yourself.

Donepezil has been prescribed to a client with cognitive impairment. Which statement by the family member indicates understanding of the nurse's instructions on this medication? 1. This medicine will control agitation and aggression. 2. This medication should be given at bedtime since it is for insomnia. 3. Notify the primary healthcare provider if the client is vomiting coffee ground material. 4. This drug is given as needed for confusion.

3. Correct: A rare but very serious side effect that can occur: black stools, vomit that looks like coffee grounds, severe stomach/abdominal pain. Notify the primary healthcare provider immediately. 1. Incorrect: An antipsychotic medication such as risperidone is used for agitation, aggression, hallucinations, thought disturbances, and wandering. Donepezil helps to decrease the symptoms of dementia (impairment of memory, judgment, abstract thinking and personality changes) in client's with Alzheimer disease. 2. Incorrect: Donepezil should be given in the evening just before bedtime, however, it is not for insomnia. Sedative/hypnotics such as zolpidem and temzaepam are given for insomnia. 4. Incorrect: Donepezil should be given regularly in order to get the most benefit from it. Do not stop taking it or increase the dosage unless the primary healthcare provider changes the dose. It may take a few weeks before the full benefit of this drug takes effect.

The nurse is caring for a client who is receiving weekly infusions of Factor VIII for Hemophilia. What assessment finding by the nurse related to the client's skin is indicative of a therapeutic response? 1. An absence of jaundice 2. The presence of petechiae 3. A reduction of bruising 4. A capillary refill time of < 3 seconds

3. Correct: A reduction in bruising indicates an increase in circulating coagulating substances in the blood of hemophilia clients. Factor VIII is the clotting factor that is deficient in hemophilia clients. Administration of Factor VIII in these clients would result in a reduction of bleeding episodes and the s/s associated with them.1. Incorrect: Jaundice is an indicator of elevated unconjugated bilirubin levels. Elevated unconjugated bilirubin levels are seen with liver disease and/or rapid destruction of RBCs.2. Incorrect: Petechiae are commonly seen with thrombocytopenia and can be an indicator of decreased clotting capability of the blood. The treatment goal with hemophilia is to increase the blood's ability to clot.4. Incorrect: Capillary refill is an indicator of tissue perfusion and not the blood's ability to clot.

The nurse is planning a teaching session with the family members of a client diagnosed with moderate Alzheimer's disease. Which topic is most important for the nurse to discuss? 1. Encouraging dependence on family members 2. Performing passive range of motion 3. Providing a safe environment 4. Monitoring vital signs every 8 hours

3. Correct: A safe home environment is a priority. When you see a safety answer always consider it. This client has a memory deficit and may wander away, leave food on the stove cooking or burn themselves with hot water. Safety is a priority. 1. Incorrect: It is important to promote independence in self-care activities to promote dignity and autonomy. The client cannot make decisions alone but the family can give the client choices to pick from., Never promote dependency. 2. Incorrect: Active range of motion and regular exercise are encouraged, but this is not the most important topic. The stem does not mention that the client is mobility impaired. Walking is usually intact until late stages of Alzheimer's. 4. Incorrect: Focus is on cognitive and behavioral symptoms. V/S would be monitored as needed. This client is at home with family and nothing indicates the need to take the client's vital signs three times a day.

The nurse has initiated instruction for an 11 year old child newly diagnosed with diabetes mellitus. The child indicates anxiety about the need for daily insulin injections. What nursing action would best address this issue? 1. Tell the child it only hurts for a moment. 2. Have the parents administer the shots. 3. Show the child how to give self injections. 4. Provide toy syringe for the client to play with.

3. Correct: A school age child needs a sense of achievement and control of the situation. Because diabetes will be a life-long disease, it is important for the child to begin learning about self-care which includes daily insulin injections. Age eleven is not too young to begin administering self injections. 1. Incorrect: This is a false statement, considering the fact that pain perception varies. Minimizing the amount of potential discomfort will instill distrust in the child, decreasing compliance with the health regimen. This is false assurance. 2. Incorrect: While parents may administer injections for much younger children, school aged children are capable of becoming independent with all aspects of diabetes. Additionally, an 11 year old client needs to develop a sense of mastery and achievement to accomplish this stage successfully. 4. Incorrect: The client is too old for pretend play with imitation syringes. That process is more appropriate for a preschool child. It would be beneficial to allow this child to handle regular syringes without a needle initially, and then add all the necessary equipment when the client feels more comfortable handling everything.

The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Which client should the nurse assess first? 1. Lumbar puncture reporting a headache. 2. Cystogram reporting burning on urination. 3. Thoracentesis reporting shortness of breath. 4. Cardiac catherization with a decreased pedal pulse below insertion site.

3. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. This client should report an improved respiratory, not shortness of breath. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. 1. Incorrect: A lumbar puncture involves removing cerebral spinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. 2. Incorrect: The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a biopsy. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Although this will require assessment, this client is not the priority at this time. 4. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catherization. This invasive procedure results in some edema to the vessel used for the procedure but assessing only one pedal pulse does not provide sufficient data to verify a complication.

Following surgery, a client has an indwelling urinary catheter attached to a collection bag. The nurse empties the collection bag at 0900. At the change of shift at 1500, the collection bag contains 100 mL of urine. The system has no obstructions to urinary flow. What would be the nurse's most appropriate initial response? 1. Elevate the head of the client's bed. 2. Start giving the client 8 ounces of oral fluid per hour. 3. Check circulation and take the vital signs of the client. 4. Continue monitoring, because this is an expected finding.

3. Correct: A urine output (U/O) of 100 mL over a 6 hour period is dangerously low. This client could be experiencing hypovolemic shock. In clients who are "shocky", the kidneys stop making urine to try to hold on to what little volume the body has left. The nurse is checking the vital signs for low BP and increased HR, indicators of hypovolemic shock. Also, when the urine output is this low, the client is at risk for renal failure. 1. Incorrect: Elevating the head of the client's bed is a good choice when the client is having difficulty breathing, but not here. Raising the HOB will cause the BP to drop lower. Clients in shock should be supine. 2. Incorrect: Normally, pushing fluids is a good choice if the urine output were low. 100 mL over six hours requires more aggressive treatment to combat shock. 4. Incorrect: This is not an expected finding. Urine output less than 240 mL in an eight hour time frame should alert the nurse to a serious problem such as shock.

How closely monitored is access to a facility's health information system? 1. No monitoring; the system is password protected. 2. Monitored intermittently. 3. Monitored closely and constantly for inappropriate use. 4. Monitored daily and sporadically.

3. Correct: Access to a health care facility's computerized health information system is monitored closely and constantly. Records of each healthcare team member's time and date of access, as well as the information that was accessed, are kept by the information technology services department. Access can be suspended, restricted, or revoked for unauthorized or inappropriate use. 1. Incorrect: This is like doing nothing. Healthcare providers must be diligent about maintaining confidentiality, which includes the use of technology that contains confidential client information. 2. Incorrect: Intermittent monitoring is not adequate. Access should be monitored closely and constantly. A breach of confidentiality could occur if intermittent monitoring was done.4. Incorrect: Access should be monitored closely and constantly. Sporadically and once daily is not adequate for protecting client confidentiatlity.

The nurse is caring for a diabetic client. The client's glucose level at 0700 is 265. What is the nurse's best action? Exhibit 40 units NPH insulin every AM Regular Insulin per Sliding Scale both AC and HS Sliding Scale: Blood glucose < 200: 0 units Blood glucose 200-249: 2 units Blood glucose 250-299: 4 units Blood glucose 300-349: 6 units Blood glucose 350-399: 8 units Blood glucose 400 or >: Call primary heal 1. Hold the NPH and regular insulin 2. Give 8 units of regular insulin and hold the NPH 3. Give the NPH and 4 units of regular insulin 4. Give 40 units of NPH and hold the regular insulin

3. Correct: According to the prescription and sliding scale, the client will need 40 units of NPH and 4 units of regular insulin for a glucose level of 250-299.1. Incorrect: According to the prescription and sliding scale, the client will need 40 units of NPH and 4 units of regular insulin for a glucose level of 250-299.2. Incorrect: According to the prescription and sliding scale, the client will need 40 units of NPH and 4 units of regular insulin for a glucose level of 250-299.4. Incorrect: According to the prescription and sliding scale, the client will need 40 units of NPH and 4 units of regular insulin for a glucose level of 250-299.

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

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

The behavioral health nurse is providing crisis intervention follow-up with a client and is teaching concepts regarding crises. Which statement by the client would best indicate understanding of the teaching? 1. "I must have a type of mental illness because I was not able to cope with the stressful situation." 2. "I will usually not be able to identify a stressor that can cause a crisis in my life." 3. "This crisis has the potential to help me grow psychologically." 4. "Because this situation created a crisis for me, I can expect this crisis to recur for me."

3. Correct: Although a crisis threatens personality organization and the individual is not able to function as usual, it also presents an opportunity for psychological growth. 1. Incorrect: Individuals, other than those with mental illness, can experience crises. These individuals can be mentally healthy, have functioned well in the past, but find themselves in a state of disequilibrium. Being unable to effectively cope during a stressful situation does not mean that a person has a mental illness. 2. Incorrect: The primary cause of a crisis is a traumatic event, which the client could readily identify. 4. Incorrect: Crises are considered acute and time limited, usually lasting approximately 4 to 6 weeks. A goal of crisis intervention is not only to promote the optimal level of functioning, but also to prevent further emotional disruption. Therefore, the client would hopefully gain the needed resources and coping skills needed to prevent future problem situations from occurring.

What is the most effective method of stroke prevention that the nurse should teach to the public? 1. Administering platelet inhibitors to prevent clot formation. 2. Undergoing transluminal angioplasty to open a stenosed artery and improve blood flow. 3. Maintaining normal weight, exercising, and controlling comorbid conditions. 4. Administering tissue plasminogen activator (tPA).

3. Correct: Although administering platelet inhibitors, tPA, and undergoing transluminal angioplasty may improve cerebral blood flow, the goals of stroke prevention include health promotion for the healthy individual and education and management of modifiable risk factors to prevent a stroke. Health promotion focuses on a healthy diet, weight control, regular excercising, no smoking, limited alcohol consumption and routine health assessments. 1. Incorrect: This is not the most effective method to prevent a stroke. Anti platelet drugs are usually the chosen treatment to prevent stroke in clients who have had a TIA. 2. Incorrect: This is not the most effective method to prevent a stroke. Transluminal angioplasty is an invasive procedure to improve blood flow. 4. Incorrect: This is not the most effective method to prevent a stroke. tPA is administered IV to reestablish blood flow through a blocked artery in a client with acute onset of ischemic stroke symptoms.

The nurse sees the following rhythm on the cardiac monitor for a client recovering from a myocardial infarction. What would be the nurse's first action upon entering the client's room? Exhibit: VF 1. Attempt defibrillation 2. Begin CPR 3. Assess for carotid pulse 4. Administer lidocaine

3. Correct: Although the rhythm strip looks like ventricular fibrillation, you must first check the client. Assess for consciousness, airway, breathing, circulation first. 1. Incorrect: Assess the client first. Do not rely on the strip alone. It may be artifact. If there is no pulse, then you defibrillate. 2. Incorrect: Assess the client first. Defibrillate, then CPR. 4. Incorrect: While CPR is in progress after defibrillation, start IV, if one is not available, then give lidocaine.

A client is admitted with new onset hyperthyroidism. Which medication is of concern to the nurse while reviewing the client's routine medications? 1. Ranitidine 2. Furosemide 3. Amiodarone 4. Propranolol

3. Correct: Amiodarone, a class III anti-arrhythmic drug, has multiple effects on myocardial depolarization and repolarization that make it an extremely effective antiarrhythmic drug. However, amiodarone is associated with a number of side effects, including thyroid dysfunction (both hypo- and hyperthyroidism), which is due to amiodarone's high iodine content and its direct toxic effect on the thyroid. 1. Incorrect: Ranitidine has not been found to contribute to the development of hyperthyroidism or hypothyroidism. 2. Incorrect: Furosemide has not been found to affect the thyroid. 4. Incorrect: Beta blockers are given to hyperthyroid clients to decrease myocardial contractility BP, and HR. It also decreases anxiety. This will help the hyperthyroid client.

An LPN/VN has been floated to the emergency room following a chemical plant explosion. What task would be best to assign to the LPN/VN? 1. Identify and assess each incoming client. 2. Triage and assign color-coded tags to each client. 3. Gather and apply dressings to open wounds. 4. Initiate oxygen and IV lines as needed.

3. Correct: An LPN/VN's scope of practice includes tasks such as wound care. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. 1. Incorrect: Although it will be crucial to identify each incoming client, the LPN/VN's scope of practice does not include assessment. That task would require an RN or primary healthcare provider. 2. Incorrect: In a mass casualty situation, triage allows the nurse or primary healthcare provider to quickly determine which clients are critical versus those stable enough to wait. Because this involves assessment, an LPN/VN would not be assigned this task. 4. Incorrect: Initiating intravenous lines is not within the scope of the LPN/VN. Additionally, the decision to apply oxygen involves assessment of the respiratory system, which also is not within the LPN/VN's scope of practice.

The school nurse has been observing a 13 year-old student during the past few months as the student has steadily lost weight. Which assessment finding would be the best indication of the beginning of an eating disorder? 1. Clothing size has decreased by 2 sizes. 2. Student eats most meals with peers. 3. Client reports a fear of gaining weight. 4. Diet consists mostly of fruit or raw vegetables.

3. Correct: An adolescent reporting a fear of gaining weight may indicate the beginning of an eating disorder. This is the best indicator of an eating disorder. 1. Incorrect: A decrease in clothing size does not indicate a problem. It may be an indicator of an eating disorder but in itself does not mean there is an eating disorder.2. Incorrect: A client with an eating disorder may eat alone, or not at all. Eating with peers shows the feeling of acceptance which is not usually present with an eating disorder. 4. Incorrect: Eating snacks of fruit and vegetables is a healthy behavior. This alone does not contribute to an eating disorder. Also, it says the diet is "mostly" fruit and vegetables.

A client diagnosed with an embolic stroke has been admitted to the medical unit. Which nursing assessment would the nurse include to identify an early sign of increased intracranial pressure (ICP)? 1. Bradypnea 2. Bradycardia 3. Irregular respirations 4. Elevated systolic pressure

3. Correct: An early sign of increased ICP is irregular respirations. The increased ICP is precipitating neurological changes which results in a decrease in cerebral perfusion. This action results in irregular respirations due to the vasomotor center being stimulated 1. Incorrect: Bradypnea is a late sign of increased ICP. The normal breathing rate for an adult is 12 - 20 breaths per minute. Increased intracranial pressure will compromise the blood flow in the brain. The result of the decreased blood flow is bradypnea. 2. Incorrect: As the intracranial pressure increases and hypertension occurs the parasympathetic system is stimulated. The parasympathetic system stimulation results in bradycardia. Bradycardia is a pulse less than 60 beats per minute. Bradycardia is not an early sign of increased ICP. 4. Incorrect: The cerebral blood flow decreases as intracranial pressure elevates. The response is an increase in the systolic pressure as result of the arterial pressure increase. This is a later sign of increased ICP.

A client arrives on the orthopedic unit following an open reduction-internal fixation (ORIF) of a fractured femur. Following the initial assessment, the nurse offers pain medication. The client refuses, indicating a preference to control personal pain with meditation. What observations by the nurse would indicate this method has been successful in controlling the client's post-op pain? 1. Client shuts eyes tight when leg repositioned. 2. Client is restless and makes facial grimaces. 3. Client vitals are at baseline during activity. 4. Client is able to sleep through the night.

3. Correct: Any type of post-op movement can be quite painful, particularly with broken bones. One of the first indications of pain is an elevation of blood pressure, pulse or respiratory rate. Since the client's vital signs remained within normal limits ("at baseline") even with activity, this is a good indicator the client is able to control the pain quite well. 1. Incorrect: Tightly shut eyes, rigid body posture and agitation are indications pain is not being well controlled. Post-operative pain from a fractured femur may be very severe, particularly with any movement. Shutting eyes is one of several non-verbal cues of discomfort. 2. Incorrect: Restlessness, jaw clenching and facial grimacing are all non-verbal indications of unrelieved pain. If observed in the client, the nurse should again assess the need for pain medication, in the event the client has changed perspectives on that topic. 4. Incorrect: Being able to sleep through the night does not necessarily indicate pain control. There are numerous reasons a client might be able to sleep during the night. Perhaps the client is exhausted from a stressful day, or ordinarily is a deep sleeper. This action does not necessarily mean the client is pain free.

A client who has had a stroke presents with lethargy, facial droop, and slurred speech. The client has a history of gastroesophageal reflux disease (GERD). From this history, what does the nurse recognize as an increased risk for this client? 1. Diminished colonic motility 2. Esophageal hemorrhage 3. Aspiration pneumonia 4. Stress ulcers

3. Correct: Anyone who has had a stroke is at risk for aspiration, especially with a history of reflux disease. It is important to remember that the stomach is full of acid. When aspiration of this acid occurs, it causes irritation to the lung tissue. The client can develop a severe pneumonitis. That's what could kill the client, so this answer takes priority. 1. Incorrect: Diminished colonic motility may become a problem, but aspiration pneumonia is more acute. Remember airway, breathing, and circulation will take priority. 2. Incorrect: Esophageal hemorrhage is seen with esophageal varices, not reflux disease. 4. Incorrect: GERD is not associated with increased risk for stress ulcers, but GERD can also lead to strictures and/or precancerous lesions called Barrett's esophagus.

The nurse is caring for a client admitted with heart failure associated with an acute MI. At which time point did the nurse begin to intervene incorrectly? Exhibit Nitroglycerin 25 mg in 250 mL D5W IV administered per protocol. 1. 1115 2. 1120 3. 1125 4. 1130IV D5W at 20 mL/hr

3. Correct: At 1125, the nurse failed to follow protocol for nitroglycerin infusion. The nurse increased the IV rate by 6 mL/hr (going from 10-20 mcg/min). 1. Incorrect: The nurse mixed the nitroglycerin appropriately and connected the tubing at the correct IV site. The infusion rate was started at 3 mL/hr which delivered the appropriate starting dose at 5 mcg/min. 2. Incorrect: At 1120 the client is still hurting and the BP is above 120 systolic, so the nitroglycerin infusion can be increased by 5 mcg/min which would increase the rate to 6 mL/hr. 4. Incorrect: At 1130 the client is still hurting and the BP is above 120 systolic, so the nitroglycerin infusion can be increased by 5 mcg/min which would increase the rate to 15 mL/hr.

Which action should the nurse take for a client who is of the Roman Catholic faith? 1. Notifying dietary that all food is required to be kosher. 2. Administering last rites to the client if death is imminent. 3. Ensuring there is no meat served with meals on Fridays during Lent. 4. Positioning the dying client's bed facing Mecca (east).

3. Correct: Avoiding eating meat on Fridays during Lent is a practice of those of the Catholic faith; this action demonstrates cultural sensitivity and spiritual support. 1. Incorrect: Kosher food is required in Judaism. Kosher diet is based on a section of Jewish law which identifies which foods can be eaten. 2. Incorrect: A priest, not the nurse would administer last rites of the sick. Only a priest has been trained to celebrate the Sacrament of Reconciliation and the Anointing of the sick (last rites). 4. Incorrect: Persons of the Muslim (Islam) faith who are dying want their body turned to Mecca (east). The body or the heels should be positioned to the Mecca (east).

A concerned mother is asking the nurse about activities that would be best for her child who has been diagnosed with asthma. In order to minimize the risk of exercise induced asthma, which activity would be best for the nurse to suggest? 1. Track 2. Basketball 3. Baseball 4. Soccer

3. Correct: Baseball is an activity that is considered "asthma friendly". It requires short, intermittent periods of exertion and is therefore tolerated better by children with asthma. 1. Incorrect: This activity requires extended periods of exertion and is not considered "asthma friendly" and often not tolerated by clients with asthma. 2. Incorrect: This activity requires extended periods of exertion and is not considered "asthma friendly" and often not tolerated by clients with asthma. 4. Incorrect: This activity requires extended periods of exertion and is not considered "asthma friendly" and often not tolerated by clients with a

Which medication does the nurse expect will help decrease tremors in a client diagnosed with hyperthyroidism? 1. Steroids 2. Anticonvulsants 3. Beta blockers 4. Iodine compounds

3. Correct: Beta blockers help anxiety and tremors. Beta blockers reduce the effects of adrenaline in the body and help decrease anxiety. In times of stress and emergency the adrenal gland produces adrenaline that acts on various organs in the body to enable us to deal with the situation. For example, the heart beats faster due to adrenaline. In order for adrenaline to be able to do this, various organs have beta receptors to accept the adrenaline and use it to behave differently in times of stress. Beta blockers block these receptors. They stop various organs in the body from accepting adrenaline. Taking them means the heart does less work generally and doesn't get over-worked in times of stress. One of the main symptoms of anxiety is a speeding heart which is part of the fight-or-flight response. In times of danger our body produces adrenaline to stop the heart from beating faster makes us feel calmer. Taking beta blockers for anxiety also makes us feel less shaky. The energy boost to our muscles (from the increased supply of blood and oxygen) which makes us feel 'jittery' and 'on-edge' doesn't happen without a fast heartbeat. 1. Incorrect: Steroids influence the body system in several ways, but they are used mostly for their strong anti-inflammatory effects and in conditions that are related to the immune system function such as arthritis, colitis (ulcerative colitis, and Crohn's disease), asthma, bronchitis. Steroids are used to treat systemic lupus, severe psoriasis, leukemia, lymphomas, idiopathic thrombocytopenic purpura, and autoimmune hemolytic anemia. These corticosteroids also are used to suppress the immune system and prevent rejection in people who have undergone organ transplant as well as many other conditions. 2. Incorrect: Anticonvulsants are used to normalize the electrical activity in the brain which in turn reduces the risk of seizures. But anticonvulsants have also been shown to work on mood disorders such as depression or mania. Anticonvulsants help increase the naturally occurring nerve calming chemical known as GABA while decreasing the nerve exciting chemical known as glutamate. Tremors can actually be a side effect of anticonvulsants. 4. Incorrect: Iodine compounds decrease the production of thyroid hormones in the treatment of hyperthyroidism. It does not have an effect on tremors.

The nurse is teaching a client diagnosed with asthma about using a peak expiratory flow meter. The nurse asks the client what action should be taken if the reading is 65% of the client's personal best value. What statement by the client indicates to the nurse that education was successful? 1. "This is a good reading for me, so I can go about my usual activities." 2. "I will administer my long-term inhaler medication." 3. "My as needed inhaler medication needs to be administered." 4. "I need to immediately call 911."

3. Correct: Between 50% and 79% of the client's personal best value indicates asthma is getting worse and the client should immediately take the "as needed" medication which should be a short-acting bronchodilator. 1. Incorrect: 80% to 100% of a client's personal best value is considered "doing well" and is the range recommended that the client can do usual activities. However, a reading of 65% falls below this recommended level, so the client may not be able to perform usual activities. 2. Incorrect: 80% to 100% of a client's personal best value indicates continuation of long term inhaler medication each day. The level of 65% of the client's personal best value confirms the need for a rescue medication. 4. Incorrect: If the client is unresponsive to immediate therapy, emergency care may be required.

A client with the diagnosis of mild anxiety asks the nurse why the primary healthcare provider switched medications from lorazepam to buspirone. What should the nurse tell the client? 1. "Lorazepam takes longer to start working than buspirone so the primary healthcare provider decided to switch medications." 2. "Buspirone can be stopped quickly if neccessary." 3. "Buspirone does not depress the central nervous system like lorazepam does, so you should not have as much sedation." 4. "You need to ask your primary healthcare provider why the medication was changed from lorazepam to buspirone."

3. Correct: Buspirone does not depress the CNS system and is believed to produce the desired effects through interaction with serotonin, dopamine, and other neurotransmitter receptors. 1. Incorrect: Buspirone takes 1-2 weeks to take effect and can take up to 4-6 weeks to achieve full clinical benefits. Lorazepam is a benzodiazepine and begins to work within a few hours to 1-2 days. 2. Incorrect: The client should not stop taking any antianxiety medications abruptly. Serious withdrawal symptoms can occur: depression, insomnia, anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, delirium.4. Incorrect: The nurse should be able to discuss medication administration with the primary healthcare provider.

At what age does the nurse expect to see a child build a tower of 9 blocks? 1. One 2. Two 3. Three 4. Four

3. Correct: By the age of 3 years, the nurse would expect the child to build a tower of 9-10 blocks. 1. Incorrect: At one the child is working on gross motor skills rather than dexterity skills. 2. Incorrect: By age 2 the child can build a tower of at least 4 blocks. 4. Incorrect: The four year old can build high towers of more than 10 blocks.

During the hospital discharge instructions a client asks the nurse, "What do you think I should do about my husband's smoking?" Which statement by the nurse is appropriate? 1. "Why are you asking me for advice?" 2. "I think you should talk to your husband." 3. "What do you think you should do?" 4. "You need to support him through his addiction."

3. Correct: By using the therapeutic communication of reflecting, the nurse is referring the client back to their statements. The communication direction is returned to the client for their reflection on questions and feelings. 1. Incorrect: The nurse is asking a direct question back to the client. This is the nontherapeutic communication technique of requesting an explanation. The nurse is controlling the direction of the communication. The nurse needs to provide answers that the client requested not information that the nurse wants to address. 2. Incorrect: The nurse is sharing with the client their ideas of what the client should do. The nurse is utilizing nontherapeutic communication technique of giving advice. When the nurse is giving advice, the client is placed in a dependent role. 4. Incorrect: The nurse is focusing the communication to the needs of the husband and not the client. This nontherapeutic communication technique of defending the husband will act as a communication block with the client.

A 70 year-old client reports not sleeping well at night, having trouble staying asleep, and awakening about 4:00 a.m. What should the nurse teach the client about sleep patterns in the elderly? 1. Don't worry about a few hours of lost sleep. 2. Elders need as much sleep as younger adults. 3. Caffeine and some medications may interfere with sleep. 4. Elders sleep more than younger adults.

3. Correct: Caffeine and some medications may interfere with sleep. 1. Incorrect. The client is concerned about the sleep problem, and the nurse should address the client's concerns. Sleep disturbances can also indicate depression. This option is denying their concerns. 2. Incorrect. Elders actually require less sleep because they are less active. Elderly do not need as much sleep. 4. Incorrect. Elders are likely to have more disturbed sleep. They usually do not need more sleep.

The nurse working in a pediatrician's office is teaching a couple with small children about proper medication administration for children. What statement by the couple would indicate that further teaching is needed? 1. We should carefully measure elixir medication with the provided dropper. 2. Our children should not watch us take medicine. 3. We tell our children the medicine is candy so they will take it without a fuss. 4. Even though medicine comes in a childproof container, we will put medication out of reach.

3. Correct: Calling medication "candy" is inappropriate and misleading to the child. Children may take medication to eat as candy if they have access to it.. 1. Incorrect: This is a correct statement by the parents. Medication should be measured closely because too much or too little might cause harm to the child. 2. Incorrect: Taking medicine in front of children is not recommended, as children often try to imitate adult behavior. 4. Incorrect: All medication should be placed out of the reach of children.

The nursing unit manager is reviewing cardiopulmonary resuscitation protocols with a group of new nurses. When the unit manager asks for an indication of effective CPR on an adult, what new nurse response would be most accurate? 1. Chest wall visibly rises with rescue breathing. 2. Skin color and temperature becomes pink and warm. 3. There is a palpable femoral pulse with a compression. 4. A sinus beat appears on monitor during compression.

3. Correct: Cardiopulmonary resuscitation is considered effective if the nurse or medical personnel can palpate a femoral pulse with each chest compression. Though the lay person is taught to assess a carotid pulse, the femoral pulse is utilized in a hospital setting. 1. Incorrect: While it is true that the chest should visibly rise during effective rescue breathing, the question is asking about cardiopulmonary resuscitation, not rescue breathing. 2. Incorrect: Chest compressions during cardiopulmonary resuscitation are designed to keep vital internal organs oxygenated until an AED or defibrillator is available to restart the heart. Skin is not considered a vital organ and therefore skin color and temperature does not change unless a heartbeat is restored. 4. Incorrect: Any complex or rhythm noted on the monitor during chest compressions indicates only electrical impulses within the heart muscle and does not actually indicate a contraction unless accompanied by a pulse. This is referred to as 'pulseless electrical activity', and CPR should continue.

A client with a history of eczema has been admitted with cellulitis of the left forearm. Which admission order should the nurse question immediately? 1. Start IV of normal saline at 100 mL per hour. 2. Keep left arm elevated on pillow at all times. 3. Apply ice packs to affected area every shift. 4. Ibuprophen 800 mg po every 6 hours prn pain.

3. Correct: Cellulitis is a bacterial skin infection resulting in warm, redden and edematous tissue, sometimes accompanied by fever and chills. Swelling in the affected area impedes blood flow and increases pain. In order to decrease the edema, warm, moist compresses are used to stimulate circulation and speed reabsorption of the fluid within the tissue. This order should be questioned immediately. 1. Incorrect: An infection serious enough to require hospitalization indicates this client is either septic or may need intravenous antibiotics. Fluids are a primary treatment for sepsis along with bedrest and antibiotics. A basic solution of normal saline at 100/mL per hour would be an appropriate order for this client. 2. Incorrect: The swelling characteristic in cellulitis in painful and diminishes circulation to the area. Elevation on one or two pillows at all times helps to improve blood flow so that healing can take place. In some facilities, clients are provided with a wedge shaped cushion that provides better support of the affected area. This order is appropriate. 4. Incorrect: Ibuprophen provides relief from both pain and inflammation associated with cellulitis. A dose of 800 milligrams by mouth every 6 hours as needed for pain would be appropriate for this client. This is not an order the nurse should question.

A client who is four days post-op cholecystectomy complains of severe abdominal pain. During the initial assessment the client states, "I have had two almost black stools today." Which nursing action is most important? 1. Start an IV with D5W at 125 mL/hr 2. Insert a nasogastric tube 3. Contact the primary healthcare provider 4. Obtain a stool specimen

3. Correct: What's going on inside? They are hemorrhaging. Assume the worst. The primary healthcare provider is the only one who can stop the bleeding. 1. Incorrect: There's nothing wrong with starting an IV, but isn't the client bleeding while you do this? 2. Incorrect: How does that help the bleeding stop? It doesn't. 4. Incorrect: You are going to wait on a stool specimen and Hemoccult? Don't delay care! Notify the primary healthcare provider first.

A client with a history of intolerance to fatty foods is admitted to the hospital with a sudden onset of severe right upper quadrant pain radiating to the right shoulder. What should be included in the nurse's initial focused assessment of this client? 1. "Do you have pain in the middle of your stomach that is relieved by vomiting?" 2. "Have you noticed any red splotches on your skin?" 3. "Please describe your bowel habits and stool." 4. "Tell me how often you eat high fat meals."

3. Correct: Clay colored stools are a sign of biliary obstruction and are due to lack of bile in the stool. Bile adds a darker color to the stool. Asking the client to describe stool is open ended and will give the nurse more detail. 1. Incorrect: Epigastric pain relieved by vomiting is found with clients who suffer from peptic ulcers. 2. Incorrect: Spider angiomas are seen in clients with liver disease 4. Incorrect: This does not relate to the client's pain and will not obtain needed information about the client's current condition.

Which task would be appropriate for the Labor, Delivery, Recovery, Postpartum (LDRP) charge nurse to assign to an LPN/VN? 1. Administering IV pain medication to a client three days postopertive cesarean section. 2. Drawing a trough vancomycin level on a client 3 days postpartum with bilaterial mastitis. 3. Reinforce how to perform perineal care to a primipara who is four hours postpartum. 4. Drawing routine 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: Drawing lab work on a client with severe infection and only 3 days postpartum is an unstable client and needs care from the RN. 4. Incorrect: Drawing routine admission labs on a client in final stages of labor would be inappropriate because the client is potentially unstable and needs experienced LDRP nursing care.

Which nursing action takes priority once a term infant has delivered vaginally? 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. The stimulus of drying the skin also promotes vigorous crying and lung expansion in most healthy infants. 1. Incorrect: A task that needs to be done before the baby leaves the delivery room, but is not immediate priority.2. Incorrect: Eye prophylaxis may be delayed until the end of the first hour after birth without adverse effects. Because the ointment may temporarily blur the infant's vision, parents may wish to delay treatment for a short time during initial bonding. 4. Incorrect: A task that needs to be accomplished before the baby leaves the delivery room, but is not immediate priority.

A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse initiate? 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 assessment and allows the nurse to assess if there is a change in the appearance of the affected knee to the unaffected knee. 1. Incorrect: The extent of the injury is not known until after an assessment is done. Remember the nursing process here. Assess first. Extending the affected knee may cause further damage.2. Incorrect: You don't want the child to move the extremity prior to assess 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 assess whether or not an injury occurred.

The client has been diagnosed with cutaneous anthrax in a cut on the right hand. What measure should be implemented by the nurse to prevent further spread of the disease? 1. Wear mask only. 2. There are no precautions necessary. 3. Standard precautions. 4. Limit interactions with client.

3. Correct: Cutaneous anthrax is not spread person-to-person. However, it can be spread to others in rare events if the wound is draining. Standard precautions should protect the individual.1. Incorrect: Inhalation is not the mode of transmission for cutaneous anthrax; standard precautions should be used with every client.2. Incorrect: Standard precautions should be used in the care of every client.4. Incorrect: Clients need personal care and assistance throughout the treatment of the infection. Stay away from answers that ask you to limit interactions with the client.

The nurse discovers that a client diagnosed with severe depression formerly taught art classes at a local school. The nurse offers to obtain needed supplies if the client would instruct a few interested clients on simple painting techniques. The nurse is aware this type of intervention may help the client achieve what outcome? 1. Distract client from depressive thoughts of hopelessness. 2. Encourage client to begin communicating with others. 3. Utilize client's own strengths to increase self-esteem. 4. Establish the trusting nurse/client relationship.

3. Correct: Depressed clients often feel hopelessness, failing to recognize personal value or purpose. The nurse is drawing attention to the client's personal strengths and abilities to help achieve the goal of recognizing self-worth and improving self-esteem. 1. Incorrect: The process of treating a client for severe depression utilizes multiple therapeutic techniques, including possible medications, and interactive communication. However, distracting the client instead of talking through emotions is not the purpose of painting. 2. Incorrect: A client diagnosed with depression tends to withdraw from social interactions, particularly in groups. Instructing a small group of individuals may require the client to communicate but this activity is not specifically for that purpose. 4. Incorrect: While it is crucial to establish a trusting relationship with the client, the suggested painting activity is not for that purpose.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Encourage client to express grief related to loss of independence. 2. Irrigate a client's ear canal. 3. Disconnect client's nasogastric (NG) tube suction to allow ambulation. 4. Show client who has conjunctivitis how to clean the eyes.

3. Correct: Disconnecting NG tube suction is an appropriate task for the UAP. 1. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. 2. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. It is not a routine task. 4. Incorrect: The nurse cannot assign teaching to the UAP.

The nurse is talking to the parents of a 4 year old who is suspected to have iron deficiency anemia. What statement by the parents would suggest the cause of this anemia to the nurse? 1. "Breakfast consists of iron fortified cereal most days." 2. "A typical lunch would be a chicken sandwich with orange slices." 3. "Our child drinks 30 ounces (887 mL) of milk a day." 4. "It is difficult to get our child to eat broccoli."

3. Correct: Drinking excess amounts of milk may lead to iron deficiency because the calcium in milk blocks iron absorption. 1. Incorrect: ¾ cup of 100% iron fortified prepared cereal provides 18 mg of iron. 2. Incorrect: The body's absorption of iron increases when drinking citrus juice or eating other foods rich in vitamin C (oranges) while high-iron foods (chicken) are eaten. 4. Incorrect: Broccoli is rich in calcium, not iron.

A nurse is caring for a client admitted with a diagnosis of depression and suicidal thoughts. The client states, "My husband doesn't love me anymore, and so life is just not the same." What would be the most appropriate response by the nurse? 1. "Even though your husband does not love you, life can still be very meaningful." 2. "Many couples go through difficult times in their marriage, but you should not assume that he does not love you anymore." 3. "Tell me what has led you to believe that your husband doesn't love you anymore." 4. "You really need to try not to let your husband make you depressed and feel that life is not worth living."

3. Correct: During this initial assessment, the nurse should use therapeutic communication to try to explore the client's feelings and perceptions and demonstrate acceptance of the client. This can best be accomplished by allowing the client to discuss the events that played a role in the development of beliefs that her husband no longer loves her. 1. Incorrect: This dismisses the client's feeling that the worth of life is closely related to the relationship with her husband. The nurse should not make comments that negate the client's feelings. 2. Incorrect: Telling the client that couples go through difficult times and for her not to assume that the husband does not love her is communicating that her feelings are not valid. In addition, the nurse is using a cliché' that all couples have problems which further invalidates her feelings in the situation she is experiencing. 4. Incorrect: Telling the client to try not to let the husband make her feel depressed is giving advice. This does not allow the client to verbalize or explore her feelings and does not provide the client with a sense of support from the nurse.

The previous shift nurse reported to the oncoming nurse a suspicion that a client's central line has developed a fibrin sheath. Which prescription does the nurse anticipate the healthcare provider will prescribe? 1. Heparin 2. Enoxaparin 3. Alteplase 4. acetylsalicylic acid

3. Correct: If a catheter becomes partially blocked due to a fibrin sheath or loses its blood return, a fibrinolytic is typically prescribed. Currently, alteplase is the preferred thrombolytic to treat thrombotic occlusions.1. Incorrect: Systemic anticoagulation with heparin for treatment of a fibrin sheath has not been proven to be beneficial. 2. Incorrect: Enoxaparin is a low dose molecular heparin and is not beneficial in treating a fibrin sheath.4. Incorrect: One of the effects of acetylsalicylic acid is its inhibition of platelet aggregation. However, these blood thinning effects are not beneficial in treatment of a fibrin sheath.

A client is sedated. His wife asks the nurse about her husband's test results. The client does not have a healthcare proxy or durable power of attorney executed at this time. How should the nurse respond in compliance with HIPAA (Health Insurance Portability and Accountability Act) regulations regarding the confidentiality of the sedated client's health information? 1. I can't give you those results. You should ask his primary healthcare provider the next time that he comes in to examine your husband. 2. Those test results are confidential, but since you are his wife I can give them to you. Let me look them up in the computer system. 3. The health information of all clients is confidential and is protected by law. Those test results cannot be released without the consent of the client in order to protect the client's right to choose who receives health information. 4. Your husband is only lightly sedated. I can wake him up and ask him if it is all right to release these test results to you.

3. Correct: Each client's health information is confidential and protected by law. The nurse should inform the client's wife 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 wife is not automatically able to receive personal health information about her husband.The husband has to list the wife 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 without the client's consent. 2. Incorrect: Healthcare employees, including primary healthcare providers, are bound by law to keep health information confidential without the client's consent. 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.

Which statement by the spouse of a client diagnosed with Alzheimer's indicates to the nurse that the spouse is dealing appropriately with stressors? 1. "I am in charge of every aspect of the care provided." 2. "I do not expect our children who live out of town to help." 3. "I keep a list of small tasks ready for people who ask me if they can help." 4. "I only go to my primary healthcare provider when I am sick."

3. Correct: Encourage caregivers to say "yes" when someone offers assistance. It's smart to have a list ready of small tasks that others could easily take care of, such as picking up groceries or driving the person to an appointment. 1. Incorrect: The caregiver should be willing to surrender some control. Delegating is one thing. Trying to control every aspect of care is another. People will be less likely to help if the caregiver micromanages, or insists on doing things their way. 2. Incorrect: The caregiver should spread the responsibility. Get family members involved as much as possible. Even someone who lives far away can help. Encourage the caregiver to divide up caregiving tasks. One person can take care of medical responsibilities, another with finances and bills, and another with groceries and errands. 4. Incorrect: Encourage the caregiver to stay healthy by keeping on top of primary healthcare provider visits. They should not skip annual routine, checkups, or medical appointments.

The nurse is caring for a client undergoing electroconvulsive therapy (ECT) for major depression. What is the nurse's most important intervention during the treatment? 1. Monitor vital signs and cardiac functioning. 2. Provide support to the client's arms and legs. 3. Provide suctioning as needed. 4. Place electrodes on temples.

3. Correct: Ensuring patency of the airway is the nurse's first priority. The client should also be NPO for 6-8 hours prior to the procedure. 1. Incorrect: This is an intervention, but does not come before airway. Vital signs do need to be monitored but the client's breathing is a higher priority. 2. Incorrect: This is an intervention, but does not come before airway. Support the extremities due to the seizure activity but highest priority remains airway. 4. Incorrect: This is done prior to initiation of the procedure to deliver the electrical stimulation. The question asks for the most important intervention during the treatment.

A client at 34 weeks gestation with pregnancy induced hypertension (PIH) reports "heartburn." Which action by the nurse has priority? 1. Administer an antacid per standing orders. 2. Check client's blood pressure. 3. Call the primary healthcare provider immediately. 4. Assure client this is a normal discomfort of pregnancy.

3. Correct: Epigastric discomfort is commonly described as "heartburn" by pregnant clients, but epigastric discomfort is a symptom of impending rupture of the liver capsule and seizures associated with worsening PIH and eclampsia. As a new nurse we need to assume the worst. Call the primary healthcare provider. 1. Incorrect: Not a concern as much as impending seizure symptoms. Administering an antacid will not fix the problem if PIH is worsing. This is delaying care. 2. Incorrect: Not a concern as much as impending seizure symptoms. Checking the client's blood pressure is not the priority in this situation. It will not fix the problem. 4. Incorrect: Not in this situation. Heartburn is a normal discomfort or right upper quadrant pain in a client with PIH may indicate impending rupture of the liver capsule which is a life threatening complication.

A client is brought to the emergency room following a serious motor vehicle accident. Standing orders include initiating an IV line and inserting a foley catheter. What action should the nurse take first? 1. Obtain all supplies for the procedures. 2. Explain the procedure to the client. 3. Check the client's identification band. 4. Verify client has signed consent forms.

3. Correct: Even in an emergency, the nurse follows the nursing process by initially gathering data, including identifying the client before beginning any ordered interventions. The client's identity must always be verified before any procedure or treatment. 1. Incorrect: It is important to make sure all necessary supplies are present before beginning an intervention. Stopping in the middle of a procedure to get supplies could expose the client to infection or other complications. However, gathering supplies is an action, which is not the first step when providing care to any client. 2. Incorrect: While it is important to explain any procedure to the client, the scenario does not indicate if this client is even conscious. The nurse has another important priority. 4. Incorrect: When stabilizing an injured client, consent is implied for life-saving procedures such as initiating an IV or applying oxygen. Additionally, obtaining or verifying consent is not a nursing responsibility.

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. Massage the face several times daily using a gentle upward motion. 3. Proper methods of closing eyelids and eye patching. 4. Acupuncture may provide great improvement in symptoms.

3. Correct: Even though all are educational points that need to be provided to the client, this is the most important point. 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: Acupuncture may provide a potential small improvement in function. The priority however, is protection of the eye.

What should the nurse teach a client about testicular self examination? 1. This exam should be performed bi-annually. 2. The exam should be performed during a cold shower. 3. Gently roll each testicle with slight pressure between the fingers. 4. The epididymis should feel like a hard, knotty rope.

3. Correct: Examine one testicle at a time. Use both hands to gently roll each testicle, with slight pressure, between the fingers to feel for lumps, swelling, soreness or a harder consistency. 1. Incorrect: All men 15 years and older need to perform this examination monthly. 2. Incorrect: The exam should be performed during or right after a warm shower or bath when the the scrotum is less thick. 4. Incorrect: The epididymis should feel soft, rope like, and slightly tender to pressure. It is located at the top of the back part of each testicle. It is not a lump.

The licensed practical nurse (LPN) is assisting with care for a client who has an absolute neutrophil count of 500. Which action by the LPN would warrant intervention by the RN? 1. Using an alcohol-based hand rub for hygiene before and after glove removal. 2. Advising visitor with known respiratory infection to not enter the client's room. 3. Taking fresh flowers into the client's room that were delivered by the local florist. 4. Leaving the thermometer and sphygmomanometer in the client's room.

3. Correct: First of all, did you recognize that the absolute neutrophil count (ANC) was very low? So what does this mean for this client? The neutrophils are an important component of the blood that is responsible for fighting infections. A client with a low neutrophil count is considered to be neutropenic and precautions for preventing infections are needed to protect the client. Carrying the fresh flowers into the room that were delivered by a florist may seem like a harmless gesture. But, it is not! Plants and flowers can harbor fungal spores that can be harmful to clients who are immunosuppressed. Therefore, the RN should intervene and not allow the fresh flowers to be taken into this client's room. 1. Incorrect: Using an alcohol-based hand rub for hygiene is the preferred method for decontaminating the hands, unless the hands are visibly soiled. This should be used before and after glove removal. Therefore, the LPN would be using an acceptable practice and the RN would not need to intervene. 2. Incorrect: Since the client has a low neutrophil count and is at risk for infections, the nurse should institute measures to protect the client. This would include advising any visitor with a known respiratory infection to not enter the client's room. The LPN would be protecting the client, and this would not require intervention by the RN. 4. Incorrect: The room for a client with neutropenia should have its own equipment that is not taken out and shared with other clients. This includes such things as thermometers and sphygmomanometers. This equipment should be properly disinfected prior to being brought into the client's room and is not shared with other clients to reduce the risk of contamination to the immunosuppressed client. The LPN would be performing safe nursing care and would not require intervention by the RN.

The charge nurse on the postpartum unit is making assignments. Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. Which nurse should be assigned to care for this client? 1. The RN with 8 years' experience in the Intensive Care Unit. 2. The RN with 10 years' experience pulled from the ER. 3. The RN with 5 years' experience in the Labor and Delivery unit. 4. The RN with 2 weeks' experience on the post-partum unit.

3. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. This client needs careful monitoring and specialized care. Therefore, the nurse with Labor and Delivery experience would be the most appropriate one to assign to care for this client who has postpartum preeclampsia. 1. Incorrect: Although this nurse may be accustomed to caring for clients in acute situations requiring a higher level of care, this nurse is not familiar with caring for clients with preeclampsia. Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. 2. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. Therefore, this would not be the most appropriate nurse to assign to this client. 4. Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. This situation needs advanced monitoring and care, so this nurse with very little postpartum experience would not be the most appropriate to assign to this client.

A high school nurse is assessing multiple students reporting general flu-like symptoms. Which additional symptoms reported by a student would prompt the nurse to immediately call an ambulance? 1. Blurred vision and Trousseau's sign. 2. Vomiting and a Murphy's sign. 3. Sensitivity to light and Kernig's sign. 4. Fever and a Chvostek's sign.

3. Correct: Flu-like symptoms, sensitivity to light and a positive Kernig's sign, often accompanied by neck stiffness, suggests possible meningitis, a serious inflammation of the brain and meninges. Kernig's sign is elicited by placing the client in a supine position with one leg flexed up toward the abdomen. The lower leg is then gently extended upward, producing severe pain in the presence of meningitis. It is important to isolate the student until the type of meningitis is diagnosed. Because bacterial meningitis is contagious, the student should be transported to the emergency room immediately to initiate definitive diagnosis and treatment. 1. Incorrect: Blurred vision in the presence of flu-like symptoms could indicate a number of non-life threatening factors, including dehydration or fatigue. Trousseau's sign is used to assess for tetany with suspected hypocalcemia. It is elicited by applying and inflating a blood pressure cuff while observing for hand spasms. These symptoms would not require immediate transport to the hospital. 2. Incorrect: Although vomiting is unusual in cases of the flu, a Murphy's sign is an indication of possible gall bladder inflammation. Placing fingers under the right rib cage and asking the client to take a deep breath causes intense pain that indicates diseased gall bladder. The presence of either of these signs would not require urgent transport to a hospital. 4. Incorrect: Fever is not uncommon for those with the flu. However, Chvostek's sign is an assessment tool used to determine possible hypocalcemia. To elicit this sign, the client's cheek is tapped gently, which causes muscle spasms on the opposite cheek. Neither of these symptoms would require immediate transport to the hospital.

The nurse is caring for a client with a closed head injury. Three days after admission, urinary output for 8 hours was 1800 mL. In response to this data, what would be the appropriate nursing action? 1. Hydrate the client with 500 mL of IV fluid in the next hour. 2. Monitor BUN and creatinine. 3. Check urine specific gravity. 4. Recognize this as a side effect of dexamethasone.

3. Correct: For any client with a head injury and abnormally high urinary output, the nurse knows the client is at risk for ADH (anti-diuretic hormone) problems. The pituitary gland is located in the brain. ADH is produced in the pituitary gland. In head injured clients, ADH can get messed up. If the client does not have enough ADH large volumes of water will be lost in the urine. The name of this disease is diabetes insipidus (DI). Large volume losses place the client at risk for shock. The nurse knows to further investigate the problem by checking a urine specific gravity. For clients in DI, the urine specific gravity will be very, very low because they are losing so much water. When you see the letters DI, think of the "D" for diuresis and think SHOCK first.

A client diagnosed with celiac disease has been prescribed a gluten-free diet. Which meal, if chosen by the client, would indicate to the nurse that the client understands this diet? 1. Cream based chicken soup 2. Breaded baked chicken with peas 3. Grilled catfish with mixed vegetables 4. Marinated talapia with green beans

3. Correct: Fresh meats, fish and poultry (not breaded, batter-coated or marinated), fruits and vegetables are allowed on a gluten-free diet. 1. Incorrect: This may contain hidden gluten as wheat may be used as a thickener. 2. Incorrect: Fresh meats, fish, and poultry are allowed, but not if breaded, batter-coated, or marinated. 4. Incorrect: Fresh meats, fish, and poultry are allowed, but not if breaded, batter-coated, or marinated.

The emergency department nurse is assuming care of a client with full thickness burns to both legs. Which primary healthcare provider prescription should be implemented first? 1. Administer IV morphine 2. Insert oropharyngeal airway 3. Start two large bore IVs 4. Apply silver sulfadiazine to burn area

3. Correct: Full thickness burns of both legs would result in a severe fluid volume deficit. A priority treatment for burns include fluid replacement; therefore, insertion of 2 large bore IVs is a priority. 1. Incorrect: Pain is important but not priority over fluid volume status. Remember, pain never killed anybody.2. Incorrect: This client does not have airway involvement. These burns are on the legs; there is no indication in the stem that the airway is involved. 4. Incorrect: Application of silver sulfadiazine does not take priority over fluid replacement.

A middle-aged client has a strong positive family history of type 2 diabetes mellitus. What should the nurse teach the client regarding the best method to prevent or delay the development of this disease? 1. Test serum glucose values monthly. 2. Avoid starches and sugars in the diet. 3. Obtain a normal body weight and exercise regularly. 4. Maintain a normal serum lipid panel.

3. Correct: Genetics and body weight are the most important factors in the development of type 2 diabetes mellitus. The client cannot alter his genetics. Therefore, a normal body weight is imperative. Regular exercise reduces insulin resistance and permits increased glucose uptake by cells. This serves to lower insulin levels and reduce hepatic production of glucose. 1. Incorrect: Monthly glucose monitoring is not sufficient. It will tell you when the client becomes a diabetic but will not prevent it from happening. 2. Incorrect: Starch and sugar intake should be decreased, not avoided. 4. Maintaining a normal serum lipid panel may not be achievable in some clients, but it is always the goal. Medication may be needed.

A client's membranes spontaneously rupture at 10 cm dilation and +2 station. The nurse notes that the fluid is colored green. What client preparation is the priority nursing action? 1. Emergency cesarean delivery 2. Immediate high forceps delivery 3. Equipment for immediate suctioning of the newborn 4. Administration of IV oxytocin

3. Correct: Green stained fluid indicates fetal passage of meconium. The fetus must be suctioned by the healthcare provider when the head is still on the perineum and before the baby takes its first breath. This will remove any particulate matter from the meconium that may cause aspiration. 1. Incorrect: Delivery will probably occur soon and vaginal delivery is preferable to cesarean. This is an unrealistic and inappropriate action for this client. 2. Incorrect: High forceps are never indicated and would not provide safe delivery for the baby. The concern is the meconium stained fluid and potential aspiration for the baby. 4. Incorrect: The meconium passage is an indicator of fetal stress, and increased uterine contractions may stress the fetus further. This would not be safe for the baby or the mother at this stage of labor.

What information should be included when a nurse is teaching a group of college students about the transmission of hepatitis B and human immunodeficiency virus (HIV)? 1. HIV is transmitted via toilet seats whereas hepatitis B is not. 2. HIV is transmitted by sexual contact whereas hepatitis B is not. 3. Hepatitis B is more readily transmitted via needle sticks than HIV. 4. Neither virus is transmitted via body fluids.

3. Correct: Hepatitis B virus (HBV) and HIV can be transmitted in similar ways, but hepatitis B is more infectious. Studies show hepatitis B is more readily transmitted via needle sticks than HIV. More than 1 million people currently have HIV in the United States. Hepatitis B is 50-100 times more infectious then HIV. 1. Incorrect: Neither virus is transmitted via toilet seats. Both are spread by contact with infected body fluids such as blood, semen and vaginal fluid, or from a mother to her baby during pregnancy or delivery.2. Incorrect: Both hepatitis B and HIV are transmitted via body fluids through sexual contact. Therefore, condoms should be used during sexual contact. Using a latex condom reduces the chances of hepatitis B and HIV being passed on during sex. Syringes and other injecting drug equipment should never be shared. 4. Incorrect: Both hepatitis B and HIV are transmitted via body fluids through sexual contact. Standard precautions should be implemented for both HIV and hepatitis B. The CDC recommends HBV vaccination for people who are at risk for or living with HIV, including men who have sex with men (MSM); people who inject drugs; household contacts and sex partners of people who have HBV; people with multiple sex partners; anyone with a sexually transmitted infection; people with diabetes; and health care and public safety workers who may be exposed to blood on the job.

A client in the manic phase of bipolar disorder is constantly walking around the day room and refuses to sit down to eat the spaghetti and meatballs sent by the kitchen. Which food should the nurse request from dietary? 1. Carrots and apples 2. Donuts 3. Pepperoni pizza sticks 4. Strawberry pastry

3. Correct: High protein, high calorie, nutritious finger foods are required when the client will not sit down to eat. This client needs food they can eat "on the go" because they are burning more calories in this phase of bipolar disorder. 1. Incorrect: Although nutritious, these foods are not high calorie or high protein. 2. Incorrect: Donuts are high in calories but do not have high nutritional valve. 4. Incorrect: Pastries are also high in calories but do not have high nutritional valve. They are also not very easy to eat "on the go"

A client in active labor has an epidural catheter inserted for management of pain. Which finding should the nurse report to the primary health care provider? 1. Early decelerations 2. Fetal heart rate (FHR) 160/min 3. Blood pressure 90/62 4. Temperature of 99.6° F (37.5° C).

3. Correct: Hypotension is an adverse effect of epidural analgesia due to vasodilation. Maternal hypotension reduces blood supply to the placenta, decreasing fetal oxygen supply. Immediate intervention is required. 1. Incorrect: Early decelerations are not associated with fetal compromise and require no intervention. 2. Incorrect: The fetal heart rate is within normal range. The normal fetal heart rate (FHR) averages from 110 to 160 beats per minute (bpm) for a full term baby. 4. Incorrect: Maternal fever after epidural analgesia is common, but this is a slight elevation in temperature which is not life threatening.

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

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

A float nurse arrives on the unit to assist in the care of clients for the shift. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. Based on this information,what should the nurse do? 1. Ask the float nurse, "Have you been drinking?" 2. Assist the float nurse with the clients case. 3. Notify the charge nurse of the observations. 4. Notify the board of nursing (BON) that the float nurse is an alcoholic.

3. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. Confrontation should occur in the presence of a charge nurse or supervisor. This can prevent harm to client's. 1. Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. The nurse should not lecture, scold or argue with the float nurse. 2. Incorrect: This response overlooks a potentially severe problem. Nurses dependent on drugs or alcohol can harm clients. The nurse should not be assigned to provide care if impairment is suspected. Patient safety must remain the priority. 4. Incorrect: If a report is made to the BON, it should be a factual documentation of specific events and actions, not a statement of impairment. The report should contain consequences. Each state BON differs in that also some have treatment programs they administer themselves.

A float nurse arrives on the unit to assist in the care of clients for the shift. During report, the charge nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. Based on this information, what should the charge nurse do? 1. Ask the float nurse, "Have you been drinking?" 2. Assign the float nurse to the least acute clients. 3. Notify the nursing supervisor of the observations. 4. Notify the board of nursing (BON) that the float nurse is an alcoholic.

3. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. Confrontation should occur in the presence of a supervisor or other nurse and should include the offer of assistance in seeking treatment. This can prevent harm to client's and save the nurse's career or life. 1. Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. The charge nurse should not lecture, scold or argue with the float nurse. 2. Incorrect: This response overlooks a potentially severe problem. Nurses dependent on drugs or alcohol can harm clients. The nurse should not be assigned to provide care if impairment is suspected. Patient safety must remain the priority. 4. Incorrect: If a report is made to the BON, it should be a factual documentation of specific events and actions, not a statement of impairment. The report should contain consequences. Each state BON differs in that also some have treatment programs they administer themselves.

Which physical assessment finding noted in a client would be of concern to the nurse? 1. Generalized tympany with abdominal percussion 2. Nonpalpable spleen 3. Liver palpated 3 cm below right costal margin 4. Negative rebound tenderness

3. Correct: If the client has chronic obstructive pulmonary disease, large lungs, or a low diaphragm, the liver may be normal and palpable at 0.4 to 0.8 inches (1 - 2 cm) below the right costal margin. Palpating the liver 3 cm below the right costal margin is abnormal and would be of concern to the nurse. 1. Incorrect: The purpose of percussing the abdomen is to estimate the size of the liver and determine the presence of fluid, distention, and masses. Air produces a higher pitched, hollow sound termed tympany. Tympany is the predominant percussion sound of the abdomen. 2. Incorrect: The spleen is normally not palpable. 4. Incorrect: The nurse should check any probl

A nurse is to administer a time release capsule to a client who has difficulty swallowing. Which intervention would be the best course of action for the nurse to take? 1. Open the capsule and sprinkle it on applesauce. 2. Melt the capsule in juice or water. 3. Call the primary healthcare provider to change the order. 4. Break the capsule in half using a pill splitter.

3. Correct: If the client has difficulty swallowing a capsule or tablet, ask the primary healthcare provider to substitute a liquid medication if possible. 1. Incorrect: Sprinkling the medication over applesauce or pudding may be the only option the nurse has if there is no other form, but since this medication is time-released, the best answer and priority would be to get a liquid form, if available, for the drug. 2. Incorrect: Never melt a time release capsule or tablet as this would release the medication all at once. 4. Incorrect: Breaking or splitting would also release the medication in boluses and could cause harm to the client.

A client has been admitted with advanced cirrhosis. The nurse's assessment reveals an abdominal girth increase of 5 inches (12.7 cm) and a weight increase of 6 lbs. (2.72 kg) since yesterday's measurements. Based on this data, what would be the nurse's priority assessment? 1. Stool for occult blood 2. Ammonia blood level 3. Blood pressure 4. Level of consciousness

3. Correct: In ascites, the client is in FVD and we worry about shock. If my blood pressure drops, I will have decreased perfusion of my vital organs. Poor perfusion leads to organ damage and failure. 1. Incorrect: We are worried about bleeding because the liver is sick, but this is not the first priority in this case. Third spacing (ascites) has increased placing the clietn at risk for FVD and shock. 2. Incorrect: Ammonia level would indicate a worsening liver condition, but this is not a priority here. 4. Incorrect: LOC is a good indicator of perfusion, but it may be affected by other factors, such as the ammonia level, as well. The BP will tell us the most about shock, and that is what I am worried about here.

Which action would the nurse need to perform to increase stability while initiating a client transfer? 1. Lift with the back. 2. Put on a back belt. 3. Spread feet to width of the shoulders. 4. Lean forward slightly.

3. Correct: In order to increase stability, the nurse will need to increase the base of support. This can be done by spreading the legs to the width of the shoulders. 1. Incorrect: Do not use your back to do heavy lifting. They are not your strongest muscles. Use your legs. 2. Incorrect: A back belt will not increase the base of support. 4. Incorrect: The nurse should not lean forward or backward. The ears, shoulders, hips and feet should be aligned.

A client receiving palliative care is reporting constipation. What intervention should the palliative care nurse provide first? 1. Increase foods high in fiber. 2. Administer an enema 3. Increase fluid intake 4. Administer docusate sodium

3. Correct: Increase fluid intake is correct. Dehydration is one of the most common causes of constipation. Fluids keep your stool soft and easy to pass. 1. Incorrect: Fiber should be increased. This is true but water is the first intervention that should be implemented. Fiber will increase bulk and help with passage of stool but fluids should be first. 2. Incorrect: Administering an enema would not be the first thing to try for constipation. Least invasive first. Avoid medicines as long as possible. 4. Incorrect: Docusate sodium is colace and a stool softener, although appropriate avoid medicines as long as possible.

A nurse is caring for an 80 year old client with a total hip arthroplasty (THA) 8 hours ago. Which nursing postoperative intervention has priority for an elderly client. 1. Reorient to time and place 2. Position in an abduction pillow 3. Coughing and deep breathing exercises Q2H 4. Turn the client toward the unaffected side

3. Correct: Increased stiffness of the lung tissue is a normal physiological change with the elderly. The increased stiffness of the lung tissue will increase the risk of postoperative pulmonary complications. The priority postoperative intervention is to implement coughing and deep breathing exercises. Coughing and deep breathing exercises will promote ventilation by opening the client's large and small bronchi. 1. Incorrect: The elderly client may experience disorientation following surgery, but this is not the priority nursing intervention. Coughing and deep breathing exercises is the priority nursing intervention. Maintaining a client's airway is always a priority. 2. Incorrect: The purpose of an abduction pillow is to prevent the dislocation of the prothesis. The abduction pillow will prevent adduction of the legs. The abduction pillow is an appropriate nursing intervention, but the abduction pillow is not the priority nursing intervention. 4. Incorrect: Turning the client to the unaffected side is an appropriate nursing intervention, but this is not the priority nursing intervention. Coughing and deep breathing exercises are a higher priority intervention.

The nurse caring for a client who had a transurethral resection of the prostate (TURP) would increase the flow of the continuous bladder irrigation for which assessment data? 1. The drainage is continuous but slow. 2. The drainage is cloudy and dark yellow. 3. The drainage is bright red. 4. No drainage of urine or irrigation solution is noted.

3. Correct: Indicates blood and increasing the flow helps flush the catheter. 1. Incorrect: Continuous irrigation causes continuous drainage. 2. Incorrect: The color is noted and color from pink to amber is expected. 4. Incorrect: Indicates a possible obstruction.

Which statement by a client diagnosed with infectious mononucleosis indicates to the nurse that education has been successful? 1. "I should let my primary healthcare provider know if I start having pain in the side of my stomach" 2. "I can return to my normal activities in 5 days." 3. "I will not let others drink from my glass." 4. "My immediate family needs to get vaccinated against mononucleosis."

3. Correct: Infectious mononucleosis, caused by the Epstein-Barr virus is transmitted by saliva and intimate physical contact like kissing, sharing of utensils, and eating/drinking after others. 1. Incorrect: The client should observe for left upper quadrant abdominal pain radiating to the left scapula as this is an indicator of splenic rupture, a complication of infectious mononucleosis. 2. Incorrect: This is too soon. Most people get better in 2 to 4 weeks; however, some people may feel fatigued for several more weeks. Occasionally, the symptoms of infectious mononucleosis can last for 6 months or longer. 4. Incorrect: There is no vaccine to protect against infectious mononucleosis. The best way of the Epstein-Barr virus is to eliminate contact with oral secretions.

A 17 year old adolescent and girlfriend are being treated in the emergency room for moderate injuries following a motorcycle accident. The adolescent is unconscious and will need surgery but family cannot be located to give consent. What does the nurse know is true about informed consent? 1. Informed consent can be provided by the girlfriend. 2. Consent is not necessary in this particular situation. 3. Surgery must be delayed until the family is located. 4. Surgery cannot be done while client is unconscious.

3. Correct: Informed consent means the client has been informed of the risks associated with a specific procedure and acknowledges understanding. In a situation where a 17 year old adolescent client is unconscious, the parents as 'next of kin' must provide consent. Since the parents cannot yet be located, the surgery will be delayed until consent is obtained. 1. Incorrect: The girlfriend is not related to the unconscious client, and therefore cannot legally provide consent. In this situation, only the parents or a legal guardian of the client could provide consent. 2. Incorrect: If an individual has life or limb threatening injuries, then written consent would not be needed. That would be considered "implied consent", which means a client would have agreed to surgery, if able, to save life or an extremity. In this case, the client has only moderate injuries. 4. Incorrect: This statement infers that the client must awaken to provide consent before being anesthetized, which is false. Many trauma clients are rushed to surgery without regaining consciousness, depending on the critical nature of the injuries.

The labor nurse is assessing a client admitted in preterm labor. Which client finding would require a social service consult? 1. Very quiet and avoids eye contact. 2. Reports that she is not married. 3. Has injuries in various stages of healing. 4. Reports frequent arguments with her partner.

3. Correct: Injuries in various stages of healing indicate a pattern of abuse. Abuse not only harms the mother, but also increases the risk of fetal harm or death and preterm delivery. 1. Incorrect: While these signs may indicate abuse, cultural differences may explain her demeanor. 2. Incorrect: Single parenthood is not an indicator for referral to social services. 4. Incorrect: Frequent arguments with her partner are not an indicator for referral to social services. This could also be from other stressors in the client's life, emotional mood swings from hormone changes, or other factors unrelated to the pregnancy.

A nurse is preparing to administer an insulin infusion to a client. The nurse calculates the infusion pump setting as 9 mL/hr. What should the nurse do next? 1. Administer the calculated medication dosage. 2. Call the primary healthcare provider to clarify the dosage. 3. Ask another nurse to calculate the dosage. 4. Notify pharmacy of the pump setting for the calculated dosage.

3. Correct: Insulin is a high alert drug and must be double checked by another nurse before it is administered. High alert drugs that could have significant side effects if administered improperly. 1. Incorrect: Insulin is a high alert drug and must be double checked by another nurse before it is administered. High alert drugs that could have significant side effects if administered improperly. 2. Incorrect: Calling the primary healthcare provider is inappropriate. The nurses are trained to properly calculate this drug calculation problem. 4. Incorrect: The nurse will calculate the infusion rate and then have a second nurse verify the rate. There is no reason to notify pharmacy.

A client prescribed oral iron medication is reporting nausea after administration. What should the nurse teach the client to decrease this symptom? 1. Take the iron with a class of milk. 2. Eat bran cereal immediately after ingesting iron. 3. Drink orange juice with the iron medication. 4. Take docusate sodium at bedtime.

3. Correct: Iron is best absorbed on an empty stomach, however, if nausea and vomiting occur, drink orange juice with the iron. It will help decrease nausea and vomiting, and will enhance absorption of the iron. 1. Incorrect: Do not take iron with milk, calcium and antacids as they bind with iron to decrease amount delivered to the body. The client should wait at least two hours after having these before taking iron supplement. 2. Incorrect: Foods that affect absorption and should not be eaten at the same time as iron is taken include: high fiber foods such as whole grains, bran, and raw vegetables. 4. Incorrect: Docusate sodium is a stool softener used to treat constipation which can occur with iron intake. But it does not help nausea.

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.

The nurse is teaching a pregnant teenage client about resources available through the health department. The client says, "I am not sure that I want to have this baby. What do you think about an abortion?" What should the nurse say? 1. What does the baby's father think about an abortion? 2. I know this is a difficult decision. 3. What are your thoughts about abortion? 4. There are many options other than abortion.

3. Correct: It is important that the client talk about her thoughts regarding abortion. The nurse must be careful to protect the client's right to autonomy without imposing personal values onto the client if not solicited. However, the nurse should talk with the client and explore her fears, feelings, and available options. Once the client's choice is made, the client can be referred to the appropriate services. 1. Incorrect: This is asking about another person's opinions and not assisting the client to formulate their opinion. Decisions that are made based on other's thoughts and opinions may lead to regret or guilt later. 2. Incorrect: The nurse is responding with sympathy and not assisting the client exploring their feelings. Since the client specifically asked the nurse about feelings related to abortion, the nurse should answer the client in a way that gets the client to explore her own feelings, thoughts, and concerns. 4. Incorrect: To move to other options immediately discounts the client's right to autonomy and the need to discuss this very personal issue with the nurse. The nurse should use the opportunity to first explore her concerns, feelings and thoughts. It is appropriate to discuss available options with her in order for her to make her own decisions.

After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. The RN requests reassigning at least one of the clients to another nurse. What is the best response by the charge nurse? 1. Offer to take one of the clients. 2. Notify the nursing supervisor of the situation. 3. Ask the RN why the assignment is too heavy. 4. Explain to the RN that all the nurses have the same number of clients.

3. Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. The charge nurse needs additional information to make a decision. This will allow the charge nurse to analyze the situation to make a better decision as to whether the assignment should be changed. 1. Incorrect: Volunteering to take a client would add more work to the charge nurse when this might not be necessary. The charge nurse's best response is to first obtain the needed information to make the best decision. 2. Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. The situation should be explored before bringing the supervisor in on the situation. 4. Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. Something new could have occurred with the clients, making the assignments too heavy. The charge nurse might not have realized all the responsibilities of taking this team of clients. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients.

The nurse is caring for a client in the Emergency Department (ED) who reports a migraine headache unrelieved by over the counter medications. This is the 4th visit to the ED for this problem in 6 weeks. What is the priority nursing intervention? 1. Refer the client to their primary healthcare provider in the morning. 2. Make the client an appointment with the chronic pain clinic. 3. Rate the client's pain using the pain scale used in the ED. 4. Perform a visual acuity test.

3. Correct: Just because a client is a frequent visitor to the emergency department reporting migraines does not mean that the client is addicted to narcotics or that the client is not really experiencing the pain. Pain is what the client says it is and assessment is priority. 1. Incorrect: This is delay of treatment and does not address the pain. The nurse should have the client rate the pain in order to become objective data. 2. Incorrect: This is the primary healthcare provider's decision and also indicates you think the pain is not real. Assessment by the nurse and primary healthcare provide are warranted. Don't delay treatment. 4. Incorrect: Assessment of the eyes could be an option since eye strain can lead to headaches. Rating their pain would be the priority assessment however.

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, 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 healthcare provider. Now, with most questions on NCLEX there is something to worry about 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: Probably not, just a sign of blood flow in healing wound. Wet to dry dressing helps to debride the wound. So if you remove the dressing will debridement occur? No.

A female client has used medroxyprogesterone acetate injections for birth control for several years. For the past 6 months, attempts to become pregnant have been unsuccessful. What instruction should the nurse provide to the client? 1. Be seen in the fertility clinic by a primary healthcare provider who specializes in this problem. 2. Have a sperm count performed on the client's partner. 3. Be aware that ovulation may not occur for many months after using medroxyprogesterone acetate. 4. Ensure proper nutrition, rest, and establish an exercise program.

3. Correct: Medroxyprogesterone acetate is an injectable progestin that prevents ovulation for 14 weeks (although injections should be scheduled every 12 weeks). After discontinuing injections, it may take approximately 9 to 10 months to reestablish normal ovulation and menstruation. 1. Incorrect: A fertility workup for the client and her partner may be warranted after adequate time to reestablish ovulation has passed. Fertility is not expected to return until approximately 9 to 10 months and this couple has only been attempting a pregnancy for 6 months. 2. Incorrect: A sperm count on the client's partner may be warranted after adequate time to reestablish ovulation has passed. 4. Incorrect: Good nutrition, rest, and exercise are important for all individuals, but does not apply to this client's concerns.

The nurse assesses a diabetic client in the emergency department and notes a blood glucose of 400 mg/dL (22.2 mmol/L), muscle twitching, and an increased respiratory rate. What is the nurse's priority concern? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

3. Correct: Metabolic acidosis. Look at the hints you have been given. Diabetes, blood sugar of 400 mg/dL (22.2 mmol/L), muscle twitching, and increased respirations. This client is going into diabetic ketoacidosis (DKA), which leads to metabolic acidosis. 1. Incorrect: The problem is not a respiratory problem, so respiratory acidosis in not correct. 2. Incorrect: The problem is not a respiratory problem, so respiratory alkalosis in not correct. 4. Incorrect: This client would be breaking down body fat, which produces ketones. Ketones are an acid, so the client would be in metabolic acidosis, not metabolic alkalosis.

The nurse is completing the admission assessment on an elderly client newly arrived on the orthopedic unit. When asked about past medical history, the client indicates "some joint problems", but cannot provide further information. What further statement by the client suggests to the nurse the disease is likely rheumatoid arthritis? 1. "My joints are really stiff and hurt every morning." 2. "I have pain in my knees if I've been sitting a while." 3. "I am better for a few months, but then get bad again." 4. "My fingers hurt and the knuckles seem to get bigger."

3. Correct: Most types of arthritis include pain, stiffness and swelling of joints. However, rheumatoid arthritis is an inflammatory, autoimmune disorder which attacks not only the joints but also many body systems, including the eyes, heart, lungs and even blood vessels. The classic characteristic of all autoimmune diseases is the occurrence of remissions and exacerbations. The client notes getting better for a period of time, and then experiencing worse symptoms. 1. Incorrect: Regardless of the type of arthritis, a common complaint is pain and stiffness in the morning after being immobile all night. This symptom is the same regardless of the type of arthritis. 2. Incorrect: Joints that support body weight or are overused are likely to be affected first. Usually the fingers, and then the knees, cause pain, particularly if not used over a period of time. Ironically, daily exercise helps to reduce pain over time. 4. Incorrect: It is true that clients with osteoarthritis may develop Heberden's nodes, or large deposits of bone, around the fingertip joints from swelling and cartilage damage. But clients with rheumatoid arthritis may also develop bony growths which eventually deform the fingers.

After the unexpected death of a Jewish teenager, the coroner tells the family that an autopsy has been requested. The teen's mother starts crying hysterically and refuses to allow the autopsy. After calming the mother, what should the nurse do next? 1. Explain that the coroner does not need the family's permission to perform the autopsy. 2. Ask the primary healthcare provider for a sedative for the mother. 3. Notify the coroner that the family is Jewish. 4. Call the rabbi of the family's synagogue to discuss the nature of the autopsy.

3. Correct: Mutilation of the body is forbidden. Autopsy is allowed only when mandated by civil authorities, such as when murder is suspected. If an autopsy is performed, all body parts must be returned for burial. 1. Incorrect: Permission is not needed when foul play is suspected. The keyword is "unexpected". The law can require an autopsy be performed when death is the result of foul play, homicide, suicide or accidental causes such as motor vehicle crashes, falls, the ingestion of drugs or deaths within 24 hours of hospital admission. 2. Incorrect: The nurse has calmed the mother. The sedative is not needed and does not solve this problem. Remember to stay away from medications as long as possible. 4. Incorrect: A rabbi is usually requested at the time of death, but this will not solve the autopsy problem. The rabbi may pray in a minyan, a group of 10 adults over the age of 13.

A client makes an initial visit to the prenatal clinic, informing nurse the probably date of conception was May 15th. The first day of the last menstrual cycle was on May 1st. Using Naegele's rule, the nurse determines the client's due date should be when? 1. February 22nd 2. August 8th 3. February 8th 4. August 22nd

3. Correct: Naegele's rule for determining a client's expected due date is to count backward three months from the first day of the last menstrual cycle, then add seven days to that date. May is the 5th month, minus three months makes it February. Adding seven days makes the expected date of delivery February 8th of the following year. 1. Incorrect: Although the month is correct, this calculation added the seven days to the 15th, which the client stated was the probable date of conception. But the rule is to add seven days to the first day of the last menstrual cycle. 2. Incorrect: August is not correct because three months was added to the month of May, instead of being subtracted. 4. Incorrect: The month of August is not correct because three months should have been deducted from May, not added. The numerical date of 22nd is not correct either.

A full term infant is being assessed 12 hours after birth. The infant's respiratory rate is 50 and shallow, with periods of apnea. What action by the nurse takes priority? 1. Apply oxygen by mask at 1 liter. 2. Prepare for emergency intubation. 3. Continue monitoring every 15 minutes. 4. Notify the primary healthcare provider stat.

3. Correct: Normal respirations in the healthy neonate are generally shallow and expected to be between 30 and 50 times per minute with short periods of apnea up to 5 seconds. This infant is displaying a normal respiratory status for the newborn. The nurse should continue to monitor the infant. 1. Incorrect: This infant is showing normal adaptation to extrauterine life. The rate of 50, even with short periods of apnea, is within expected limits for a newborn. No need for oxygen at this time. 2. Incorrect:There is no indication that this infant is experiencing respiratory distress which would require intubation. Shallow respirations at the rate of 30 to 50 times per minute are expected, even with short apneic periods of 5 seconds. 4. Incorrect: There is no need to contact the primary healthcare provider. The respiratory status of this infant, even with short periods of apnea, is normal for a full term infant 12 hours after birth. Continued monitoring is all that is needed at this time.

The nurse is caring for an elderly client who is approaching death and expressing intense despair and anxiety. Based on Erikson's theory, the nurse recognizes that this client's despair and anxiety would most likely be based on what? 1. An inappropriate desire for youthfulness and staying young. 2. The decision to never marry. 3. The lack of a sense of wholeness, purpose, and a life well lived. 4. The fear of experiencing a painful death.

3. Correct: Older adults who view their lives as purposeful and full have an increased ability to view death as a meaningful part of life. 1. Incorrect: As people age they lose physical function and don't look as youthful as they once did. But the stage the elder adult faces is despair and anxiety regarding the life lived. 2. Incorrect: Individual choice that may or may not lead to satisfaction. 4. Incorrect: Conversely, older adults who view their lives as meaningless and full of lost opportunities view their approaching death with despair and conflict.

Which goal is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit? 1. Reduction of anxiety 2. Referral to community resources 3. Identification of lifestyle changes 4. Verbalization of energy-conservation techniques

3. Correct: On admission, the best starting point is to survey what is good and what needs to be changed.1. Incorrect: No, people need some anxiety to change.2. Incorrect: Not yet.This may be done, but it is not the most important thing right now.4. Incorrect: For cardiac rehab we want to exercise, not conserve, at this point. Conserving energy is for times of hypoxia or angina.

A client is admitted to the hospital reporting chills, fatigue and left lower leg pain for nearly a week. During initial assessment, the nurse notes wide-spread swelling and redness of left ankle in addition to a fever of 103.5° F (39.72° C). Which admission order should the nurse implement first? 1. Perform sterile wound care to lower leg. 2. Start I.V. for administration of antibiotics. 3. Place client on bedrest with left leg elevated. 4. Draw blood for serial cultures and lab work.

3. Correct: Osteomyelitis is a serious inflammation of bone tissue caused when bacteria or fungus has entered the body through an open wound, an infected prosthetic, or even animal bite. Symptoms include fever, chills, nausea, and fatigue with decreased mobility in the affected extremity. The client can quickly become septic as the illness spreads through the system. Bedrest along with massive doses of antibiotics are necessary to prevent the spread of the infection, resulting in possible bone death or even amputation. 1. Incorrect: Since the nurse is in the process of admitting this client, wound care is not a priority action. There are more urgent orders to be implemented in order to stabilize the client. 2. Incorrect: Intravenous antibiotics are generally prescribed for up to six weeks, and the client may need a PICC line to continue antibiotic therapy in the home setting. While starting an I.V. line for antibiotic administration is important, this is not the most crucial first action. 4. Incorrect: Lab tests can provide valuable diagnostic information about clients with osteomyelitis. The Healthcare provider would most likely order a complete blood count (CBC) and sediment rate, expecting elevations in both. Blood cultures would also confirm whether the infection has become systemic. However, a venipuncture can wait until a more important action has been completed.

A client is admitted with an acute episode of diverticulitis. What symptom would the nurse promptly report to the primary healthcare provider? 1. Midabdominal pain radiating to the shoulder 2. Nausea and vomiting periodically for several hours 3. Abdominal rigidity with pain in the left lower quadrant 4. Elimination pattern of constipation alternating with diarrhea

3. Correct: Pain in the lower left quadrant with abdominal rigidity indicates the client is experiencing a perforated diverticuli and is a medical emergency. Abdominal rigidity indicates either perforation or internal bleeding. Both of these symptoms are considered an "acute abdomen" and are emergencies. 1. Incorrect: Midabdominal pain radiating to the shoulder is a common s/s for a client with cholecystitis but is not a medical emergency. 2. Incorrect: Nausea and vomiting periodically for several hours is often seen with diverticulitis but is not a medical emergency. 4. Incorrect: Elimination pattern of constipation alternating with diarrhea indicates a partial bowel obstruction and may require further investigation, but this is not a medical emergency.

Which side effect of vincristine should the nurse immediately report to the primary healthcare provider? 1. Nausea 2. Fatigue 3. Paresthesia 4. Anorexia

3. Correct: Paresthesia is a side effect of some chemotherapeutic medications and if it occurs, the primary healthcare provider needs to modify the dosage or discontinue. 1. Incorrect: Nausea and vomiting are common side effects of many chemotherapeutic medications. 2. Incorrect: Fatigue is a common side effect of many chemotherapeutic medications. 4. Incorrect: Anorexia is a common side effect of many chemotherapeutic medications.

A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client? Exhibit 1. Partially compensated metabolic acidosis 2. Partially compensated respiratory alkalosis 3. Partially compensated metabolic alkalosis 4. Partially compensated respiratory acidosis pH - 7.5 PaO2 - 94% PaCO2 - 58 HCO3 - 35

3. Correct: Partially compensated metabolic alkalosis is indicated by these ABGs. The pH is 7.5 (normal 7.35-7.45) which is high, which means alkalosis. The PaCO2 is 58 (normal 35-45) which is high. Greater than 45 is acidosis from too much CO2. The HCO3 is 35 (normal 22-26) which is high. A high bicarb level equals alkalosis. The HCO3 matches the pH as both indicate alkalosis. The initial problem was a kidney problem or metabolic alkalosis. The lungs are trying to compensate by holding on to more acid. So the correct answer is Option 3: Partially compensated metabolic alkalosis. 1. Incorrect: A pH of greater than 7.45 indicates alkalosis rather than acidosis. So this option is incorrect. 2. Incorrect: The PaCO2 would be low rather than high if the problem was respiratory alkalosis. 4. Incorrect: A pH of greater than 7.45 indicates alkalosis rather than acidosis. So this option is incorrect.

A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client? Exhibit pH - 7.5 (7.35-7.45) PaO2 - 94% PaCO2 - 58 (35-45) HCO3 - 35 (22-26) 1. Partially compensated metabolic acidosis 2. Partially compensated respiratory alkalosis 3. Partially compensated metabolic alkalosis 4. Partially compensated respiratory acidosis

A nurse is caring for client with a left above the knee amputation 48 hours postop. The client is experiencing left lower leg pain on a scale of 6 out of 10. Which pain relief intervention would the nurse implement? 1. Position the client in a supine position. 2. Rewrap the ace bandage on the stump. 3. Instruct the client in guided imagery techniques. 4. Initiate range of motion exercises to the knee.

3. Correct: Phantom limb pain (PLP) may be experienced in the amputated part after surgery. The client may describe the PLP as crushing, cramping, and burning. Complementary therapy is a non-pharmacological comfort measure that can be utilized to reduce the client's PLP. Instructing the client to implement guided imagery techniques will assist the client in reducing PLP. 1. Incorrect: Placing the client in various positions in bed by the nurse will not reduce the client's PLP. The client's PLP can be addressed with complementary therapy and medications such as calcitonin, beta-blockers, antiepileptics, antispasmodics or antidepressant medications. 2 Incorrect: Rewrapping the ace bandage on the stump by the nurse will not reduce the phantom limb pain. Wrapping the stump will decrease edema, secure the dressing, and assist in shrinking the limb. 4. Incorrect: Range of motion exercises will decrease the possibility of flexion contractures of the hip and knee. The improved flexion of the hip and knee with range of motion will not decrease PLP.

What nursing intervention takes priority for the client one day postoperative bowel resection reporting pain of a 6 on a 0 to 10 pain scale? 1. Assist the client in changing positions. 2. Use a distraction technique. 3. Administer the prescribed analgesic. 4. Encourage the client to walk.

3. Correct: Pharmacological intervention is indicated. 1. Incorrect: There is no information to indicate repositioning may be effective. 2. Incorrect: Distraction is not an effective strategy for severe pain. 4. Incorrect: There is no information to indicate walking would be effective.

The primary healthcare provider prescribed phenytoin for a client with grand mal seizures. What intervention would the nurse plan for the client's care? 1. Offer the client frequent high calorie snacks. 2. Check the apical pulse before each dose. 3. Perform or assist with oral hygiene every shift. 4. Give the medication 30 minutes prior to meal.

3. Correct: Phenytoin is an anticonvulsant. It works by slowing down impulses in the brain that cause seizures. A major side effect is gingival hyperplasia. Oral hygiene is important for decreasing this complication while the client is on phenytoin. 1. Incorrect: Weight gain or loss are not typically a concern with phenytoin. 2. Incorrect: The apical pulse is checked with digoxin, not phenytoin.4. Incorrect: The medication often causes gastric distress and may need to be taken with a meal, not before.

What intervention should the nurse take when providing oral care for the unconscious client? 1. Brush teeth with a stiff toothbrush. 2. Use thumb and index finger to hold the client's mouth open while brushing teeth. 3. Position the client on their side. 4. Rinse by injecting water into the center of client's mouth.

3. Correct: Placing client on side helps fluid run out of the mouth. 1. Incorrect: A soft bristled brush should be used. 2. Incorrect: Fingers should not be placed in client's mouth. 4. Incorrect: Should be injected into the sides of the client's mouth.

The nurse is caring for a preoperative client who received intravenous lorazepam 5 minutes ago and is now requesting to void. What is the appropriate nursing action? 1. Ask the unlicensed assistive personnel to assist the client to the bathroom. 2. Insert a indwelling urinary catheter since the client is going to surgery. 3. Place the client on a bedpan. 4. Allow the client to go to the bathroom.

3. Correct: Placing the client on a bedpan is the safest and least invasive choice. Lorazepam can cause drowsiness and the client should not be allowed to ambulate. 1. Incorrect: The client does not need to get up after receiving lorazepam because it can cause drowsiness. The client might fall. Think safety. 2. Incorrect: Not all surgical clients require a indwelling urinary catheter. This is not the least invasive choice. 4. Incorrect: Lorazepam can cause drowsiness and the client should not be allowed to ambulate. The risks of falls, especially alone, is too great.

A client who had a triple lumen catheter placed in the right subclavian vein 30 minutes ago reports chest discomfort and shortness of breath. The assessment reveals BP 92/58, HR 104, Resp 28, and unequal breath sounds over lung fields. What problem should the nurse suspect this client is exhibiting? 1. Myocardial infarction 2. Atelectasis 3. Pneumothorax 4. Pneumonia

3. Correct: Pneumothorax is the number one potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. 1. Incorrect: The hints point to a pneumothorax rather than an MI. The triple lumen catheter and unequal breath sounds are the biggest hints. 2. Incorrect: Atelectasis is the collapse of alveoli and is caused by a blockage of the air passages or by pressure on the outside of the lung. Examples of causes of atelectasis are mucus that plugs the airways, anesthesia, pleural effusion, prolonged bedrest with few position changes, and shallow breathing. 4. Incorrect: Pneumonia is an infection that causes inflammation of the air sacs in one or both lungs. The air sacs may fill with fluid or pus (purulent material), causing a cough with phlegm or pus, fever, chills, and difficulty breathing.

The parents of a toddler are worried about their child's poor meat intake resulting in a low iron level. What would be the best recommendation for the nurse to make? 1. Offer split pea soup once a week with a glass of milk. 2. Provide spinach twice a week. 3. Cook with an iron skillet. 4. Encourage fresh fruit intake.

3. Correct: Possibly one of the greatest cast iron skillet health benefits is that it adds iron to food. Many people suffer from iron deficiency and cooking with cast iron pans can help increase iron content by as much as 20 times. 1. Incorrect: The body may only absorb as little as 2 percent of the iron in legumes, such as lentils, black beans and split peas unless given with foods high in vitamin C. Milk will decrease absorption of iron. 2. Incorrect: Spinach is a source of non-heme iron, which is found in vegetable sources. Non-heme iron is not as bioavailable to the body as the heme iron found in animal products. Raw spinach contains an inhibitor called oxalic acid or oxalate. Oxalic acid naturally binds with minerals like calcium and iron, making them harder for the body to absorb. Cooking spinach can help unlock these iron absorption inhibitors and hence increase iron bioavailability. In other words, cooking spinach helps make iron more available to your body. However, once a week would not provide enough iron. 4. Incorrect: Fresh fruit increases fiber not iron. Fruit is high in vit C (Foods high in vitamin C include citrus fruits, dark green leafy vegetables, bell peppers, melons and strawberries). Good food sources of beta-carotene and vitamin A include carrots, sweet potatoes, spinach, kale, squash, red peppers, cantaloupe, apricots, oranges and peaches.

The nurse has just received shift report from the off-going nurse. Which client is the priority and should be seen first by the nurse? 1. Client with a chest tube who has bubbling in the suction control chamber of the closed drainage unit (CDU). 2. Client with emphysema with moderate expiratory wheezing. 3. Client post op with a pulse of 120 bpm who the off-going nurse reports as "anxious". 4. Client with pneumonia who reports pain in the chest and a bad cough.

3. Correct: Post op, mild tachycardia and anxious...well that sounds like hypoxia to me. If I have to choose just one client to go see, then I better go see the one that might be experiencing respiratory distress and hypoxia! 1. Incorrect: Is this good bubbling or bad bubbling? Good, right? We expect bubbling in the suction chamber. 2. Incorrect: Wheezing, especially upon exhalation, is commonly seen in clients with emphysema. It does indicate that air is being forced through narrow passages and air trapping is a manifestation of emphysema. However, the client who is anxious and has tachycardia is exhibiting early signs of hypoxia and takes priority. 4. Incorrect: Well, when a client has pneumonia, pain in the chest and a bad cough are expected findings, so this is not the priority over the client with signs of hypoxia.

A client comes into the women's clinic with amenorrhea, breast tenderness, and urinary frequency. Which term should the nurse use to describe these signs/symptoms of pregnancy? 1. Probable 2. Positive 3. Presumptive 4. Early

3. Correct: Presumptive signs and symptoms suggestive of pregnancy that may also indicate another condition. They occur early and are more subjective than other signs. The presumptive signs are amenorrhea, nausea and vomiting, frequent urination, and fatigue. 1. Incorrect: Probable signs are objective findings that can be documented by the examiner. The probable signs are more certain than presumptive signs but are not definitive. They include elevation of basal body temperature, breast tenderness and swelling, chloasma, linea nigra, chadwick sign, abdominal enlargement, softening of the cervix, ballotability of the uterus, quickening, and a positive pregnancy test result. 2. Incorrect: Positive signs are signs only attributable to the presence of a fetus. Three unmistakable signs of pregnancy are fetal heart tones heard on auscultation, fetal skeleton seen on x-ray or ultrasonogram, and fetal parts felt on palpation. 4. Incorrect: Early is not one of the three classifications indicating pregnancy.

During a health fair, a client asks the nurse about the methods used to detect prostate cancer. What should the nurse tell the client about the detection process? 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. 2. Incorrect: Hypercalcemia may indicate cancerous bone involvement, but it's not a screening tool. 4. Incorrect: MRI is a diagnostic tool, not a screening tool.

The home health nurse is caring for an elderly client who lives with an adult child. The client's child is divorced, works full-time, and is responsible for caring for two young children. Recently, the client has become incontinent of urine. Which stressor on the caregiver may increase the risk for abuse of this elderly client? 1. Care of young children 2. Being divorced 3. Recent increased care demands 4. Loneliness of the adult child

3. Correct: Recently increased care demands place a greater strain on the time and money required to provide care. The changing level of demands may increase the risk of abuse. 1. Incorrect: The adult child has been successfully managing the children and the elderly client up to this point. The physiological changes of incontinence for the client and increased care required for this is the most significant risk factor that could cause abuse. 2. Incorrect: The divorce is not a recently added stressor so is not a current change or stressor that would trigger the risk for abuse. 4. Incorrect: There is no mention of loneliness as a possible stressor in this scenario. This would be reading into the question and assuming incorrect data.

Priority and Delegation What task would be most appropriate to assign to the UAP when caring for a client with ulcerative colitis? 1. Sharing successful anxiety reduction measures. 2. Encouraging the client to express concerns about an ileostomy. 3. Reminding the client to avoid cold foods and smoking. 4. Explaining the rationale for needing a low residue diet.

3. Correct: Reminding clients to follow through on teaching performed by the RN such as to avoid cold foods and smoking would be an appropriate task for the UAP. 1. Incorrect: Sharing successful anxiety reduction measures is teaching. This is the role of the RN and would not be appropriate to delegate to the UAP. 2. Incorrect: Although encouraging a client to express concerns about the possibility of having an ileostomy sounds like something that could be assigned to the UAP, this would require assessment of the client's concerns and should be performed by the RN. 4. Incorrect: Explaining the rationale for needing a low residue diet is teaching. This is outside the scope of practice for the UAP. The RN should retain all tasks related to teaching.

When preparing to administer the client a dose of intravenous (IV) antibiotics, the nurse notes that the IV pump cord is frayed with wiring visible. What priority action should the nurse take? 1. Notify maintenance to come and check the pump immediately. 2. Continue to use the IV pump and fill out an equipment maintenance request. 3. Obtain a replacement pump. 4. Tag the equipment for maintenance.

3. Correct: Removing potentially hazardous equipment is priority. Continued use of a faulty IV pump could lead to client endangerment such as electrical shock or fire. 1. Incorrect: Maintenance should be notified, but after equipment is removed from client care and properly tagged. Do not leave potentially hazardous equipment in patient's reach. 2. Incorrect: The equipment maintenance request should be filled out but after the equipment is removed from client care. The nurse needs to get a properly working IV pump to administer the antibiotics. 4. Incorrect: This should occur after it has been removed from the client's room. Patient safety is always the priority.

The nurse is caring for a client who is taking an antipsychotic medication for the treatment of schizophrenia. The nurse is told in report that the client has akathisia, as a side effect of their antipsychotic medication. What symptom should the nurse expect this client to have? 1. Upward gaze of the eyes. 2. Involuntary movement of the tongue. 3. Reports of restlessness. 4. Lack of movement or slowed movement.

3. Correct: Reports of restlessness, inability to sit still, and nervous energy indicate akathisia. These symptoms respond poorly to treatment. If possible, the dose of the medication may be reduced.1. Incorrect: Upward gaze of the eyes indicates dystonia, a possible adverse reaction to the antipsychotic medications.2. Incorrect: Tardive dyskinesia has the symptoms of involuntary movement of the tongue, chewing movements of the mouth, and lip smacking. These symptoms may be irreversible.4. Incorrect: Slowed movement refers to the side effect of bradykinesia. Lack of movement is referred to as akinesia.

The nurse is helping a UAP transfer a bed-fast client from a litter into the bed. What is the nurse's priority action? 1. Verify the client's identity band is correct. 2. Pull curtain to protect the client's privacy. 3. Lock wheels on both the litter and the bed. 4. Use a transfer board to move client safely.

3. Correct: Safety is a priority with clients at all times and in all situations. When transferring a client, the nurse must be certain there is no potential for harm to either staff or the client. In this scenario, two individuals are moving the client from flat surface to flat surface. Therefore, the priority is to be certain neither surface can move during the transfer by making certain all wheels are locked on both litter and bed. 1. Incorrect: Although it is important to be certain staff has the correct client for that room, another issue takes priority in this situation. 2. Incorrect: Client privacy is always of concern and should be observed during any nursing activity, particularly when transporting or moving the individual. However, a greater concern exists. 4. Incorrect: A transfer board is a device similar to a small surfboard which is placed under the client's back, allowing staff to carefully and safely slide a client between two surfaces. However, such a device is not always mandatory, nor even available. A client can be moved without such equipment.

The homecare nurse is visiting a newly diagnosed diabetic being treated for a small left foot wound. What is the nurse's priority assessment on this first home visit? 1. Determine stage and drainage of foot wound. 2. Assess the client's ability to prepare and administer insulin. 3. Check home environment for potential hazards. 4. Assess client's knowledge of signs of hypoglycemia.

3. Correct: Safety is always a priority concern, particularly in the client's home environment. This diabetic client already has a foot wound, and anything which might cause further damage or another injury should be addressed by the homecare nurse. 1. Incorrect: Although the nurse will be assessing and providing care for the client's wound, this is not an initial priority. 2. Incorrect: A new diabetic must learn a variety of essential procedures, including how to store, prepare, and administer insulin injections. This is an important teaching topic but not the current priority. 4. Incorrect: Learning signs and symptoms of hypoglycemia or hyperglycemia would definitely be crucial knowledge for the client to understand, along with treatment for either condition. However, the homecare nurse has another initial priority.

The nurse is caring for a client who is unresponsive during a postictal state. Which position is correct for this client? 1. Orthopneic 2. Dorsal recumbent 3. Sims' 4. Reverse trendelenburg

3. Correct: Sim's is a semi prone position where the client is halfway between lateral and prone positions. Often used for enemas or other examinations of the perianal area. Sim's is used for unconscious client's because it facilitates drainage from the mouth and prevents aspiration. 1. Incorrect: Orthopneic position places the client in a sitting position with arms resting on an overbed table. It allows maximum expansion of the chest. This would not be a safe position for an unresponsive client. 2. Incorrect: Dorsal recumbent is a back lying position where the shoulders are slightly elevated on pillows. it is used after surgeries and anesthetics. 4. Incorrect: Reverse trendelenburg is where the body the body is completely straight but the head is elevated and the feet are down. This position helps with gastroesophageal reflux disease, snoring, and with some surgeries.

A young adult client frequently engages in high risk behaviors, including driving at high speeds, using alcohol in excess, and engaging in high risk sexual behaviors. Which problem is priority for the nurse to assess? 1. Antisocial personality traits causing the disregard for life. 2. Impaired judgment caused by arrested psychological maturation. 3. Unconscious suicidal thoughts. 4. Unhealthy grieving.

3. Correct: Since all the behaviors could lead to death, these are considered indicators of self-destructive behaviors. The resulting conflict of weakness and strengths can produce negative emotions. These emotions can be manifested in risky behaviors. 1. Incorrect: Disregard for life and the needs of others is most often recognized in personality disorders. There is no indication of this in the stem of the question. 2. Incorrect: The underlying cause of arrested psychological maturation is past trauma or disturbances in childhood or adolescence and seen to be more specifically related to disruption or problematic parent-child relationships in the early developmental stages. It may occur from causes such as rejection, incest, molestation, emotional abuse or physical abuse. Arrested psychological maturation is when a person may be changing physically according to their age, but has not progressed emotionally past their teenage years. There is no indication of arrested psychological maturation in the question even though they are making unwise choices. 4. Incorrect: There is no indication in this question of a loss that would have precipitated grieving.

The nurse is assessing the client's blood pressure using an electronic blood pressure machine and notes that the blood pressure reading is much higher than it has been since admission. The client denies history of hypertension. What action should the nurse take? 1. Call the primary healthcare provider and report the elevated blood pressure. 2. Check the blood pressure again in 4 hours and compare to the current blood pressure. 3. Re-check the blood pressure using a manual blood pressure cuff. 4. Call the nursing supervisor and prepare for a possible hypertensive emergency.

3. Correct: Since this client does not have a history of hypertension and has not had elevated blood pressure since admission, the nurse should question the accuracy of the electronic blood pressure machine. Therefore, the nurse should re-check the BP using a manual cuff to determine if the high blood pressure reading was accurate. 1. Incorrect: Notifying the primary healthcare provider that the blood pressure is elevated could lead to treatments being prescribed that may not be needed and could possibly cause harm to the client if the blood pressure reading was not accurate. This would be a safety issue for this client. The nurse should verify the accuracy of the blood pressure reading and then notify the primary healthcare provider if the blood pressure is indeed elevated. 2. Incorrect: This is delaying care! If the blood pressure reading from the electronic machine is accurate, immediate treatment may be needed. The client could possibly experience serious effects if the nurse waits 4 hours to re-check it and the elevated blood pressure is not treated. However, if the blood pressure is checked manually and found to be within normal limits, the accurate blood pressure reading as checked manually would need to be documented. Documentation of the elevated blood pressure reading would be an error in this situation. 4. Incorrect: The nurse should verify the blood pressure before taking any actions. However, if the blood pressure is confirmed to be elevated, the nurse should notify the primary healthcare provider, not the nursing supervisor. This would be delaying care.

The client who is scheduled for a cholecystectomy asks the nurse about her opinion on the surgeon who is going to perform the surgery. The nurse says to the client, "You should get a second opinion because your surgeon has been involved in several client lawsuits." Because the surgeon has not been involved in any client lawsuits, the nurse has initiated which tort? 1. Assault 2. Libel 3. Slander 4. Negligence

3. Correct: Slander is sharing verbal untruths that will harm the reputation of the surgeon being accused of untrue rumors. The nurse is verbally defaming the surgeon about possible lawsuits. 1. Incorrect: Assault is a physical attack on another person. The nurse is not physically touching the client or the surgeon, but is verbally accusing the surgeon of untrue rumors. 2. Incorrect: Libel is the defamation of character by print or pictures. The nurse is not writing her statement about the surgeon, but verbally expressing rumors about the surgeon. 4. Incorrect: Negligence is the commission of an act that of reasonably prudent nurse would not do under similar situation. The nurse slandered the surgeon, but did not fail to do an act that another nurse would do under the same situation.

A client is seen in the clinic for recurrent, unexplained, vague stomach pain over the past 5 years. Esophagogastroduodenoscopy (EGD), colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the pain. The client tells the nurse, "the pain is so bad sometimes that I can't function!" What disorder is this client likely experiencing? 1. Conversion disorder 2. Pseudocyesis 3. Somatization disorder 4. Dysmorphic disorder

3. Correct: Somatization disorder is a syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychosocial distress and long-term seeking of assistance from healthcare professionals. Symptoms are vague, dramatized, or exaggerated in presentation. The disorder impairs social, occupational and other forms of functioning. 1. Incorrect: Conversion disorder is a loss of or change in body function resulting from a psychological conflict, the physical symptoms of which cannot be explained by any known medical disorder. This disorder affects voluntary motor or sensory functioning suggestive of a neurological disease. 2. Incorrect: Pseudocyesis is false pregnancy that may represent a strong desire to be pregnant. The client has nearly all the usual signs and symptoms of pregnancy such as enlarged abdomen, weight gain, cessation of menses and morning sickness.. 4. Incorrect: Dysmorphic disorder is characterized by the exaggerated belief that the body is deformed or defective in some way. Most common complaints are slight flaws of face or head, such as thinning hair, acne, wrinkles.

A female client considers using spermicidal agents because she wants both birth control and protection from sexually transmitted infections (STIs). What information should the nurse provide the client about spermicidal agents? 1. Effectively reduces vaginal fungal infections such as Candida albicans. 2. Eliminates bacterial and viral sexually transmitted infections. 3. Most effective when used in conjunction with barrier methods, such as a diaphragm. 4. Causes few side effects.

3. Correct: Spermicidal agents have an approximately 25% failure rate in preventing pregnancy. These agents kill sperm by destroying the protective surface of sperm and preventing metabolic activities necessary for survival. 1. Incorrect: They do not kill fungi such as Candida albicans, even in high concentrations. 4. Incorrect: Spermicidal agents are used only when sexual intercourse is expected, but side effects include vaginal and penile irritation, lesions, and ulcerations due to the detergent effect. Disruption of normal protective vaginal flora results in an increased risk of opportunistic vaginal infections and urinary tract infections. 2. Incorrect: Spermicidal agents do not eliminate bacterial and viral STIs.

Which assignment would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Obtaining a sterile urine specimen from a Foley catheter. 2. Inserting an in-and-out catheter on a client postpartum. 3. Taking vital signs on a client 12 hours postpartum. 4. Removing a Foley catheter on a client postpartum.

3. Correct: Taking vital signs is within the scope of practice for the UAP, but the nurse is responsible for evaluating the vital signs. 1. Incorrect: Invasive procedures are not appropriate tasks for UAP (obtaining sterile specimen from Foley catheter). 2. Incorrect: Invasive procedures are not appropriate tasks for UAP (inserting catheter). 4. Incorrect: Invasive procedures are not appropriate tasks for UAP (removing foley catheter).

Which activity by the unlicensed assisted personnel (UAP) assisting a client with Parkinson's disease would require intervention by the nurse? 1. Assisting the client with ambulating to the bathroom and back to bed 2. Reminding the client not to look down while walking 3. Performing bathing and oral care for the client 4. Encouraging the client to feed self

3. Correct: The UAP should encourage the client to be as independent as possible. The nurse should intervene and teach UAP about client performing as much care as possible to encourage independence. 1. Incorrect: The UAP should assist the client when ambulating. This would not require intervention. 2. Incorrect: The UAP should remind the client to watch the horizon and not look down. This would not require intervention. 4. Incorrect: The UAP is encouraging independence. This is appropriate intervention and would not require intervention.

A 12 year old female, with a history of juvenile rheumatoid arthritis, is being admitted for re-evaluation. The child reported these symptoms for the last week: temperature of 102.9ºF/39.4ºC at 4:00 pm every day, increased pain in joints, loss of appetite, and fatigue. What would be an appropriate room assignment by the charge nurse? 1. Private room only. 2. Rooming with a 12 year old male in skeletal traction due to a fractured femur. 3. Rooming with a 10 year old female that has been admitted for sickle cell disease. 4. Rooming with a 14 month old female that has been admitted for orthopedic surgery.

3. Correct: The appropriate answer is to room her with the 10 year old being worked up for sickle cell disease. This is an acceptable age/sex to pair as roommates. Each has a chronic illness and this allows them to see how another person with limitations adjusts. 1. Incorrect: It is not necessary for this child to be in a private room. The fever at a particular time of the day is a symptom of juvenile rheumatoid arthritis and does not mean an infection. 2. Incorrect: It would be inappropriate to room her with a 12 year old male due to opposite sex and age. 4. Incorrect: The 12 year old who is in pain, feverish, and fatigued would be unable to rest as needed in a room with a 14 month old who is postoperative.

A client admitted with biliary atresia has just arrived on the pediatric unit. The unit is very busy and the other RNs are busy with other clients at this moment. What action by the charge nurse would be most appropriate? 1. Instruct the unlicensed assistive personnel (UAP) to obtain clients vital signs and a weight. 2. Assign an LPN/VN to perform the initial nursing history and physical assessment. 3. Have an LPN/VN perform collect data on the client and report results to RN. 4. Inform one of the RNs that a new client is on the floor and that a nursing history should be completed as soon as possible

3. Correct: The best answer is to have the LPN/VN collect intial data on the client and report it to the RN. The RN can evaluate data and initiate the priorities of care. Assessment on the new client should be completed by an RN within eight hours of arriving on the unit. It is acceptable to let the LPN/VN initiate the process. It would be best if a licensed person did a brief initial assessment on the child instead of the UAP. 1. Incorrect: Initial assessment is priority and must be done by RNs or a licensed person assigned by the charge nurse. The charge nurse is accountable for the initial assessment and must take the data and evaluate it and set the plan of care. 2. Incorrect: The RN can assign this takes but is accountable to verify the information and sign off on the data. The RN cannot delegate the assessment process but can obtain data collection assistance from the LPN/VN. 4. Incorrect: Initial assessment is priority and must be done first. The charge nurse cannot ignore a newly admitted client. Anew admission is always considered unstable and requires an initial observation and data collection by a licensed personnel. As soon as information is collected, the RN must evaluate it and set the priority to obtain the entire nursing history and initial plan of care.

The community health nurse plans to educate a client diagnosed with tuberculosis (TB) how to avoid spreading the disease to others. What should the nurse include when educating this client? 1. Wear a N95 respirator when around family at home. 2. Have adult family members get the TB vaccine. 3. Complete TB medication regimen. 4. Live at a sanatorium until cured of TB.

3. Correct: The best way to prevent the spread of TB is by completing the medication regimen. TB bacteria die very slowly, and so the drugs have to be taken for quite a few months. Even when a client starts to feel better they can still have bacteria alive in their body. So the person needs to keep taking the TB treatment until all the bacteria are dead. All the drugs must be taken for the entire period of TB treatment. If the entire treatment is not taken then the bacteria may not all be killed. They may then become resistant to the TB drugs which then don't work. 1. Incorrect: This is not required. It is expensive and must be fitted to each family member. Cloth or disposable masks can be used. Also, the client should cover mouth when coughing or sneezing, as TB is spread through the air. 2. Incorrect: The vaccine, BCG, works against a severe type of TB that affects young children but it is not effective against the type of bacteria found in adults. That severe type of TB is called military TB, is rare in the US, so the vaccine isn't used on young children here. 4. Incorrect: This used to be common treatment protocol, but no longer.

Two nurses are checking a unit of packed red blood cells (PRBCs) for client compatibility prior to infusion. What action should the primary nurse take after completing this process? Exhibit 1. Initiate the PRBCs transfusion at 25 mL/hour for the first 15 minutes. 2. Ask blood bank personnel to type and cross match for PRBCs sent to unit. 3. Send unit of PRBCs back to the blood bank. 4. Notify the primary healthcare provider.

3. Correct: The blood compatibility label does not match the PRBC unit sent to the unit. Note that the donor numbers are not the same. So, this unit needs to be sent back to the blood bank and the correct unit needs to be obtained. 1. Incorrect: Do not give uncrossed matched blood. This unit is not the one that was cross matched to the client. The unit numbers are different. 2. Incorrect: It takes a while to cross match blood and the blood cannot stay out of the refrigerator that long. And what if it is not compatible. A unit of blood has been wasted. 4. Incorrect: The wrong unit of PRBCs has not been hung. There is no need to contact the primary healthcare provider.

A nurse is caring for a client on the second day after a thoracotomy. The client reports incisional pain. The nurse assesses the client and evaluates the vital signs. Based on the data documented in the chart, what action should the nurse take first? Exhibit Client reports incisional pain as 8/10. Wound is clean and dry, without redness, edema, or drainage. Shallow respirations noted at 24/min. Adventitious lung sounds noted in bilateral bases. Vital Signs Oral temperature 100º F/37.8ºC Heart rate 92/min and regular BP 130/80 Respirations 24/min 1. Have client cough and deep breathe. 2. Administer acetaminophen for fever 3. Administer the prescribed analgesic 4. Assist the client to ambulate.

3. Correct: The client described in this question is post thoracotomy. With ANY post-op client, the number one concern, especially as a brand new nurse, is preventing pneumonia. A thoracotomy is very painful and the client is unlikely to breathe deep unless the pain is relieved. Temperature of 100º F/37.8ºC, HR 92, respirations 24, bilateral crackles (indicating atelectasis) all reveal this client is heading for pneumonia. 1. Incorrect: Coughing and deep breathing exercises are exactly what the client needs, but the client will not cough and deep breathe if it hurts. Give pain medication first. 2. Incorrect: Acetaminophen is not potent enough to relieve pain. The goal is to "fix the problem". The problem is that the client is not properly deep breathing due to pain. 4. Incorrect: Assisting the client to ambulate is a good idea, but the nurse has to fix the problem, and the problem is that the client is not deep breathing.

A client diagnosed with major depression has been admitted to a psychiatric facility for medication management. During nighttime rounds, an LPN/VN notes the client is not in bed. Which behavior by the client should the LPN/VN report to the RN immediately? 1. Sitting in a chair crying. 2. Reports inability to sleep. 3. Rearranging furniture. 4. Pacing around the room.

3. Correct: The client has been diagnosed with major depression, but is actively moving furniture around the room. While major depression is characterized by low energy, fatigue and lack of interest. Moving furniture indicates the client is displaying manic behavior which should be reported to the RN immediately. 1. Incorrect: Crying would be an expected behavior for clients diagnosed with major depression, along with decreased energy, irritability, and disinterest in most activities. Finding this client sitting in a chair and crying would not be an unusual behavior and would not need reported to the RN. 2. Incorrect: Major depression encompasses a variety of symptoms, such as a feeling of helplessness and hopelessness, despair and sleep disturbances that range from constant sleep to not sleeping at all. The inability to sleep would not be unusual for this client and would not need to be reported by the LPN/VN. 4. Incorrect: Pacing is one of a variety of behaviors displayed by clients diagnosed with major depression, which may also include irritability, sleep disturbances and lack of focus. While pacing the room should be monitored, there is another activity that is of more concern.

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

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

A client is scheduled for surgery today. As the nurse prepares the pre-op medication, the client says, "I have changed my mind. I don't want to go through with the surgery." What should the nurse do first? 1. Convince the client to proceed with the plans for surgery. 2. Notify the surgery department to cancel surgery. 3. Notify the primary healthcare provider of the client's decision. 4. Suggest that the client talk over the decision with family members.

3. Correct: The client has the right to make decisions about their care. The primary healthcare provider should be notified about the client's decision to not have the surgery. 1. Incorrect: The nurse should not try to convince the client into having the surgery. If the nurse tries to have the client do something they do not want to do, the client is being coerced to make a decision by the nurse. This breaches the client's rights. 2. Incorrect: The primary healthcare provider should be notified prior to the surgery department being notified. The primary healthcare provider will need to review the client's plan of care with the client. 4. Incorrect: The client has informed the nurse of their decision. The nurse should not suggest any further action related to the client's decision. The client has the right to make decisions autonomously.

The nurse is working on an in-patient psychiatric unit. The nursing care plan includes teaching a client about assertiveness. The client has a long history of being manipulated by the employer and spouse. What is the best rationale for including assertiveness training in this client's treatment plan? 1. All clients should have assertiveness skills. 2. The client has low self-esteem. 3. The client is being taught self-advocacy. 4. No client deserves to be manipulated by an employer.

3. Correct: The client is being taught assertiveness and thus self-advocacy is learning to speak up for yourself and one's needs. The nursing role includes advocacy. This client will be discharged soon and needs improved skills in assertiveness for the word place and home environment. 1. Incorrect: This maybe true; however, it does not serve the best rationale for this client. Specifically this client needs assertiveness to assist their return to employment and home environment. 2. Incorrect: This statement is maybe true; however, it does not serve as an accurate rationale assertiveness training. 4. Incorrect: No the person should not be manipulated by an employer; however, the rationale in this question is to teach the client self advocacy through assertiveness training.

The nurse is planning an activity for the client who has a diagnosis of paranoid schizophrenia. Which activity would be most appropriate for the client? 1. A game of Scrabble with peers 2. A group game of basketball. 3. An individual art project. 4. A card game with the nurse.

3. Correct: The client is likely to be most comfortable with solitary activities. When the client is extremely distrustful of others, solitary activities are best. Activities that demand concentration keep the client's attention on reality and minimize hallucinatory and delusional preoccupation. 1. Incorrect: The client is paranoid; therefore, he would not be comfortable within a group. Noisy environments may be perceived as threatening. 2. Incorrect: The client is likely to be very suspicious of the other players, thereby increasing their own anxiety level. The noisy basketball game may be too threatening for the client. Physical games are not the best choice for the paranoid schizophrenic client. 4. Incorrect: As trust builds with the nurse, this may be an appropriate activity, but there is a better answer. The "most" appropriate is an individual art project. The second best answer would be a card game with the nurse.

The nurse is caring for a client who is severely depressed and has an extremely low energy level. The client answers questions by using one or two words, and makes no eye contact. Which intervention is most appropriate for this client? 1. Ask the client to go to the group session with you. 2. Remind the client to interact with the nurse today. 3. Sit with the client and make no demands. 4. Allow the client to decide when to talk with the nurse.

3. Correct: The client is severely depressed and does not wish to have one on one interaction. Sitting with the client without demands demonstrates that the client is worthy of your time. The silence may also encourage the client to talk with you. 1. Incorrect: The client's energy level is low, so the client would not respond positively to this request. Depressed clients may speak slowly and have slowed comprehension. Group therapy would not be appropriate at this time. 2. Incorrect: The client may not have adequate energy for spontaneous interaction today. Also, reminding the client to interact is not therapeutic. The client may view this as the nurse thinking they are worthless. 4. Incorrect: When clients are extremely depressed, they cannot make decisions independently. Extreme fatigue interferes with social activities and relationships.

When planning post procedure care for a client who is having a barium enema, what must the nurse include? 1. Cardiac monitoring for potential arrhythmias 2. Monitoring urinary output 3. Administration of a laxative or enema after the procedure 4. Reordering the client's diet

3. Correct: The client must expel the barium post procedure. If the barium is not eliminated, it can harden in the colon and cause an obstruction. 1. Incorrect: It is not standard practice to place clients on a cardiac monitor after a barium enema. 2. Incorrect: Monitoring urine output has nothing to do with this procedure and does not answer the specific question related to this diagnostic procedure. 4. Incorrect: Reordering the client's diet is important but is not as life-threatening as a bowel obstruction.

A client is transported to the emergency department by the police following a sexual assault. What is the nurse's priority intervention? 1. Instruct the client to remove all of her clothes so they can be bagged as evidence. 2. Ask the client to describe what happened . 3. Tell the client she is safe here. 4. Perform a rape kit in order to preserve the evidence .

3. Correct: The client who has been sexually assaulted often experiences great fears and must be reassured of her safety. She may also be overwhelmed with self-doubt and self blame. This statement will instill trust. Remember, safety first! The most helpful things a nurse can do is listen and let the victim talk. 1. Incorrect: This needs to be done, but you must first build trust and establish a feeling of safety with the client. A woman who feels understood is no longer alone. She then feels more in control of the situation to remove her clothes. 2. Incorrect: This may be done, but you must initially build trust and establish with the client that she is safe. Non-judgmental listening provides an avenue for catharsis that the client needs to begin healing. A detailed account may need to be given for legal follow-up. A caring nurse, as a client advocate, may help to lessen the trauma of evidence collection. 4. Incorrect: This needs to be done. But you must build trust and establish the client feels safe initially. The nurse must maintain a nonjudgmental attitude and provide nonjudgmental care before the rape kit can be obtained.

The nurse is reinforcing proper use of the walker with partial weight-bearing to a client with a total hip arthroplasty. Which action would indicate to the nurse that the client is using the walker correctly? 1. Leaning over the walker. 2. Using a walker with 4 wheels. 3. Elbows positioned at 30 degrees. 4. Lifts the walker when climbing steps.

3. Correct: The client's elbows are bent at a 30 degrees which indicates that the height of the walker is appropriate for this client. Also, the elbows should be bent to relieve pressure on the elbow joint. 1. Incorrect: The client must be erect over the walker. If the client is leaning over the walker, this will cause increased strain on the arms and back muscles. 2. Incorrect: The client should be using a walker with 2 wheels for partial weight bearing. A walker with 4 wheels is prescribed for a client who has full weight bearing. 4. Incorrect: When climbing steps, the client should place the walker on the step in front of them. All tips or wheels should be on the ground or the next step prior to moving forward.

A client diagnosed with a right embolic stroke is admitted to the rehabilitation unit. The client is presenting with dysphagia. Which nursing intervention would the nurse implement for a client with dysphagia? 1. Flex the neck backwards 2. Request a liquid diet for the client 3. Place food on the right side of the mouth 4. Turn the client's plate around halfway through the meal

3. Correct: The client's neurological deficit will determine where to place the food in the person's mouth. The food should be placed on the right side of the mouth due to the client's left facial weakness. 1. Incorrect: The neck should be flexed forward. If the neck is flexed backward, food/liquids will have more difficulty moving through the esophagus to the stomach. The client's risk of aspiration into the trachea increases. 2. Incorrect: Liquid foods are not recommended on a dysphagia diet because liquid foods will increase the risk of aspiration. The client should eat foods that are softer in texture and thickened liquids to aid their ability to swallow. 4. Incorrect: Turning the plate is an intervention for homonymous hemianopsia. Homonymous hemianopsia is losing half of your visual field in one or both eyes. The client is exhibiting dysphagia, and is not experiencing a visual deficit. Turning the plate is not an intervention for dysphagia.

The nurse has received the change-of-shift report. What client should the nurse assess first? 1. A client with fibromyalgia reporting generalized pain of 7 out of 10. 2. A client diagnosed with rheumatoid arthritis needing discharge teaching. 3. A client with a fractured right humerus who reports the cast is too tight. 4. A client with an above the knee amputation reporting phantom pain.

3. Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. Compartment syndrome could be developing which can impede circulation and cause nerve damage. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. 1. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. 2. Incorrect: The client who was diagnosed with rheumatoid arthritis will need discharge teaching and may be wanting to go home quickly, but this client would not take precedence over the client with the cast that has become too tight. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. 4. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? No! However, it remains true pain for this client and the client would need intervention to help manage this pain. This client would not be a priority to be seen before assessing the client with the cast that is too tight who may be developing compartment syndrome.

The client, who recently started college, tells the nurse, "I am having trouble studying for my tests. Every time I try to study, my mind begins to wander." What is the nurse's best response? 1. "Stop making excuses and make a study schedule you will follow." 2. "I wouldn't worry. You are smart enough to pass college." 3. "You are having difficulty concentrating?" 4. "What do you mean you can't study?"

3. Correct: The correct answer demonstrates the therapeutic communication technique of "restating". The main idea is to let the client know whether or not an expressed statement has been understood and gives him or her the chance to continue or clarify if necessary. 1. Incorrect: This response is disapproving and gives advice. It is not therapeutic. The nurse does not know the client is making excuses and should not assume. 2. Incorrect: This response is giving reassurance. This statement seems like the nurse is somewhat "blowing off" the client. It does not address this issue.4. Incorrect: This response is belittling. This statement does not address the client's problem. It also implies that the client should not have problems studying.

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

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

A client is admitted to the hospital at 36 weeks gestation with a diagnosis of placental abruption. Following an initial assessment, what action by the nurse is most important? Exhibit Pulse - 120 and regularRespirations - 26, non-labored Blood pressure - 90/50 Fetal heart rate - 110 1. Apply the fetal monitor. 2. Complete an abdominal prep. 3. Insert large bore intravenous line. 4. Have client sign the consent form.

3. Correct: The exhibit shows the client's blood pressure is dangerously low, most likely due to loss of blood, placing the client at risk for hypovolemic shock. When the mother's blood pressure drops, the fetal heart rate also drops. The priority is to immediately place a large intravenous line to administer fluids or medications. 1. Incorrect: A fetal monitor would most likely already be in place; however, if not, the placement of a fetal monitor is not the initial priority. The priority should focus on the client; in this case, it is the mother, whose well being will directly affect fetal outcome. 2. Incorrect: Because the fetus is being affected by the mother's low blood pressure, an emergency cesarean section may need to be performed. But an abdominal prep is not a priority, and could, in fact, be completed in the operating room. 4. Incorrect: It is not the nurse's responsibility to get the consent form signed. That is the duty of the primary healthcare provider or surgeon performing the procedure. Because this is a medical emergency, even a family member could sign the form later.

After artificial rupture of membranes (AROM), the baseline fetal heart rate tracking begins to show sharp decreases with a rapid recovery with and between contractions. Which of the following actions by the RN has priority? 1. Position the client on her left side 2. Increase the IV fluid rate 3. Place the client in the knee-chest position 4. Administer oxygen per tight face mask

3. Correct: The fetal heart pattern is that of repetitive deep variable decelerations. This pattern is likely due to a prolapsed umbilical cord after AROM. The priority intervention is to relieve the pressure on the cord from being trapped between the presenting part and the pelvis. This can be accomplished by manual pressure on the presenting part, placing the client in Trendelenburg position, or placing her in the knee-chest position. 1. Incorrect: This intervention will improve placental perfusion, but will not relieve compression of a prolapsed cord. If the cord is compressed, it doesn't matter how well perfused the placenta is because the oxygen cannot reach the baby. Late decels and low BP would be an indicator that we need to increase uterine perfusion by positioning on left side. 2. Incorrect: This intervention will not improve placental perfusion. IV fluids will not relieve compression of a prolapsed cord. 4. Incorrect: This intervention will improve placental perfusion, but will not relieve compression of a prolapsed cord. If the cord is compressed, it doesn't matter how well perfused the placenta is because the oxygen cannot reach the baby.

What is the nurse's first priority when treating a client with a chemical burn? 1. Attach client to a cardiac monitor. 2. Apply a sterile bandage to prevent infection. 3. Rinse the area with copious amounts of water. 4. Remove the client's clothing.

3. Correct: The first action in treating a chemical burn is to rinse the affected area with large amounts of cool water. 1. Incorrect: This is necessary with electrical burns. 2. Incorrect: This may come later, not first priority. 4. Incorrect: This can be accomplished while you are rinsing them with water.

A nurse is providing discharge teaching to a client who has had a cystectomy and formation of an ileal conduit. What client statement indicates that teaching was successful? 1. I should restrict my fluid intake to decrease the need to empty the drainage bag. 2. I will change my appliance daily to prevent skin excoriation from the leakage of urine. 3. I will change my drainage bag whenever it is leaking, giving special attention to my skin around the bag. 4. I will restrict going to events outside the home because leakage is common and embarrassing.

3. Correct: The goal is to prevent skin irritation by changing the bag regularly and using proper equipment to prevent leakage. The client with an ileal conduit (urinary diversion) must be educated appropriately to ensure that self-care abilities are complete and safe. As long as the bag is not leaking and no skin breakdown is evident, changing the appliance bag only has to be done as needed, not daily. 1. Incorrect: Clients with ileal conduits are encouraged to increase fluid intake, as opposed to restricting it, to maintain adequate urine flow for prevention of urinary tract infections (UTI). 2. Incorrect: Changing the apparatus daily is too often and will cause trauma and skin breakdown.4. Incorrect: Clients with ileal conduits are encouraged to maintain an active and normal lifestyle. People with ileal conduits have a generally low incidence of complications and high client satisfaction level due to the ease of care and minimal lifestyle changes.

A parent asks the nurse why their child should be immunized against Rubella. What should the nurse tell the parent? 1. Rubella can cause a severe rash over the body, and a high fever which can lead to febrile seizures. 2. Rubella is the most common cause of meningitis and acquired deafness. 3. If a pregnant woman gets rubella from an unimmunized child during the first trimester, there is a chance the child will have a birth defect. 4. Rubella complications can include swelling of the testicles or ovaries, deafness, encephalitis or meningitis and can lead to death.

3. Correct: The goal of rubella immunization is to protect unborn children from developing birth defects in utero. 1. Incorrect: Rubella can cause a mild rash on the face and low-grade fever. 2. Incorrect: Before the vaccine, mumps was the most common cause of meningitis and acquired deafness. 4. Incorrect: These are complications of the mumps.

The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation? 1. Clots in urine 2. Bladder pressure 3. Clear urine 4. Bladder spasms

3. Correct: The irrigation is regulated so that the urine is free of clots and slightly pink tinged. When it becomes clear after surgery, the fluid is going too fast and not clearing any blood clots effectively. 1. Incorrect: The irrigation should be increased if you see clots in order to keep the catheter patent. 2. Incorrect: Bladder pressure may mean that the indwelling urinary catheter is obstructed. Either increase flow or manually irrigate catheter to ensure patency and no retention of fluid in the bladder. 4. Incorrect: Bladder spasms occur with clots so you do not want to slow the irrigation if this happens. This would indicate the need for increasing the irrigation fluid rate.

The nurse manager is making rounds in a long-term care facility and discovers an unfamiliar client standing in the hallway in a puddle of liquid. What is the nurse manager's priority action? 1. Ask client to state name and room number. 2. Find dry clothes and clean client completely. 3. Wipe up puddle of liquid and call housekeeping. 4. Contact unit charge nurse to identify the client.

3. Correct: The issue in this scenario is safety. Whether the nurse manager knows this client is not important at the moment. Liquid on the floor poses a safety hazard for clients, visitors, and staff. The priority action is to remove this risk immediately before an injury occurs. 1. Incorrect: Even though the nurse does not recognize this particular client, the priority concern is not focused on identifying this individual. 2. Incorrect: While the client will certainly need clean, dry clothes, the most immediate concern is a safety issue. The nurse can summon a UAP to help the client after addressing the safety issue. 4. Incorrect: The identity of the client is not the initial priority at this time. Consider the whole picture when thinking about safety.

A hospitalized American Indian elder is actively dying and is surrounded by a large group of family members. The client's spiritual beliefs include burning a tiny amount of incense while chanting softly. The roommate summons the nurse, complaining about the noise and the odor despite the fact the curtain is drawn between the beds. What is the most appropriate action by the nurse? 1. Tell the client's family the noise and odor bothers the roommate. 2. Move the elder to a private room so family can continue ceremony. 3. Offer to move the roommate to another room in a quieter area. 4. Explain the client is dying and the family will soon be leaving.

3. Correct: The most appropriate action in this situation is to move the roommate to a quieter location, allowing the family and dying client privacy while also fulfilling the roommate's request. 1. Incorrect: The client and family are dealing with an impending death and have the right to embrace any cultural or spiritual traditions to ease that situation. This comment by the nurse would insult the family and not solve the situation. 2. Incorrect: Despite the fact that a private room would be ideal for the dying client and family, the stress and chaos of moving to another room would be physically and emotionally overwhelming. In fact, it could even hasten the client's death. 4. Incorrect: Although the roommate may be aware of the client's condition, the nurse has violated HIPAA regulations by revealing information to the roommate. Even when the elder client does pass away, the family may choose to stay in the room for an extended period of time. This action does not solve the problem.

A client has just found out that she is pregnant and asks the nurse, "When is my baby due?" The client's last menstrual period began March 3. What date will the nurse calculate as the expected date of confinement? 1. December 3 2. December 7 3. December 10 4. December 13

3. Correct: The most common method of determining the expected date of confinement is by Nagele's rule. To use this method begin with the first day of the last menstrual period, add seven days, subtract 3 months and add one year. So the expected date of confinement for this client would be December 10. 1. Incorrect: To use Nagele's rule begin with the first day of the last menstrual period, add seven days, subtract 3 months and add one year. So the expected date of confinement for this client would be December 10. 2. Incorrect: To use Nagele's rule begin with the first day of the last menstrual period, add seven days, subtract 3 months and add one year. So the expected date of confinement for this client would be December 10. 4. Incorrect: To use Nagele's rule begin with the first day of the last menstrual period, add seven days, subtract 3 months and add one year. So the expected date of confinement for this client would be December 10.

The nurse manager is presenting a seminar on HIPAA regulations to a group of newly hired graduates. When discussing the most common cause of violating client privacy, the nurse knows teaching was successful when the graduates select what situation? 1. Failure to cover client fully during a bed bath. 2. Leaving chart open in full view when at the desk. 3. Discussing client with staff not providing direct care. 4. Healthcare provider not pulling curtain to talk to client.

3. Correct: The most common violation of HIPAA privacy regulations occurs when healthcare workers discuss a client with those not directly involved in the care of the client, including other staff members. Those working in a facility are not entitled to have access to client health data unless providing direct care to that client. 1. Incorrect: Exposing more of the client than necessary during a bed bath is definitely considered a violation of privacy. However, the graduates are to select the most common situation, and bed bath issues are less common. 2. Incorrect: Leaving a client's chart open in full view of staff and visitors does violate a client's privacy. But, such a problem is not as common as another situation. 4. Incorrect: The problem of overhearing conversations may occur in facilities where multiple clients share the same room or in an emergency room where only a curtain exists between clients. Pulling the curtain does not guarantee that voices will not carry, though most primary healthcare providers try keep voice levels at a minimum.

A client who is ventilator dependent is scheduled to be discharged home. What is the most critical assessment for the nurse case manager to make? 1. Financial stability for home health care. 2. Long-term home care needs. 3. Safe home environment. 4. Home medical equipment needed.

3. Correct: The most critical assessment is to make sure that the client is going home to a safe environment. Then the other assessments could be made. Without a safe environment the client does not need to go home. Information about electrical wiring, back-up power, hygiene and infection control needs all provide a safe environment for this client. 1. Incorrect: This is not the most critical assessment and can be done after making certain the client will be safe. Remember Maslow's Hierarchy of Needs. After you determine needed resources (#4) then financial stability would be next. 2. Incorrect: Long term goals are very important but we are worried about short term needs right now. Remember in a priority question all options are plausible but only one is critical now. 4. Incorrect: Once the environment is considered safe for the needed or required care of the client, then the needed equipment would be next.

Following a lumbar puncture, the client reports a headache on a pain scale of 8 out of 10. What priority action should the nurse perform 1. Instruct the client to drink at least 8 ounces 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 ordered 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. 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.

Following a lumbar puncture, the client reports a headache on a pain scale of 8 out of 10. What priority action should the nurse perform? 1. Instruct the client to drink at least 8 ounces 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.

A frightened client comes to the nurses' station during the night and reports hearing the voice of the devil speaking to them. Which response by the nurse is priority? 1. "Could you have overheard the staff talking at the desk?" 2. "I will get you some medication for anxiety." 3. "What did the voice tell you? " 4. "You do not have to worry about this. You are safe."

3. Correct: The most important thing the nurse needs to find out is what the voice was telling the client. This is a safety issue. The nurse needs to know if the voice was telling the client to harm themselves or others. 1. Incorrect: In this question, this is not the priority response. This is voicing doubt and also presenting reality. This response could come later in the interaction. 2. Incorrect: This is changing the subject, which is non-therapeutic. The nurse needs to do something prior to giving medicine. 4. Incorrect: This is giving reassurance, which can be a non-therapeutic response. However, it could be used later in the interaction if the nurse finds out the client is safe. This statement does not address the voice heard by the client.

What action should the nurse take when testing a client's near vision? 1. Have client read a Snellen chart from 20 feet away. 2. Have client read Ishihara plates at 30 inches (75 cm). 3. Have client read a newspaper at 14 inches (36 cm). 4. Have client alternate gaze from a near object to a distant object.

3. Correct: The nurse can get a general idea of near visual acuity by asking the client to read from a newspaper. The newspaper should be held 14 inches from the eyes. This exam can also be done with the Jaeger chart containing a few short lines or paragraphs of printed text. The size of the print gradually gets smaller. The client is asked to hold the card about 14 in. (36 cm) from the face and read aloud the paragraph containing the smallest print he/she can comfortably read. Both eyes are tested together, with and without corrective lenses. This test is routinely done after age 40, because near vision tends to decline as one ages (presbyopia). 1. Incorrect: The Snellen chart is used to test distant vision. To test distance vision, individuals stand 20 feet from the Snellen eye chart, cover one eye, read aloud the smallest line they can clearly see, and then repeat this process with the other eye. After performing an eye test, a person's visual acuity is written as a fraction. Normal vision is defined as 20/20 visual acuity, which means at 20 feet away from the eye chart, the person is able to read the line that most human beings with normal vision can read at 20 feet away.

A client admitted to the Coronary Care Unit (CCU) following a myocardial infarction (MI) expresses fear of the equipment and noise in the busy unit. What is the most therapeutic response by the nurse? 1. "Everyone gets scared here at first." 2. "Why are you afraid of equipment?" 3. "This all seems frightening to you." 4. "You won't have to be here very long."

3. Correct: The nurse is making a statement that reflects back the feeling of fear expressed by the client. This therapeutic communication tool acknowledges that the nurse has heard the client while providing an open-ended approach which will allow the client to continue to communicate emotions. Encouraging the client to continue to express feelings is important. 1. Incorrect: This is a belittling response in which the nurse is focusing on everyone, rather that this specific client. It is a closed, non-therapeutic reply that discourages further interaction with the client and does not allow for further expression of feelings. 2. Incorrect: When a client expresses emotions, asking why demands an explanation that is neither necessary nor therapeutic. In most cases, clients may not be able to provide any explanation and the need to do so further restricts the potential for open communication. 4. Incorrect: Instead of focusing on the client's feelings, the nurse has changed the topic and blocked the potential for the client to communicate further. Therapeutic communication should provide open-ended opportunities in which the clients can freely express concerns

A charge nurse is caring for clients when a new admit arrives on the unit. What action by the charge nurse is most appropriate? 1. Instruct the unlicensed assistive personnel (UAP) to complete emptying the catheter bag, and assess the new admission. 2. Send the UAP to take VS on the new admit and begin the history until she can get there. 3. Assign a nurse on the floor to initiate the assessment process. 4. Ask the unit secretary to make the client and family comfortable until she can complete her present task.

3. Correct: The nurse is the only one who can assess. 1. Incorrect: The UAP can empty the urinary catheter bag, but can not assess the client. 2. Incorrect: It is out of the scope of practice for a UAP to complete any portion of the admission assessment. 4. Incorrect: The unit secretary can welcome the client, but the admission assessment must be completed by an RN.

An adolescent client, diagnosed with anorexia nervosa, discloses an incestuous relationship to a nurse. What is the most therapeutic response by the nurse? 1. "It's okay. Let's talk about this." 2. "Have you discussed this with your primary healthcare provider?" 3. "Can you tell me how you feel about what happened?" 4. "Tell me more about what happened when you were younger."

3. Correct: The nurse is using a therapeutic approach by encouraging the client to express feelings about the relationship using an open-ended question. 1. Incorrect: The nurse is providing false reassurance by saying, "It's okay." This is a statement not a question to see how the client feels about talking with the nurse. The nurse should use open-ended questions to determine whether or not the client wishes to discuss the incestuous relationship further at this time. 2. Incorrect: This is a non-therapeutic, closed ended question that only requires a yes or no answer. This is not a priority at this time. An open ended question will allow the nurse to see if the client is ready to share with the nurse. 4. Incorrect: The nurse should not probe for a factual account about a past event and should keep the focus of the discussion on the client's feelings about the event. Again, this is a statement, not an open ended question.

The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. In order to reorganize staffing, the nurse manager should initiate which action first? 1. Announce the new changes at the monthly staff meeting. 2. Ask for any staff objections to rearranging work hours. 3. Invite staff to contribute ideas on scheduling changes. 4. Explain administration is demanding a decreased overtime.

3. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. One important aspect is encouraging the flow of ideas between management and staff members. Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. 1. Incorrect: While it is true that the nurse manager is ultimately responsible for implementing and announcing new schedule changes, doing so without any staff input can create discontent in the work environment. When staff do not feel vested in any new process, there is a sense of underappreciation. This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. 2. Incorrect: Although this action appears to be opening lines of communication, the nurse manager is actually fostering animosity in a situation where the outcome is already pre-determined. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. 4. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. Assigning blame for the changes to administration will not help staff adjust.

An adult client's parent, who is a physician, comes to the nurse's station and requests the client's chart. The physician is not the client's primary healthcare provider but is employed by the hospital. What action should the nurse take? 1. Provide the physician with the chart. 2. Ask the primary healthcare provider to consult the physician in the client's care. 3. Explain to the physician why access to the chart cannot be provided. 4. Obtain verbal permission from the client for the physician to view the chart.

3. Correct: The nurse must maintain the client's right to confidentiality. The parent, even though a physician, is not the client's primary healthcare provider, thus has no medical need to see the chart. The nurse should not allow the physician access to the chart. 1. Incorrect: The parent (physician) is not the client's primary healthcare provider. Providing access to the chart breaches confidentiality. 2. Incorrect: The nurse should be advocating for the client and should not allow access to the chart without written permission from the client. Circumventing confidentiality by requesting a consult is not the action the nurse should take. 4. Incorrect: Written permission is required from the client, who is an adult.

Prior to signing a consent form for surgery, the client states, "I am not sure that I understand the possible risks for this surgery and what the alternative treatments are." What should the nurse do first? 1. Clarify any questions that the client may have and then share the client's concern with the primary healthcare provider. 2. Reinforce that it is not unusual for clients to have questions about surgery. 3. Inform the primary healthcare provider that the client has concerns about the surgery. 4. Use open ended questions to explore client's concerns.

3. Correct: The nurse should call the primary healthcare provider. Further discussion with the client is warranted from the primary healthcare provider that has scheduled and most likely will be performing the surgery. This also provides the client the opportunity to ask questions appropriately. 1. Incorrect: The client has the right to make informed decisions. The client should not sign until all questions are answered by the primary healthcare provider. 2. Incorrect: Recognizes client concerns, but does not take care of problem. The nurse has a responsibility to be an advocate for the client and practice within the law. 4. Incorrect: The informed consent comes from discussion between the primary healthcare provider and the client. The nurse can do this, but it doesn't fix the problem.

The circulating nurse prepares the sterile field in the operating room (OR). Fifteen minutes later, the nurse is informed the surgery will be delayed for 20 minutes because the surgeon is working at another hospital. Which is the best action for the nurse to take? 1. Cover the sterile field with a sterile drape until the surgery is about to begin. 2. Close and tape the OR doors so that no one may enter. 3. Monitor the sterile field while awaiting the surgeon. 4. Tear down the sterile field until the surgeon arrives in the OR.

3. Correct: The nurse should monitor the sterile field while awaiting the surgeon. 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 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 tear 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 also can settle on opened sterile supplies.

A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. Based on the information provided in report, which client condition should be the nurse's priority? 1. Potassium level of 3.4 mEq/L (3.4 mmol/L) in a child with vomiting and diarrhea. 2. Platelet count of 95,000/mm3 in a child with a nose bleed. 3. Absolute neutrophil count of 400/mm3 in a child with fever. 4. Hemoglobin level of 9 g/dL (90 g/L) in a child with reports of fatigue.

3. Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. This client is at a high risk of infection. We see that the temperature is already elevated, which makes us worry that infection is present. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. 1. Incorrect: Although the potassium level of 3.4 mEq/L (3.4 mmol/L) is slightly decreased, this level can be corrected and should improve when the vomiting and diarrhea subside. The nurse should continue to monitor the potassium level, but it does not take priority over the extremely low ANC in the child with fever. 2. Incorrect: This platelet level of 95,000/mm3 is below the normal range of 150,000/mm3 to 400,000/mm3. When the level gets below 100,000/mm3, the clients should be monitored for bleeding such as a nose bleed, which this client has. However, nose bleeds are not that uncommon and can often be controlled by applying pressure to the nares for 5 to 10 minutes. We would not expect to see severe hemorrhage until the levels are much lower, so this client would not be a priority over the client with the low ANC with fever. 4. Incorrect: This hemoglobin level of 9 g/dL (90 g/L) in a child who has reported fatigue is below the normal of 11-15 g/dL (110-150 g/L). However, the fatigue can be managed by regulating the activity to conserve oxygen expenditure and prevent fatigue. The child with the low absolute neutrophil count with signs of an advancing infection would take priority over this child with a slightly low hemoglobin.

nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. Based on the information provided in report, which client condition should be the nurse's priority? 1. Potassium level of 3.4 mEq/L (3.4 mmol/L) in a child with vomiting and diarrhea. 2. Platelet count of 95,000/mm3 in a child with a nose bleed. 3. Absolute neutrophil count of 400/mm3 in a child with fever. 4. Hemoglobin level of 9 g/dL (90 g/L) in a child with reports of fatigue.

A nurse admits a client diagnosed with borderline personality disorder. Which action should be the nurse's priority when planning care for this client? 1. Employ behavior modification using covert techniques. 2. Administer tranquilizing medications on routine basis. 3. Set limits when the client exhibits self-damaging behaviors. 4. Increase therapeutic communication when the client exhibits intrusiveness.

3. Correct: The nurse's priority should be to reinforce expected behaviors by setting limits. Clients with borderline personality disorder may demonstrate a need for attention and break rules (i.e., hide contraband) which could lead to behaviors, such as self-mutilation, that are dangerous. 1. Incorrect: This action creates a lack of trust and is not therapeutic to use any hidden tactics to change the client's behavior. 2. Incorrect: No, tranquilizers are not used on a routine basis. They are prescribed by the primary healthcare provider when necessary and as needed. 4. Incorrect: The nurse's priority should be to set limits regarding negative behaviors rather than having therapeutic communication sessions.

The nurse is caring for a client who presents to the mental health unit following a violent altercation with the spouse. The client has numerous bruises on the face, chest, and back. There is one laceration where spouse "came at me" with a knife. At this time, what is most likely to be the mood of the perpetrator in this situation? 1. Extreme anger 2. Anxiety 3. Kindness 4. Irritability

3. Correct: The perpetrator has completed the acute battering phase and has now likely entered the honeymoon phase with extreme kindness and acts of love. The attacker is now calm after the tension has been released. You may witness remorseful and apologetic behaviors like bringing gifts and promises of love. 1. Incorrect: The anger phase is likely over after the attacker has beaten the victim. This anger building stage is called tension building stage and is characterized by minor incidents like pushing, shoving and verbal abuse. During this time the abused spouse may accept the abuse for fear of it getting worse so the abuser rationalizes that the behavior is acceptable. The abuser may even turn to alcohol and drugs to curb the anger. The extreme anger exhibited during the acute battering stage. The abuser releases the built-up anger and tension by brutal and uncontrollable beatings. After the beating the client is calm and described as "in shock" or have have amnesia of the event. You also see extreme anger in the escalation/de-escalation stage. 2. Incorrect: The tension or anxiety would be felt during the tension-building phase. This anger building stage is called tension building stage and is characterized by minor incidents like pushing, shoving and verbal abuse. During this time the abused spouse may accept the abuse for fear of it getting worse so the abuser rationalizes that the behavior is acceptable. The abuser may even turn to alcohol and drugs to curb the anger. The extreme anger exhibited during the acute battering stage. The abuser releases the built-up anger and tension by brutal and uncontrollable beatings. After the beating the client is calm and described as "in shock" or have have amnesia of the event. You also see extreme anger in the escalation/de-escalation stage. 4. Incorrect: Irritability would be demonstrated during the tension-building phase

A nurse is caring for a client admitted to the hospital for a total hip replacement. In preparing the post-operative plan of care for this client, the nurse recognizes which goal as the highest priority? 1. Prevent complications of shock. 2. Prevent dislocation of prosthesis. 3. Prevent respiratory complications. 4. Prevent skin breakdown.

3. Correct: The postoperative client with a total hip replacement is at risk for thromboembolism and fat emboli which can travel to the lungs and cause respiratory distress. Without proper turning, coughing, and deep breathing, pneumonia and atelectasis may occur. So preventing respiratory complications is high on the priority list. Remember the ABCs - airway, breathing, then circulation. Preventing respiratory complications is the highest priority because of the possibility of sudden death from the complications of deep vein thrombosis and pulmonary embolism. 1. Incorrect: This client is at risk for hemorrhage and/or hematoma formation related to surgical trauma to blood vessels (the hip is a very vascular area) and use of anticoagulants or antiplatelet agents before and after surgery. So the nurse will need to monitor for shock caused by loss of volume. The nurse should monitor drains, wound dressings, and intake and output. But remember, Airway and Breathing take priority. 2. Incorrect: Dislocation of the prosthesis is another complication to worry about. It will cause pain and possible deformity and is very important, but airway is the priority. Dislocation of the hip prosthesis is related to weakness of the hip muscles, improper positioning or movement of the operative extremity, and/or noncompliance with weight-bearing limitations.4. Incorrect: The client is at risk for skin breakdown if not turned and repositioned properly or ambulated as soon as prescribed. However, Airway is still the priority for this client.

The labor and delivery charge nurse is making staff assignments, including assignments to a new nurse. What client is most appropriate for the new nurse? 1. A gravida 3 para 2 in active phase of stage one, expecting twins. 2. A gravida 2 para 0 at 41 weeks gestation, awaiting induction. 3. A primigravida in active phase of stage one, waiting for epidural. 4. A 12-hour post Cesarean section needing assistance to ambulate.

3. Correct: The primigravida presents many opportunities for basic and diverse skills that would be very educational for the new nurse. This is the most appropriate client and will provide a good experience in basic labor and delivery procedures. 1. Incorrect: While this may seem like an interesting case, there is the potential for several problems. A third pregnancy generally proceeds faster, and this client is expecting multiple births. This case can quickly become too complicated for a new nurse. 2. Incorrect: Although this may seem like an interesting case for the new nurse, induction of labor can lead to many problems which could be too complicated for this new nurse. This client requires close monitoring during the induction and would not be the best choice here. 4. Incorrect: Ambulating a post-C-section for the first time would be within the level of competency for a new nurse. However, there is very little educational value in this assignment and it is important to provide learning opportunities for this new nurse.

The ICU nurse is caring for a client with massive head injuries. The nurse notices that the client's respirations have a rhythmic increase and decrease of rate and depth and include brief periods of apnea. How would the nurse document this respiratory pattern? 1. Apneusis 2. Ataxic 3. Cheyne-Stokes 4. Cluster

3. Correct: The respiratory pattern described is Cheyne-Stokes. A client with massive head injuries is at risk for this breathing pattern due to an injury with the cerebal hemispheres. 1. Incorrect: Apneusis is characterized by a sustained inspiratory effort. It does not typically have a period of apnea. 2. Incorrect: Ataxic respirations have an irregular, random pattern of deep and shallow respirations with irregular apneic periods. The irregularity of it differentiates ataxic respirations from Cheyne-Stokes respirations. 4. Incorrect: Cluster breathing is characterized by a closely grouped series of gasps followed by a period of apnea. There is no rhythmic increase and decrease as in Cheyne-Stokes respirations.

The extended family of an alert 92 year old widower has decided the client needs a PEG tube because of weight loss and extremely poor appetite. Though the client is not agreeable, the family is quite insistent and pressures the client to give consent. What action by the nurse would best encourage the client to speak up about personal wishes? 1. Leave personal cell number for client to call after family leaves. 2. Notify family that client has the right to refuse PEG tube insertion. 3. Ask client directly about personal fear or concerns regarding tube. 4. Inform healthcare provider the client does not want feeding tube.

3. Correct: The priority action in this scenario should be between the client and the nurse, with the nurse utilizing therapeutic techniques to encourage client interaction. Such communication is designed to allow the client to share thoughts or feelings in a non-judgmental atmosphere. This is particularly important in a situation where the client feels unable to speak up for self. 1. Incorrect: It is unprofessional and inappropriate for a staff member to leave personal data for any client. It is also unethical for staff to encourage a client to go against family without openly discussing any situation with the family or healthcare provider. 2. Incorrect: Although this is a factual statement, the client may agree in order to appease the family, making this statement is immaterial. The nurse could inform the healthcare provider about the client's hesitancy versus family insistence. However, if the client does not speak up for self and actually refuse the PEG tube, informing the family of client rights has little impact. 4. Incorrect: Though the nurse should notify the healthcare provider about the client's hesitancy regarding the PEG tube, this action has nothing to do with encouraging the client to speak up for self.

A client with psychosis, tells another client, "You are so adorabogalishus." Which form of thought process should the nurse document this client as having? 1. Magical thinking 2. Tangentiality 3. Neologism 4. Perseveration

3. Correct: The psychotic person invents new words, or neologisms, that are meaningless to others but have symbolic meaning to the psychotic person. Remember, do not use the invented word. "Adorabogalishus" is not a real word. 1. Incorrect: With magical thinking, the person believes that their thoughts or behaviors have control over specific situations or people. The client believes that thinking something can make it happen. 2. Incorrect: With tangentiality, the person never really gets to the point of the communication. Unrelated topics are introduced, and the original discussion is lost. The client goes off the topic which can destroy interpersonal communications. 4. Incorrect: The person who exhibits perseveration persistently repeats the same thought, phrase or motor response to different questions. This is associated with brain damage.

Which food item would the nurse include when planning diet instructions to promote bone growth for a client with a broken tibia? 1. Lettuce 2. Apples 3. Yogurt 4. Green beans

3. Correct: The serving size of 150 g of yogurt has a calcium content of 240 mg. 1. Incorrect: The serving size 50 g of lettuce has a calcium content of 19 mg. 2. Incorrect: The serving size of 182 g of apple has a calcium content of 11 mg. 4 Incorrect: The serving size of 90 g cooked green beans has a calcium content 50 mg

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 tracheostomy admitted for 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 UTI and not acutely ill at this time. The major clues are age and unattended. This child's safety is the reason the child takes priority.

Which nursing intervention will be most helpful to a middle-aged client experiencing insomnia? 1. Instruct the client to initiate an exercise routine during the day. 2. Educate the client on ways to adjust the sleep environment. 3. Instruct the client on progressive relaxation techniques to be used just before bedtime. 4. Instruct the client to decrease caffeine intake.

3. Correct: The use of progressive relaxation techniques would help the client relax before bedtime and promote sleep. 1. Incorrect: Exercise might be helpful, but not most helpful. 2. Incorrect: This intervention is not specific. 4. Incorrect: Instructing the client to decrease caffeine intake may help the client but not specific enough.

One hour after administering pyridostigmine, the nurse notes increased salivation, lacrimation, and urination in the client. What initial action should the nurse take? 1. Administer a second dose of pyridostigmine. 2. Place client in side lying position. 3. Notify the primary healthcare provider. 4. Prepare for intubation and mechanical ventilation.

3. Correct: These are signs and symptoms of cholinergic crisis. The client can get increasingly worse. The primary healthcare provider can prescribe atropine as treatment of overdose. 1. Incorrect: Giving an additional dose of pyridostigmine will make the client worse. 2. Incorrect: For better respiratory effort the client should be placed in a semi fowler's position. 4. Incorrect: This can be done after notifying the primary healthcare provider.

Which initial arterial blood gas (ABG) results would the nurse expect on a client who has overdosed on aspirin (ASA)? 1. pH 7.54, PaCO2 41, PaO2 63, SaO2 91, HCO3 36 2. pH 7.24, PaCO2 37, PaO2 83, SaO2 95, HCO3 18 3. pH 7.49, PaCO2 30, PaO2 88, SaO2 92, HCO3 25 4. pH 7.12, PaCO2 28, PaO2 72, SaO2 93, HCO3 10

3. Correct: This ABG result indicates respiratory alkalosis. Aspirin stimulates the respiratory center and causes an increase in respiratory rate and depth. This causes respiratory alkalosis by blowing off CO2 and causing the pH to increase. Losing CO2 (acid) makes the client more alkalotic, which is reflected with an increased pH, decreased PaCO2 and normal HCO3. 1. Incorrect: This ABG result indicates metabolic alkalosis. The pH is high, PaCO2 is normal and HCO3 is high. Normal pH is 7.35-7.45, normal PaCO2 is 35-45, normal HCO3 is 22-26. 2. Incorrect: The client with an initial aspirin overdose will have a respiratory alkalosis. 4. Incorrect: This ABG also indicates metabolic acidosis. The problem in the stem would result in a respiratory problem.

What action by a new nurse who is drawing up a medication from an ampule would require intervention by the supervising nurse? You answered this question Incorrectly 1. Taps the top of the ampule to remove medication trapped in the top of the ampule. 2. Snaps the neck of ampule away from the body when breaking the top off. 3. Withdraws medication using a 22 gauge needle. 4. Inverts ampule, places needle tip in liquid, and withdraws all of the medication.

3. Correct: This action should be corrected by the supervising nurse. Because tiny pieces of glass could have gotten into the medication, the nurse should attach a filter straw to a syringe. If the syringe has a needle in place, the nurse should remove both the needle and the cap and place it on a sterile surface (e.g., a newly unwrapped alcohol pad still in the open wrapper), and then attach filter straw. 1. Incorrect: This is a correct action by the new nurse. Alternatively, the new nurse can flick the top or shake the ampule by quickly turning and "snapping" the wrist. 2. Incorrect: This is a correct action by the new nurse. This will prevent shattering of class toward the hand or face. 4. Incorrect: This is a correct action by the new nurse. Two techniques can be used to withdraw medication from an ampule. The nurse can invert the ampule, place the filter straw tip in the liquid, and withdraw all of medication. The nurse does not insert the filter straw through the medication into the air at the top of the inverted ampule. This will result in medication leaking out of the ampule. Alternatively, the nurse can tip the ampule, place the filter in the liquid, and withdraw all of the medication.

A client buzzes the nurses' station to report chest pain. The nurse looks at the client's cardiac rhythm strip, then hurries into the client's room to find the client unresponsive and without a pulse. What initial action should the nurse take? 1. Administer Epinephrine 1mg IV push. 2. Begin cardiopulmonary resuscitation (CPR) for 2 minutes. 3. Defibrillate at 120 joules. 4. Insert supraglottic airway device.

3. Correct: This client had a witnessed arrest with pulseless ventricular tachycardia. The first thing that the nurse should do is to defibrillate the client at 120-200 joules. Subsequent dosing is increased in a stepwise fashion as needed. 1. Incorrect: Epinephrine, a vasopressor is used to produce vasoconstriction and to raise the BP. It is used for the treatment of Ventricular fibrillation and pulseless ventricular tachycardia for its vasoconstrictive effects. It is not the first action however. If defibrillations do not work, then CPR is done for two minutes prior to administration of epinephrine. 2. Incorrect: Defibrillation should be done immediately unless it is not readily available. Then CPR is performed until the defibrillator arrives. 4. Incorrect: Consider an advanced airway after defibrillations fail to revert the client to Normal Sinus Rhythm.

The nurse just received an arterial blood gas (ABG) report that shows a borderline high PCO2 on a client who had chest surgery. What should be the priority nursing intervention? You answered this question Incorrectly 1. Tell the client to breathe faster. 2. Medicate for pain and ambulate. 3. Have client use the incentive spirometer. 4. Prepare to administer bicarbonate to buffer.

3. Correct: This client had chest surgery and the pCO2 is high. What are you worried about? Hypoventilation. Yes, the client is probably hurting due to the incision and does not want to take deep breaths. In order to get rid of the excess CO2 the client needs to turn, cough, and deep breath. Incentive spirometry can be provided to assist the client with this effort. 1. Incorrect: Breathing faster will only work for a few minutes. The problem is the client needs to breathe deeper to get more oxygen to the tissue and more CO2 out of the lungs. Hyperventilating will lead to respiratory alkalosis. 2. Incorrect: No more sedation! The client is not breathing enough. Walking would be okay. This client needs to take deep breaths. 4. Incorrect: No, we want the client to blow off the CO2. Bircarb will make the pH happy for a short period of time but will not correct the problem. The problem is shallow respirations, so fix the problem.

The nurse is caring for a client in an outpatient clinic. The client's spouse died 8 months ago. Which statement by the client suggests that the client is achieving resolution of grief? 1. "I am starting a new life, so I have removed all of the pictures from the wall that remind me of my spouse." 2. "I'm so lonely and I'm not sure life is worth living now." 3. "Although it hasn't been easy, I accept the loss of my soul mate." 4. "If only we had spent more time together before the illness got so severe."

3. Correct: This client has begun to achieve resolution of grief by walking through the tasks of mourning: to accept the reality of the loss, to experience the pain of grief, to adjust to an environment in which the deceased is missing, and to withdraw emotional energy and perhaps invest in another relationship. 1. Incorrect: This client is still in the grieving process. Behavioral manifestations of grief include crying, withdrawal, avoiding reminders of the deceased, seeking or carrying reminders of the deceased, over activity, and a variety of changes in relationships with other people. 2. Incorrect: This client is still in the grieving process. The manifestations of grief can vary widely. This client has not accepted the reality of the loss, invested in relationships with other nor allowed themselves to go through the process of grief.4. Incorrect: This client is still in the grieving process.

The nurse is caring for four clients. Which client should the nurse see first? 1. The client hospitalized with dehydration related to diarrhea. 2. The seizure client who is currently in the postictal phase. 3. The post-op client who received Morphine 4 mg IV 15 minutes ago. 4. The client who is due pre-op medication now.

3. Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. Remember airway, breathing and circulation (ABCs). Decreased or suppressed respiration are priority. 1. Incorrect: Dehydration can produce postural hypotension, fever, confusion, agitation and if it develops quickly or is severe, coma and seizure may occur. Decreased respiratory rate would be priority. 2. Incorrect: Postictal is the phase after the seizure where they are drowsy, lethargic, and possibly asleep. Make sure the client is safe and in the recovery position. Client would need to be seen soon, but again, decreased respirations takes priority. 4. Incorrect: Decreased or suppressed respirations would be priority over the client needing pre-op medications.

A client with recurrent angina and hypertension has been started on new medications. When reviewing the admission forms, the nurse should immediately question which prescription? Exhibit Spironolactone 50 mg. PO once daily Metoprolol 25 mg. PO once daily Diltiazem 120 mg. PO once daily Potassium 10 meq PO once daily 2 gm. sodium diet 1. 2 gm sodium diet 2. Metoprolol 25 mg PO once daily 3. Potassium 10 meq PO once daily 4. Diltiazem 120 mg PO once daily

3. Correct: This client is being treated for recurrent angina with hypertension. The admission prescription includes spironolactone daily, which is a potassium-sparing diuretic; therefore, the client should NOT be taking a daily dose of potassium. 1. Incorrect: A 2 gram sodium diet is considered a low salt diet, which would be appropriate for a client with hypertension. Excessive dietary salt leads to water retention and increased blood pressure. This prescription is appropriate for the client and does not need to be questioned. 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.

A client calls the prenatal clinic at 37 weeks gestation to report expelling large amounts of fluid. What instruction by the nurse is most appropriate at this time? 1. Lie on left side and take slow, deep breaths. 2. Call an ambulance and go to emergency room. 3. Come to the clinic for assessment and evaluation. 4. Go directly to the hospital emergency room.

3. Correct: This client is full term and the expulsion of large amounts of fluid indicates the client has experienced a rupture of membranes. The next step would be to evaluate the client for effacement and dilation as well as fetal heart tones. The best approach would be for the client come to the clinic for a quick evaluation and assessment. 1. Incorrect: This is neither safe nor appropriate. The client should be examined by the primary healthcare provider as soon as possible. Lying on the left side and taking deep breaths would be a delay of the appropriate treatment. 2. Incorrect: There is no indication the client is experiencing a situation serious enough to warrant an ambulance trip to the emergency room. The question suggests normal rupture of membranes, and while the client should be assessed, this can be accomplished without a trip to the emergency room. 4. Incorrect: It is not necessary for the client to go directly to the emergency room. Because the clinic is still open, the client could be examined by the primary healthcare provider to determine the stage of labor as well as dilation. If the client had called the clinic after hours, the nurse might have recommended a trip to the labor & delivery unit.

The nurse identifies that additional teaching about skin care is needed when an 80 year old client makes what statement? 1. "I shower 3 - 4 times per week." 2. "I apply moisturizers at least daily." 3. "I bathe in the tub at least 6 times per week." 4. "I drink 64 ounces (1.89 L) of liquid per day."

3. Correct: This client will require additional teaching about skin care. The client should not bath 6 times a week. Due to the elderly client's diminished secretion of natural oils and perspiration, the client should decrease the number of times per week that the client either bathes or showers. 1. Incorrect: This is a true statement that the older adult should bathe or shower 3 - 4 times a week. Due to normal aging changes the client should decrease the number of times per week that the client either bathes or showers. 2. Incorrect: This statement does not require further teaching. The composition of the skin changes as a person ages. The epidermis will thin and the sebaceous gland produces less oil. Applying a moisturizer at least daily will protect the epidermis and compensate for less oil being produced. 4. Incorrect: Older people may experience dry skin patches. Drinking liquids will increase the skin's sweat production which will decrease dry skin patches. Drinking 64 ounces (1.89 L) per day should be enough to keep the elderly person hydrated.

The nurse is preparing to educate a client about human papillomavirus (HPV). What information should the nurse include? 1. There is no vaccine to prevent HPV. 2. HPV is the cause of most ovarian cancers. 3. The only way to prevent HPV is refraining from any genital contact with another. 4. HPV is cured by removal of genital warts.

3. Correct: This is a true statement. Latex condoms have been associated with lower risk, however, there is still a risk of coming into contact with the virus even when a condom is used correctly. 1. Incorrect: There is a vaccine against the human papillomavirus. 2. Incorrect: HPV is the cause of most cervical cancers. 4. Incorrect: Even after genital warts are removed, HPV remains, and viral shedding will continue.

A client has been taking tranylcypromine for approximately two weeks. The client is visiting the nurse at the local mental health center for follow up and group therapy. Which client comment indicates a lack of understanding of the medication that could result in a medical emergency? 1. I know that I must take this medication until my primary healthcare provider tells me to stop. 2. It is frustrating to have to follow dietary restrictions. 3. I am getting a cold, and I am going to take some over the counter cold medicine. 4. I am going to have broccoli salad and roasted turkey for lunch today.

3. Correct: This is an MAOI medication. OTC cold medications could result in hypertensive crisis when combined with the monoamine oxidase inhibitor. Warnings are placed on cold preparations and other medicines that are not to be taken with the MAOIs. Be cautious about adding over the counter medications and possible drug interactions. 1. Incorrect: This is a true statement. The primary healthcare provider's orders should be followed. This comment would not result in a medical emergency. 2. Incorrect: Foods high in tyramine should be avoided while taking tranyclpromine, and dietary restrictions must be followed. This comment indicates correct understanding of this medication. 4. Incorrect: This dietary choice demonstrates adequate understanding of the medication and dietary restrictions required.

A community health nurse is reconciling medications of a client who was discharged from the hospital with a diagnosis of congestive heart failure, hypertension, and arthritis. After reviewing the client's medications, what action is most important for the nurse to take? Exhibit Precribeb medication Furosemide 20 mg tablet by mouth every morning Carvedilol 6.25 mg one tablet by mouth twice daily Potassium Chloride 20 mEq one tablet by mouth every morning Current medication Saw palmetto one tablet by mouth every morning Adalimumab 40 mg subcutaneously every other week Captopril 25 mg one tablet by mouth every morning 1. Educate the client on the newly prescribed medications. 2. Inform the client to take the captopril at night. 3. Notify the primary healthcare provider that the client is receiving adalimumab. 4. Tell the client to stop taking saw palmetto.

3. Correct: This is the "most important" action for client safety. Medication reconciliation is "the process of comparing a client's medication prescriptions to all of the medications that the client has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner or level of care. [Adalimumab can cause serious side effects, including heart failure (new or worsening).] 1. Incorrect: Although the nurse will need to teach the client about the new medications, the most important thing for the nurse to do is inform the HCP about the client taking adalimumab. 2. Incorrect: The nurse cannot change the primary healthcare providers RX. Most HF clients go home on an ACE inhibitor, beta blockers, or both (as in this case). Ceptopril is an ACE inhibtor used for the treatment of hypertension and heart failure, and is often prescribed as two -three times daily. 4. Incorrect: Saw palmetto is used as a traditional or folk remedy for urinary symptoms associated with an enlarged prostate gland (also called benign prostatic hyperplasia, or BPH), as well as for chronic pelvic pain, bladder disorders, decreased sex drive, hair loss, hormone imbalances, and prostate cancer. Not saw palmetto contraindicated with prescribed medications.

A client diagnosed with lung cancer is told that the client only has about 6 months to live. The spouse tells the nurse, "I pray every night that God will give me more time with my loved one." Which Kübler-Ross stage of grief does the nurse recognize the spouse to be exhibiting? 1. Anger 2. Acceptance 3. Bargaining 4. Depression

3. Correct: This is the 3rd stage of grief. At this stage, the individual attempts to strike a bargain with God for a second chance, or for more time. The person acknowledges the loss, or impending loss, but holds out hope for additional alternatives. 1. Incorrect: The 2nd stage of grief is when reality sets in. Feelings include sadness, guilt, shame, helplessness, and hopelessness. Self-blame or blaming of others may lead to feelings of anger toward self and others. 2. Incorrect: The fifth and last stage of grief. At this time, the person has worked through the behaviors associated with the other stages and either accepts or is resigned to the loss. Anxiety decreases, and methods of coping with the loss have been established. 4. Incorrect: The 4th stage of grief. The individual mourns that which has been or will be lost. This is a very painful stage, during which the person must confront feelings associated with having lost someone or something of value.

3. Correct: This is the best answer because we are "worried" this client is going into SHOCK. 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: Not the priority here. We are worried about shock. 2. Incorrect: We worry about increased ICP, however, an increased UOP indicates possible diabetes insipidus, so shock is likely. 4. Incorrect: If my client is going into shock, the highest priority is to assess the blood pressure. CVP will let us know if the client has FVD, but the BP will let us know if the client is tolerating it.

A woman who is 2 weeks postpartum calls the clinic stating "All I do is cry. I am so exhausted that I can't think clearly. I can't handle this anymore." What would be the most appropriate response by the nurse? 1. "You are being too hard on yourself. Being a mom is hard. Try to cheer up." 2. "It's normal to feel a little down after having a baby. Just give it some time." 3. "Have you had any thoughts of harming yourself or the baby?" 4. "When the baby starts sleeping better and you get some rest, your thinking will get better."

3. Correct: This mother seems to be experiencing more than the baby blues that many new mothers experience. There are clues in the stem of this question that you should recognize as warning signs of something more significant than the baby blues. The mother states that she no longer is thinking clearly and expresses that she can no longer cope with the existing situation. This mother seems to be experiencing postpartum depression that can include more severe symptoms such as suicidal thoughts of thoughts of causing harm to the baby. Therefore, it is crucial that the nurse ask a very straightforward, direct question to the mother to assess if the mother has any thoughts of harming herself or the infant. Failure to do so could put the mother and/or infant's life at risk for harm. 1. Incorrect: This belittles the client's feelings of hopelessness and gives inappropriate advice to correct the problem on her own. The client might not share any further with the nurse and the situation could become much worse, including harm to her or the infant. 2. Incorrect: Although many mothers do experience baby blues in the postpartum period, you would be missing critical signs that this situation is more than the baby blues if you make the statement that many mothers feel a little down and to just give it some time. During that time, this postpartum depression that was not identified could continue to worsen to the point of more severe symptoms and possible harm to herself or the infant. 4. Incorrect: Although a lack of sleep may be a factor, telling the mother that it will get better later will not give this mother the help that she needs now. Never delay care when the health and well-being of the mother and infant could be at risk.

Which postpartum client should the nurse assign to the last private room in the Women's Health Center? 1. Placenta abruption during delivery 22 hours ago 2. Boggy fundus five hours post-delivery 3. Pre-eclamptic prior to delivery 30 hours ago 4. WBC count is 12,000/mm3 (12 x 10^9/L) at 24 hours postpartum

3. Correct: This pre-eclamptic client delivered 30 hours ago. They are trying to make you think that everything is OKAY because they say AFTER delivery... the client must have a private room because any stimulus can still precipitate a seizure. 1. Incorrect: People who are at risk for bleeding and shock do not require private rooms. 2. Incorrect: Boggy fundus....doesn't have anything to do with a private room. 4. Incorrect: This is the one most people jump on.... Most postpartum clients have elevated white counts post-delivery. Normal white count is 5,000-10,000/ mm3 or 5-10 x 109/L

A client on the med-surg unit is being treated for dehydration and pneumonia. The UAP has entered the room to complete AM care, but the client refuses, reporting feeling too tired from a "poor night's sleep". The UAP reports the refusal to the nurse. What statement by the nurse provides the best explanation to the UAP? 1. "Explain to the client that we are short staffed, so AM care needs done at this time." 2. "Don't worry about it; just tell the next shift they will need to do this client care." 3. "Let's look over your shift assignments to see if we can rearrange some other tasks." 4. "It is crucial for this client to be able to rest, so clean sheets can wait till tomorrow."

3. Correct: This response by the nurse addresses the concerns of the UAP and also suggests a solution by offering to help rearrange the tasks needing to be done. Because the nurse is the individual responsible for shift assignments, this solution would best help all concerned. 1. Incorrect: Staffing issues should never be discussed with clients, nor used as an excuse to skip appropriate care. Forcing a client to accept care after a refusal is abusive. Clients have the right to refuse care, treatments, and even medications at any time. 2. Incorrect: Leaving additional tasks for the next shift can quickly snowball into unequal workload. In a facility where care is designated at specific times for specific shifts, it is the responsibility of the assigned personnel to try to accomplish tasks as scheduled. If not possible, rearranging of tasks may allow time for completion later in the shift. 4. Incorrect: While the nurse is correct that the client needs rest, the client should not be denied clean linens for an entire day. Tasks should be rearranged to accommodate rest for the client, with care to be completed later.

An unlicensed assistive personnel (UAP) has been assigned to take vital signs on several clients. Which instruction would be most important for the RN to provide to the UAP? 1. "Notify me if the pulse oximetry reading drops below 95% in the client who has emphysema." 2. "The client in room 210 has dizziness and faintness when standing, so I need you to obtain a blood pressure reading with the client in the lying, sitting, and standing position." 3. "The client in room 212 has a pacemaker. Let me know if the apical heart rate is greater than 70 bpm." 4. "Let me know immediately if any client has a temperature of 101. 5 degrees F (38.6 degrees C) or higher."

During a treatment team meeting, a client who recently had a mastectomy shares that she can no longer stand to look at herself in the mirror and does not want her husband to see her without clothes. Which statement by the nurse on the team would be most appropriate? 1. "Try looking at yourself in the mirror 5 minutes four times daily until you feel more comfortable." 2. "I'm sure that your husband loves you just the way you are." 3. "Trying to adjust to the change in your body image must be very hard for you." 4. "You look great! Also, when the swelling goes down, you will look even better!"

3. Correct: This response by the nurse first acknowledges the difficulty that the client is experiencing while adjusting to the change in body image following her mastectomy and then encourages the client to further discuss her body image concerns. This exploration of the client's feelings will assist the nurse in addressing the client's concerns. 1. Incorrect: The client is telling you that she cannot stand to look at herself in the mirror at this point. Telling the client to look at herself in the mirror four times a day indicates that you are not listening to what she said and/or you do not care that she is struggling with her body image. You should first help her deal with the feelings that she is experiencing. Later in the process, encouraging the client to look at herself in the mirror may be incorporated into the plan of care. 2. Incorrect: This statement is pacifying and not therapeutic. You do not know that the husband loves her just the way she is. Husbands may also have a difficult time dealing with a wife's mastectomy. This statement does not assist in exploring the client's feelings nor does it assist the client to develop coping skills for dealing with loss and the altered body image. 4. Incorrect: This is a false reassurance. Nurses and healthcare providers are programmed to "fix" the problem. This is absolutely what nurses should do in most situations. However, false reassurance can inadvertently be made by trying to "fix" the client's feelings by using phrases such as "You look great!" or "Don't worry, you will look even better before long!" The client should first be encouraged to express their feelings of loss, altered body image, etc. so that these can be acknowledged and addressed. Later in the treatment plan, the nurse can provide the realistic reassurance that could serve as encouragement for the client.

A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education was successful when a nurse selects which set of ABGs as compensated respiratory alkalosis? 1. pH - 7.4, PaCO2 - 40, HCO3 - 24 2. pH - 7.48, PaCO2 - 29, HCO3 - 22 3. pH - 7.44, PaCO2 - 30, HCO3 - 18 4. pH - 7.46, PaCO2 - 32, HCO3 - 20

3. Correct: This set of ABGs indicate compensated respiratory alkalosis. The pH is normal. Both the PaCO2 and Bicarb are abnormal, but the PaCO2 is low. The bicarb is low to get rid of base. Compensation has occurred. 1. Incorrect: These are normal ABGs. 2. Incorrect: This set of ABGs indicates respiratory alkalosis. Compensation has not occurred as the pH is still abnormal and the bicarb is still normal. 4. Incorrect: This set of ABGs indicates partially compensated respiratory alkalosis. The pH is still abnormal. Both the PaCO2 and HCO3 are abnormal. The pH matches the CO2 as both are alkalotic. The reduction in bicarb shows attempt to compensate.

A client who has a history of major depression is in the emergency department. Which statement would demonstrate a risk for suicide or self-directed injury? 1. "I can't do anything right anymore." 2. "I am not sure what to do anymore." 3. "I just cannot take this loneliness anymore." 4. "No one cares about me."

3. Correct: This statement indicates that the person cannot tolerate the current situation. The client is at risk for harm to themselves. 1. Incorrect: The client has a negative outlook about themselves. This statement indicates low self-esteem. The client is not exhibiting suicidal tendencies. 2. Incorrect: The client is having difficulty making choices. This statement indicates indecisiveness, which is a symptom of depression. Indecisiveness is not a risk for suicide or self-directed injury. 4. Incorrect: This statement indicates possible social isolation and low self-esteem. The client maybe physically separated from people or the perception of being isolated from others. The client does not exhibit a loss of hope that is connected with suicide.

Which statement made by the nurse is therapeutic when the client, who has experienced deficits from a recent cerebral vascular accident, tearfully states, "I can no longer care for myself."? 1. "Right now, I am going to help you get dressed and eat breakfast." 2. "You have to focus on the positive things in your life." 3. "It is hard not to be able to care for yourself." 4. "All you need is some physical therapy and you will be back to normal soon."

3. Correct: This statement shows a recognition of the client's feelings. 1. Incorrect: Changing the topic is a nontherapeutic response. 2. Incorrect: This statement deflects the client's feelings. 4. Incorrect: This statement is condescending and may not be true for this client.

What would be the nurse's priority for a child who has arrived at the emergency department after sustaining a severe burn? 1. Start intravenous fluids. 2. Provide pain relief. 3. Establish airway. 4. Place an indwelling catheter.

3. Correct: This stem does not tell you where the child's burns are, however, you are told that the burns are severe. So assume the worse. What are you most worried about the child losing? Yes, the airway. So we want to assess, establish, and maintain an airway. 1. Incorrect: Not before airway. This child will need IV fluid resuscitation within the first 24 hours. But if you can only pick one action to complete first, it better be to make sure the airway is patent. Then you can start the IV or delegate the task to someone else. 2. Incorrect: Give pain med after starting the IV, not before airway. The best pain relief method for a severe burn is going to be through the IV route. But we must make sure the airway is patent first. 4. Incorrect: Give the pain medication before placing the indwelling catheter but not before establishing the airway. Intake and output will need to be closely monitored in the client who is severely burned. But again, it will need to be done after establishing a patent airway.

Which action should the nurse recommend to parents so that their home will be safer for a toddler? 1. Place the child in the center of an adult-sized bed when napping. 2. Buckle the child into the high chair if parents leave the room during a meal. 3. Anchor top-heavy furniture or fish tanks so that they cannot be pulled over. 4. Allow the toddler to explore stairs in the home if supervised.

3. Correct: Top-heavy furniture, TVs, and fish tanks can be pulled over by the toddler, especially if the child is trying to reach something on top of them. 1. Incorrect: The safest place for the toddler to nap or sleep is in a crib. The toddler may easily fall from an adult-sized bed.2. Incorrect: The toddler should never be left unsupervised in a highchair. It can tip if the child tries to climb out, or the child may push against something and fall.4. Incorrect: Stairs in the home present a risk for falls and accidents for the toddler. Safety gates should be in place, and the adults should hold the toddler's hand when navigating the stairs.

Fasting Glucose Creat./BUN Urine Sp. Gravity White Blood Cells Client - one 140 mg/dL (7.8 mmol/L) 0.6/ 23 mg/dL (70 µmol/L / 8.21 mmol/L) 1.020 4300 cells/mL (4.3 x 109/L) Client - two 99 mg/dL (5.5 mmol/L) 1.8/ 35 mg/dL (159 µmol/L / 12.5 mmol/L 1.026 11000 cells/mL (11 x 109/L) Client - three 80 mg/dL (4.4 mmol/L) 1.4/ 26 mg/dL (124 µmol/L / 9.3 mmol/L 1.035 8900 cells/mL (8.9 x 109/L) Client - four 75 mg/dL (4.15 mmol/L) 0.6/ 20 mg/dL (70 µmol/L / 7.1 mmol/L 1.012 17500 cells/mL (17.5 x 109/L)

3. Correct: Though many of the laboratory results are abnormal, the most concerning is the urine specific gravity in Client three, treated for sickle cell crisis. This result indicates the client is extremely dehydrated, which could lead to more complications, further exacerbating the crisis. 1. Incorrect: A child newly diagnosed with type I diabetes requires some time for the body to respond to treatment and insulin injections. Even though hospitalized, the child may periodically have elevated blood glucose readings during this adjustment period. The slightly elevated specific gravity is to be expected since hyperglycemia causes dehydration in the body. 2. Incorrect: Glomerulonephritis is an inflammatory process within the glomeruli of the kidneys, caused by a type of beta-hemolytic streptococcal infection. The elevated renal labs are to be expected with this illness, and are not abnormal enough to cause undue concern. 4. Incorrect: The client has been transferred to this unit with a diagnosis of pneumococcal pneumonia, which is very serious in children. Because of this illness, an elevated white blood count is expected. The remaining labs are within normal limits. No need to report any values here.

The nurse working on a pediatric unit is reviewing morning laboratory results. Which client's lab result should be immediately reported to the primary healthcare provider? Exhibit 1. Client one - newly diagnosed with type I diabetes. 2. Client two - admitted with acute glomerulonephritis. 3. Client three- treated with IV fluids for sickle cell crisis. 4. Client four - transferred in with pneumococcal pneumonia.

The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Which action should the nurse interrupt the UAP from performing? 1. Draining the colostomy bag on a client with diarrhea. 2. Performing passive range of motion (ROM) on the client with right sided paralysis. 3. Placing the traction weights on the bed to transfer the client to x-ray. 4. Discarding the first urine voided by the client starting a 24 hour urine test.

3. Correct: Traction should never be relieved without a primary healthcare provider's prescription. It can result in muscle spasm and tissue damage. This client could be transferred with traction still maintained.1. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP.2. Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. Each ROM movement should be repeated 5 times during the session. 4. Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. The nurse would then start the 24 hour urine once the 1st void has been discarded. The nurse also needs to be aware of the color and amount of urine voided.

A client reports excruciating paroxysmal facial pain occurring after feeling a cool breeze and drinking cold beverages. Based on this client's reports, what disorder does the nurse suspect? 1. Bell's palsy 2. Submucous cleft palate 3. Trigeminal neuralgia 4. Temporomandibular joint disorder (TMD)

3. Correct: Trigeminal neuralgia is an ongoing pain condition that affects the trigeminal nerve in the face. People who have this condition say the pain feels like an intense electric shock. The pain is triggered by things such as brushing teeth, washing the face, shaving, or putting on makeup. Even a light breeze against the face might trigger the onset of pain. 1. Incorrect: Bell's palsy is a condition in which the muscles on one side of the face become weak or paralyzed. It affects only one side of the face at a time, causing it to droop or become stiff on that side. It is caused by trauma to the facial nerve. 2. Incorrect: A submucous cleft palate (SMCP) results from a lack of normal fusion of the muscles within the soft palate as the fetus is developing in utero. An SMCP can include a very wide or split (bifid) uvula, translucency of the tissue along the middle of the soft palate, and a notch in the back of the hard palate. 4. Incorrect: The temporomandibular joint is a hinge that connects the jaw to the temporal bones of the skull. It allows the jaw to move up and down and side to side, so a person can talk, chew, and yawn. Pain or tenderness in the face, jaw joint area, neck and shoulders, and in or around the ear when chewing, speaking, or opening the mouth wide are signs/symptoms of TMD. pa-5367

A school nurse is caring for a child who fell on the playground. Upon examination of the child, the nurse notes multiple bruises in various stages of healing. What is the nurse's initial intervention? 1. Ask the parents who hit the child on the back. 2. Notify the child's primary healthcare provider. 3. Contact the Department of Health and Human Services. 4. Document the findings and observe the child over the next week.

3. Correct: Unless there is a policy to direct otherwise, the nurse who suspects child abuse is obligated to report it to the Department of Health and Human Services (DHS). 1. Incorrect: This is confrontational and will warn the parents that you suspect abuse. This may lead to greater harm for the child. 2. Incorrect: Unless there is a policy to direct otherwise, the nurse who suspects child abuse is obligated to report it to the Department of Health and Human Services. DHS, rather than the primary healthcare provider can intervene to maintain the child's safety. 4. Incorrect: This is delaying care. If the child is being abused, not reporting it could lead to serious injury or even death.

The nurse is caring for a client diagnosed with deep vein thrombosis, who has been treated with intravenous heparin for one week. The primary healthcare provider plans to change the medication from heparin IV to warfarin sodium by mouth. The nurse understands which approach would be appropriate? 1. Begin the warfarin sodium and stop the heparin simultaneously. 2. Stop the heparin 24 hours, then begin the warfarin sodium. 3. Begin the warfarin sodium before stopping the heparin. 4. Stop the heparin, wait for the coagulation studies to reach the control value, and begin the warfarin sodium.

3. Correct: Warfarin sodium is initiated while the client remains on heparin. This is done so that the client remains adequately anticoagulated during the transition from IV heparin to warfarin sodium. The onset of action of warfarin sodium is 36 hours to 3 days. 1. Incorrect: Warfarin sodium's onset of action is 36 hours to 3 days. If heparin were stopped and warfarin sodium initiated there would be a lag time when the client would be inadequately anticoagulated and at an increased risk for clotting. 2. Incorrect: Warfarin sodium's onset of action is 36 hours to 3 days. Stopping heparin 24 hours before administering warfarin sodium would cause a lag time and increased risk of clotting. 4. Incorrect: Waiting for coagulation studies before administering warfarin sodium would cause a lag time and put the client at increased risk for clotting. Additionally, heparin and warfarin are measured by different clotting lab tests. The aPTT can measure the effectiveness of heparin. The PT and INR can be used to measure the effectiveness of warfarin sodium.

What should the nurse teach a client who has been prescribed sertraline 100 mg PO daily? 1. Kidney function must be monitored regularly 2. Decrease the dose of the prescribed MAO inhibitor 3. Do not stop taking medication abruptly 4. Expect weight loss

3. Correct: We do not abruptly stop a medication that is being used for depression, plus sudden withdrawal may cause flu symptoms or thought disturbances. 1. Incorrect: No, you should monitor liver function regularly, not kidney function. 2. Incorrect: Again, no. Sertraline is an SSRI (selective serotonin reuptake Inhibitor) and should not be given with MAO inhibitors. Do you know why? Because both SSRIs and MAO inhibitors increase the levels of serotonin in the brain, we don't want to give both and double dose them! 4. Incorrect: Antidepressants usually cause weight gain.

The parents of a toddler ask the nurse how to stop their child's temper tantrums when they occur. What is the best advice the nurse should provide? 1. Spank the child gently when the tantrum occurs. 2. Promise the child a new toy if the child stops the tantrum. 3. Ignore the tantrum if the child is safe. 4. Restrain the child during a tantrum.

3. Correct: When a tantrum occurs, the best course of action is to ignore the behavior and ensure that the child is safe during the tantrum. 1. Incorrect: Physical punishment will probably just prolong the tantrum and in fact produce more intense negative behavior. 2. Incorrect: Providing a reward to stop an inappropriate behavior will reinforce that behavior. Throw a temper tantrum, get a reward. 4. Incorrect: Restraining a child may prolong the temper tantrum and produce a more intense negative behavior. If the tantrum occurs in public, it may be necessary to immobilize the child with a big bear hug and use a calm voice to soothe the child.

A housekeeper has been called to the medical-surgical unit to complete several tasks. Which tasks by the housekeeper has priority? 1. Replace the full sharps container in the medication room. 2. Clean room of discharged client who was isolated with MRSA. 3. Wipe up spilled coffee in the family waiting room. 4. Repair a malfunctioning curtain around a client's bed.

3. Correct: When considering multiple safety issues, the priority is the situation which puts the greatest number of individuals at risk. Liquid on a floor is a fall hazard to anyone in that vicinity. A family waiting room has dozens of visitors a day, including adults, children, clergy, other staff and possibly other clients. The floor needs to be clean and dry to prevent injury. 1. Incorrect: The only individuals affected in this situation would be those staff personnel authorized to be in the medication room. In addition to the housekeeper, nursing staff can also change sharps containers. Therefore, even a nurse could replace the filled containers if need be. This action is not the first priority. 2. Incorrect: Cleaning an isolation room is a time-consuming process. Waiting until more important tasks are completed will not put anyone at risk since the room cannot be used until cleaned. Another task has first priority. 4. Incorrect: The curtains that hang around a client's bed are for the purpose of privacy. Even a malfunctioning curtain, which could be anything from torn fabric to broken hooks, does not pose a hazard. Although the client may not have complete privacy, this problem would not affect other clients. There is another issue that affects many individuals.

A nurse is feeding a client diagnosed with a stroke who is exhibiting dysphagia. Which action by the nurse would be appropriate? 1. Elevate the head of the bed to 15 degrees. 2. Request the client to not hold food in their mouth. 3. Monitor for frequent throat clearing after eating. 4. Orient the client to the location of food on their plate.

3. Correct: When helping to feed a client with dysphagia, the nurse should monitor for signs of aspiration such as frequent throat clearing during and after meals. The client is trying to move the bolus of food down esophagus. Aspiration is a condition where food, liquids or saliva moves into the lungs instead of the esophagus during eating. 1. Incorrect: The client should be sitting upright or a high-fowlers position. This position allows for more flexibility of neck movement to promote swallowing. The nurse can keep the client's neck in the neutral position or their chin lowered to their chest. 2. Incorrect: Why is the client holding food in their mouth? Are they disoriented or with a cognitive impairment? Asking a client who is disoriented or with a cognitive impairment to not hold food in their mouth is not an effective intervention. 4. Incorrect: Does the location of the food on the plate affect how a client swallows the food. The location of the food will not affect the possibility of the client aspirating during swallowing food.

Post epidural anesthesia, a laboring client's blood pressure drops to 92/42. Which intervention by the nurse takes priority? 1. Elevate the head of the bed 2. Administer oxygen by face mask 3. Position client side-lying 4. Begin dopamine 5 mcg/kg/min

3. Correct: When you turn them on their side, this relieves pressure on the vena cava and the BP will go UP. 1. Incorrect: This will drop the pressure more. 2. Incorrect: O2 doesn't bring up the BP. 4. Incorrect: Stay away from drugs as long as you can.

The nurse is discussing information on adolescent obesity with parents of high-school students. What statement by the nurse is most comprehensive regarding obesity among teens? 1. Obesity among teens is often accompanied by psychologic issues like poor self-esteem. 2. Weight issues among teens are often due to excess eating out of boredom or stress. 3. Adolescent obesity is usually an inability to recognize signals of hunger or satiety. 4. Undiagnosed problems of the thyroid or pituitary contribute to teen obesity.

3. Correct: While all the options could be true in some cases, the most accurate and comprehensive basis for obesity is an individual's failure to recognize, or acknowledge, signals of hunger or satiety. Neural circuitry, along with specific body hormones, drives sensations of hunger and feeling satisfied. Adolescents experience fluctuating hormones, physical changes and emotional adjustments which can disrupt body functions, including recognition of brain signals. 1. Incorrect: Though self-esteem or concern about physical appearance is common with adolescents, it is not necessarily a cause for obesity. 2. Incorrect: Weight issues are often related to an imbalance between caloric intake and energy expenditure. While adolescent frequently snack on high-calorie junk foods in response to stress or boredom, there are more significant contributing factors for teen obesity. 4. Incorrect: It is possible that undiagnosed issues of the thyroid or pituitary could contribute to adolescent obesity. However, these disorders are not common and might also lead to extreme weight loss.

A nurse is caring for a client injured in a motor vehicle accident while driving intoxicated. After hearing that someone was critically injured because of the accident, the client mumbles, "But I only had just a few drinks". What is the most therapeutic statement the nurse could make to the client? 1. "If you only had a few drinks, how did you wreck?" 2. "What do you mean by 'just a few drinks'?" 3. "Tell me what you remember about the accident." 4. "You were driving when the accident happened."

3. Correct: While providing care to this client, it is important for the nurse to remain professional and non-judgmental. Because no life-threatening injuries are indicated, the most therapeutic approach would be to allow the client to verbalize feelings at this time. Additionally, having the client recall any specifics about the incident may provide the nurse with additional data for a neuro assessment. 1. Incorrect: Though it may be challenging to remain non-judgmental, this response demands an explanation from the client and can seem threatening. The client may have no memory of the accident; furthermore, although the client was intoxicated, there may be unknown circumstances that contributed to this accident. 2. Incorrect: This response might be helpful in situations where the nurse needs to determine the amount of alcohol a client ingests on a daily basis. However, in this circumstance, the amount of alcohol is not the issue for the nurse. The legal authorities may pursue this line of questioning. 4. Incorrect: This is a closed-ended statement that does not provide the client an opportunity to verbalize feelings. The nurse is making a statement that may, or may not, be factual. This would not be therapeutic to the client.

What is the priority electrolyte imbalance for the nurse to monitor when caring for a client post op thyroidectomy? 1. Hypercalcemia 2. Hyperkalemia 3. Hypocalcemia 4. Hypomagnesemia

3. Correct: Why is hypocalcemia the correct answer? The complication from removal of the thyroid is possible injury or removal of parathyroid glands. This produces a disturbance in calcium levels. The calcium levels fall resulting in hypocalcemia. 1. Incorrect: No, the calcium is not elevated. With possible removal of the parathyroid glands during thyroidectomy the calcium will decrease. 2. Incorrect: Potassium is not the priority electrolyte to monitor post thyroidectomy. 4. Incorrect: No, magnesium is not the priority electrolyte to monitor post thyroidectomy.

A small community has experienced a mudslide that hit a restaurant causing mass casualties. What would the nurse do first? 1. Assess the immediate area for electrical wires on the ground. 2. Attend to victim injuries as they are encountered. 3. Activate the community emergency response team. 4. Triage and tag victims according to injury.

3. Correct: With mass casualties, community response teams are needed. 1. Incorrect: This would be the second step so that further injuries are not encountered. 2. 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. 4. Incorrect: This would be the third step.

The nurse is performing sterile wound care for partial thickness burns on a client's lower right leg. Prior to initiating this procedure, what action should the nurse complete first? 1. Position client upright with right leg elevated. 2. Obtain wound culture before cleaning wound. 3. Assess current pain level and medicate. 4. Encourage client to verbalize concerns.

3. Correct: Wound care on burns is a painful process, particularly with partial thickness burns (formerly referred to as second degree) because nerve endings are intact and exposed. Pre-medicating is a priority action, since pain medication can take up to 30 minutes to activate within the body. Clients are more cooperative and heal faster when pain is well controlled. 1. Incorrect: Proper visualization during wound care is vital, as is client comfort during the procedure. However, completion of this process does not require the client to be in an upright position. In fact, that may be counter productive at this time. Additionally, whether the right leg needs elevated depends on the size or location of the burn on the right leg, and that information has not been provided in the question. 2. Incorrect: While it is true that any wound culture must be obtained prior to cleaning the affected area, this action is not presently the nurse's first priority. Consider the nursing process and choose another option. 4. Incorrect: Therapeutic communication is an on going process during any client interaction, particularly when the nurse needs to explain an upcoming procedure. Allowing the client to express fears, verbalize concerns or ask questions enhances cooperation. Although this exchange of information is occurring throughout this period of time, the nurse has another priority action that should be completed first.

A client who is experiencing paranoia is very agitated with aggressive behavior and shouts at others when it is time for a group therapy session. Which action by the nurse is correct? 1. Ask the client to sit for a few minutes. 2. Explain that shouting is not allowed. 3. Redirect the client to another activity. 4. Inform the client that their actions are unacceptable.

3. Correct: Yes! Get them active. Redirect their activity. This is too much for them right now. 1. Incorrect: The client is agitated, shouting...Now do you think it is reasonable to get them to sit and think this will decrease their anxiety? No! 2. Incorrect: Setting limits is good, but here the client is disruptive. 4. Incorrect: The client is in an agitated paranoia state. Telling the client that their behavior is unacceptable will not change the behavior.

A client who is experiencing paranoia is very agitated with aggressive behavior and shouts at others when it is time for a group therapy session. Which action by the nurse is correct? 1. Have the client sit with you and say a prayer. 2. Explain that shouting is not allowed. 3. Redirect the client to another activity. 4. Call for assistance and put the client in seclusion.

Which assessment by the nurse indicates a tension pneumothorax? 1. Sudden hypertension and bradycardia 2. Productive cough with yellow mucus 3. Tracheal deviation and dyspnea 4. Sudden development of profuse hemoptysis and weakness

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

The nurse is caring for an oncology client with a WBC-5.5 x 103 /mm3, Hgb-12g/dL, PLT-90 x 103 /mm3. Which measure should be instituted? 1. Protective isolation 2. Oxygen therapy 3. Bleeding precautions 4. Strict intake and output

3. Correct: Yes. That is the only value that is not a normal level, and it is way too low, so this client is at risk for bleeding. Bleeding precautions are the appropriate intervention. A normal platelet count ranges from 150,000 to 450,000 platelets per microliter of blood. Having more than 450,000 platelets is a condition called thrombocytosis; having less than 150,000 is known as thrombocytopenia. 1. Incorrect: The WBC is okay. An average normal range is between 4,500 and 10,000 white blood cells per microliter (mcL). Leukopenia is the medical term used to describe a low WBC count. 2. Incorrect: There is no indication of hypoxia in stem, and the Hgb is normal, so the client is not anemic. A low hemoglobin count is generally defined as less than 13.5 grams of hemoglobin per deciliter (135 grams per liter) of blood for men and less than 12 grams per deciliter (120 grams per liter) for women. 4. Incorrect: There is no indication for I & O measurement. I&O should be done with clients who have a fluid volume, cardiac, or renal problem.

A nurse is evaluating an unlicensed assistive personnel (UAP) for proper body mechanics while lifting a heavy object off of the floor. What action by the UAP would indicate a need for further instruction by the nurse? 1. Testing the weight to determine if additional assistance is needed. 2. Keeping the feet shoulder width apart. 3. Bending from the waist to pick up the object. 4. Holding the object close to the body upon rising.

3. Correct: You should not bend at the waist. This will injure your back. Lower your knees, and stay close to the object to use thigh muscles. 1. Incorrect: This is correct. If it is too heavy do not attempt to lift alone. 2. Incorrect: This is correct and will help maintain balance as you lower yourself to the floor. 4. Incorrect: This is correct. Holding close to the center of gravity will help prevent injury to your back and arms. Body mechanics describes the ways we move as we go about our daily routine. Poor body mechanics are often the cause of back problems. When we don't move correctly and safely, the spine is subjected to abnormal stresses that over time can lead to degeneration of spinal structures. The process of lifting places perhaps the greatest loads on the low back and therefore, has the highest risk of injury. Use of proper lifting mechanics and posture is critical to prevent injury. How to lift safely: Place the load immediately in front of you. Bend the knees to a full squat or lunge position. Bring the load towards your chest. Assume a neutral position with your back. Tighten the lumbar and buttocks muscles to "lock" the back. Lift now from the legs to the standing position DO NOT Lift from a twisted / sideways position. DO NOT Lift from a forward stooped / imbalanced position.

What would the nurse include when teaching a client newly prescribed timolol maleate eyedrops for glaucoma? 1. The medication works by causing the pupils to constrict 2. The medication will dilate the canals of Schlemm 3. This medication decreases the production of aqueous humor 4. The medication improves ciliary muscle contraction

3. Correct: timolol does decrease aqueous humor formation; therefore decreasing IOP 1. Incorrect: timolol does not constrict pupils 2. Incorrect: timolol does not dilate the canals of Schlemm 4. Incorrect: timolol does not cause ciliary muscle contraction

A hospital has incorporated new equipment on all units without nursing or staff input. Frustrated staff members approach the nurse manager, requesting a resolution of the situation. What response by the nurse manager would be most appropriate? 1. "You are over-reacting to this new equipment." 2. "Perhaps you just need some further training." 3. "Unexpected changes can be difficult to accept." 4. "If we work together, everything will get better."

3. Correct:The nurse manager should utilize therapeutic techniques with staff as well as clients. The introduction of new equipment, particularly with no staff input, can cause frustration, job dissatisfaction, or even anger. Open-ended statements and questions allow staff to verbalize emotions in a situation which has led to feelings of powerlessness. This approach by the nurse manager will help staff adapt more successfully to this situation. 1. Incorrect: This closed, antagonistic remark is accusatory and provides no opportunity for staff interaction. The nurse manager has responded by placing blame on the staff instead of encouraging the expression of feelings and frustrations. 2. Incorrect: Such a comment focuses on training or lack of staff knowledge regarding the new equipment. This is a closed-ended comment which focuses on the issue of staff learning rather than lack of input for the equipment. 4. Incorrect: Though the comment may seem encouraging, the nurse manager is ignoring the staff's feelings and implying everything will be okay. This belittles staff emotions and is closed-ended, eliminating the opportunity to work through feelings.

The nursing supervisor is preparing a staff development program concerning the legal parameters of torts. Which example would the supervisor include as an intentional tort? Select all that apply 1. Administering a 0900 medication at 1030. 2. Administering a medication to an incorrect client. 3. Performing an invasive procedure without an informed consent. 4. Telling a client that their medication will be withheld if client does not behave. 5. Raising the side rails without a prescription when a client is at risk to fall.

3., & 4. Correct: An intentional tort occurs when a person intends to perform an action that causes harm to another. Performing an invasive procedure without consent is considered battery because the client has not given consent for the procedure. Threatening to withhold a medication is intentionally threatening to harm the client by not administering the medication. 1. Incorrect: This is an unintentional tort. The nurse did not intend to administer the medication 90 minutes after the ordered time. 2. Incorrect: The nurse unintentionally jeopardized the safety of the client. This is an unintentional tort. 5. Incorrect: This intervention by the nurse is appropriate. In an emergency the side rails maybe raised when the safety of the client is at risk.

The nurse is caring for a client diagnosed with pneumonia. The primary healthcare provider has prescribed erythromycin ER. What teaching points should the nurse plan to teach the client regarding this medication? 1. Crush the medication if unable to swallow capsule. 2. Take erythromycin 1 hour after eating. 3. Report clay-colored stools. 4. Do not take erythromycin with grapefruit juice. 5. Keep capsules in bathroom cabinet.

3., & 4. Correct: The client should be taught signs and symptoms of liver problems such as nausea, increased stomach pain, itching, tired feeling, loss of appetite, dark urine, clay-colored stools, or jaundice. Grapefruit juice can interfere with absorption of this medication.1. Incorrect: Do not crush, chew, or break a delayed release capsule or tablet. Swallow it whole.2. Incorrect: This medication should be taken 1 hour before or 2 hours after a meal.5. Incorrect: Keep at room temperature, away from excess heat and moisture (not in bathroom).

What should the nurse emphasize when teaching clients how to decrease the risk of chronic obstructive pulmonary disease? Select all that apply 1. Avoid exposure to individuals with respiratory infections. 2. Increase intake of Vitamin C. 3. Eliminate exposure to second hand smoke. 4. Avoid prolonged exposure to occupational dusts and chemicals. 5. Get a yearly influenza and pneumococcal vaccination.

3., & 4. Correct: The most important environmental risk factor for COPD is cigarette smoking. Second hand smoking also contributes to COPD. Risk factors for COPD include prolonged and intense exposure to occupational dust and chemicals as well as indoor and outdoor air pollution. 1. Incorrect: Exposure to individuals with respiratory infections does not increase risk of chronic obstructive pulmonary disease. Respiratory infections may cause an acute exacerbation in a client with existing COPD. 2. Incorrect: Increasing intake of vitamin C does not decrease risk of obstructive pulmonary disease. 5. Incorrect: Clients should get the influenza vaccine annually in autumn. The pneumococcal vaccine should be administered every 5 years, rather than yearly.

The nurse manager of an Alzheimer's unit as completed inservice education to new nursing staff regarding guidelines for dealing with dementia. Which identified guidelines by the new nursing staff indicates to the nurse manager that education was successful? Select all that apply 1. Use a firm touch to guide the client to a different location when needed. 2. Be persistent when getting the client to do something. 3. Provide simple directions using gestures or pictures. 4. Do not argue with the client. 5. Play memory games to decrease dementia. 6. Require participation in daily activities.

3., & 4. Correct: When a person is confused and has dementia, we need to communicate in a simple manner. Provide simple directions or instructions, short sentences, and gestures. Use pictures. Do not give instructions on multiple things. Do not argue, criticize, or correct the client. This can increase anxiety, agitation, and anger. 1. Incorrect: Use a gentle touch rather than a firm touch with these clients. You do not want to be confrontational or evoke fear in the client. 2. Incorrect: Be flexible. If one approach does not work, try another. 5. Incorrect: Avoid questions or topics that require extensive thought, memory, or words. This can increase anxiety, frustration, and agitation. 6. Incorrect: Do not require or force participation in activities or events. This can increase anxiety, frustration, and agitation.

What should the nurse include when teaching a client diagnosed with Grave's disease who is scheduled to receive radioactive iodine? Select all that apply 1. Stay 6 feet from people for 2 weeks. 2. This medication is given intravenously as a one-time dose. 3. Radioactive iodine will leave the body in urine and saliva within a few days. 4. You cannot receive radioactive iodine if you are pregnant. 5. Radioactive iodine is absorbed by the parathyroid glands.

3., & 4. Correct: Within a few days after treatment, the radioactive iodine will leave the body in urine and saliva. If the client is pregnant, she should not receive radioactive iodine treatment. This kind of treatment can damage the fetus's thyroid gland or expose the fetus to radioactivity. Women should wait a year before conceiving if they have been treated with radioactive iodine. 1. Incorrect: Stay away from babies for 1 week and do not kiss anyone for 1 week. 2. Incorrect: Radioactive iodine is given in a capsule or liquid form. One dose is usually all that is needed. 5. Incorrect: Radioactive iodine is absorbed by the thyroid gland. It destroys the thyroid. So now the client becomes hypothyroid.

What personal protective equipment should the nurse wear into the room of a client who has been placed on droplet precaution? 1. Gloves 2. Gown 3. Goggles 4. Mask

The nurse is discussing frostbite prevention with a group of teenagers who participate in cold weather activities. What information should the nurse provide? Select all that apply 1. Limit alcohol intake when out in cold weather. 2. Dress in several layers of tight fitting clothing. 3. Eat well-balanced meals. 4. Synthetic clothes absorb moisture and become wet quickly. 5. Wear a wool headband over the ears. 6. Wear several pairs of socks.

3., & 5. Correct: Eat well-balanced meals and stay hydrated. Doing this even before going out in the cold will help the person stay warm. People should not diet or restrict food or fluid intake when participating in winter outdoor activities. Malnutrition and dehydration contribute to cold related illnesses and injury. Heavy woolen or windproof materials make the best headwear for cold protection. 1. Incorrect: Don't drink alcohol if planning to be outdoors in cold weather. Alcoholic beverages cause the body to lose heat faster. 2. Incorrect: Dress in several layers of loose, warm clothing. Air trapped between the layers of clothing acts as insulation against the cold. 4. Incorrect: Synthetic clothes should be worn because it moves moisture away from the body and dries quicker. Cotton clothing, especially as an undergarment, holds moisture and becomes wet quickly and contributes to the development of hypothermia and frostbite. 6. Incorrect: Wearing several pairs of socks can decrease circulation and lead to frostbite. Instead, wear socks and sock liners that fit well, wick moisture and provide insulation.

Which tasks should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply 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 delegate to the UAP. 1. Incorrect. This is a task for the RN and involves teaching and evaluation of effectiveness. 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.

Which clients would the nurse monitor for the development of hypovolemic shock? Select all that apply 1. Having an allergic reaction form multiple wasp stings 2. Post-operative cervical spinal cord surgery 3. Addisonian crisis 4. Partial thickness burns over 50% total body surface area (TBSA) 5. Type 2 diabetic with hyperglycemic hyperosmolar nonketotic coma (HHNK)

3., 4. & 5. Correct: A client in Addisonian crisis loses sodium and water and can have hypovolemic shock. A 10 year old child with 40% burns is shifting fluid to the tissues because of the tissue damage of the burns, increasing permeability. An adult with type 2 diabetes and an infection can develop HHNK. This massive polyuria can cause shock. With polyuria, think shock first. 1. Incorrect: I would worry about anaphylactic shock with this client. 2. Incorrect: I would worry about neurogenic shock with this client.

Which client diagnosis would a prescription for an intravenous infusion of 1000 mL normal saline with 20 mEq (20 mmol) potassium chloride be appropriate? 1. Major burn injury 2. Kidney disease 3. Abdominal cramping with diarrhea 4. Diabetic Ketoacidosis (DKA) 5. Hypokalemia

3., 4. & 5. Correct: Clients with abdominal cramping with diarrhea, diabetic ketoacidosis, and hypokalemia are safe to receive normal saline with potassium chloride. A primary electrolyte found in the lower GI tract is potassium. Therefore, diarrhea can result in excessive losses of potassium and associated hypokalemia can occur. When insulin is given to the client in DKA, it causes a transport of both glucose and potassium out of the blood and into the cell, resulting in hypokalemia. Finally, a client who has hypokalemia from other causes would need potassium replacement as well. 1. Incorrect: Tissue destruction from a major burn will cause release of potassium from the cell and into the blood. Thus, hyperkalemia occurs. An IV infusion with potassium will make the problem worse. 2. Incorrect: With kidney disease and the resulting diminished renal function, the client is at risk for sodium and potassium retention.

A client tells a clinic nurse of plans to travel to Europe by plane. What tips should the nurse provide the client regarding prevention of clot formation? Select all that apply 1. Do not cross legs longer than 15 minutes at a time. 2. Get up and move around the plane every 4 hours. 3. Wear compression stockings while traveling. 4. Frequently move legs while sitting. 5. Avoid coffee while traveling.

3., 4. & 5. Correct: Compression stockings put gentle pressure on the leg muscles. Studies in healthy people have shown that wearing compression stockings minimizes the risk for developing DVTs after long flights. It is important for passengers to keep moving their legs to help the blood flow, even when waiting in the airport terminal. Alcohol and coffee contribute to dehydration, which can lead to thickened blood and increased risk for DVT. 1. Incorrect: Do not cross legs at all. 2. Incorrect: The client should get up and move around at least every 2 hours. When walking, the muscles of the legs squeeze the veins and move blood to the heart.

Which tasks can the RN delegate to an unlicensed assistive personnel (UAP) when caring for a client who has had a stroke and is being rehabilitated? Select all that apply 1. Assess a client's ability to swallow. 2. Develop a plan of care for hygiene needs. 3. Assist the client using a walker. 4. Calculating the intake and output. 5. Encourage and assist the client with the use of a hairbrush on the affected side. 6. Teach the family about the need to prevent pressure ulcers.

3., 4. & 5. Correct: It is within the role of the UAP to assist a client with a walker. The UAP can collect and calculate intake and output. When assisting the client with hygiene needs, the UAP can promote strengthening of the affected side by encouraging and assisting the client to place the hairbrush in the hand of the affected side. 1. Incorrect: The UAP cannot assess a client. Assessment is not in role of the UAP and is also outside the scope of practice for LPN's. Assessments must be performed by the RN. 2. Incorrect: Although the UAP can provide care and assistance related to hygiene needs, the planning of care cannot be delegated to the UAP. This is part of the nursing process and must be performed by the RN. 6. Incorrect: Teaching cannot be delegated to the UAP and is also outside the scope of practice for the LPN. Teaching is a responsibility and in the scope of practice for the RN.

A client admitted to the psychiatric unit after a suicide attempt is placed on suicide precautions. Which nursing interventions would be appropriate? Select all that apply 1. Assign the client to a private room away from nurses station. 2. Make rounds to assess the client at regular intervals. 3. Secure a promise that the client will seek out staff when feeling suicidal. 4. Closely supervise the client during meals. 5. Formulate a no harm contract for the client to sign.

3., 4. & 5. Correct: Remove harmful objects from the client's access, such as sharp objects, straps, belts, ties, glass items, and alcohol. Close supervision is necessary during meals. Increased feelings of self-worth may be experienced when the client feels accepted unconditionally regardless of thoughts or behavior. 1. Incorrect: Clients should not be left alone for long periods of time. A private room close to the nurses' station is best. Do not allow clients to spend too much time alone in their rooms. 2. Incorrect: Make rounds frequently, at least every 15 minutes. Do not become predictable with rounds. Predictability allows the client to learn your routine and potentially harm themselves during the time they know you will not be in there.

A construction worker comes into the occupational health nurse's clinic reporting chest heaviness. The nurse should assess for what additional signs and symptoms? Select all that apply 1. Headache 2. Dry, flushed skin 3. Lightheadedness 4. Dyspnea 5. Irregular pulse

3., 4. & 5. Correct: The nurse should be thinking myocardial infarction (MI)! All of these are signs of an MI. 1. Incorrect: Headaches do not commonly occur with MI. 2. Incorrect: Skin would be cool and clammy.

The nurse is assessing an adolescent newly diagnosed with obsessive compulsive disorder (OCD). The client is nervously rearranging papers on the desk and stating "why can't I stop this?" What would be the most therapeutic response(s) by the nurse at this time? Select all that apply 1. "We can help you control impulses, but you will never be cured." 2. "You will feel much better after beginning your family therapy." 3. "Tell me what part of your disorder you find the most difficult." 4. "You seem nervous and upset about rearranging those papers." 5. "The goal of behavior control can be accomplished with help."

3., 4., & 5. CORRECT: The key in the nurse/client relationship is that interaction must be therapeutic and open-ended to encourage the client to share feelings in a nonthreatening environment. The nurse is asking the client to provide some details about living with the disorder by using a broad opening statement about the challenges of the disorder. Then the nurse is reflecting the client's behavior, indicating a perceived sense of anxiety or being upset. Finally, the nurse is addressing the client's verbalized concerns by stating the probable success of the main treatment goal, thus encouraging the client. 1. INCORRECT: Though there is truth behind this statement, such a negative comment does not provide any hope or comfort to the client. The information is presented in a non-therapeutic manner. 2. INCORRECT: There is often a component of psychotherapy, or "talk therapy" involved in the treatment of OCD. However, this disorder does not require family therapy, but rather individual analysis to help the client understand or control anxiety.

A homecare nurse is visiting a client with advanced Alzheimer's disease living in the home of a daughter. The household includes two adults and three adolescents with extremely busy schedules. The daughter admits to feeling overwhelmed but is fearful of placing the client into a permanent care facility. What interventions by the nurse would be most helpful for the family at this time? Select all that apply 1. Call Adult Protective Services and ask for recommendations. 2. Request the primary healthcare provider to order placement. 3. Provide the family with brochures from various nursing homes. 4. Encourage family to join a local Alzheimer's Support Group. 5. Talk with daughter regarding fears or concerns about placement.

4 & 5. Correct: Families often feel an obligation or desire to keep elderly family members in the home setting, unaware of how difficult care can become as Alzheimer's disease progresses. In this scenario, many adults in the home should mean more assistance; however, adolescents often demand a great deal of time with busy schedules. The primary caregiver could be overwhelmed very quickly. The nurse should encourage the family to join a local Alzheimer's support group, which can provide ideas and hints to surmount the challenges faced in the home setting. Additionally, the nurse could talk privately with the daughter, using therapeutic communication to develop an understanding about the expressed fear of placing the client into a long-term care facility. 1. Incorrect: Adult Protective Services (APS) is not the appropriate agency to contact regarding this matter. APS may be involved in cases of negligence, abuse or unsafe living situations, but this situation does not present any potential problems. 2. Incorrect: The primary healthcare provider cannot order automatic placement of an individual into long-term care unless that client is in danger, is being abused or even neglected in the current living environment. There is no indication of any major issues in this home. 3. Incorrect: The daughter has already indicated a fear of placing the client into an alternative living environment. This would not be an appropriate time to start presenting the family with brochures of facilities.

The nurse is caring for a client admitted with an episode of bleeding esophogeal varices. What should the nurse monitor for after administering propranolol to this client? Select all that apply 1. Increased systolic BP 2. Hypokalemia 3. Bradycardia 4. Wheezing 5. Decreased hematemesis

3., 4., & 5. Correct: Propranolol is a beta blocker that affects the heart and circulation. It is used in the treatment of high blood pressure, irregular heartbeats and in the prevention of angina and headaches. This medication works by blocking epinephrine and reduces heart rate, blood pressure and strain on the heart. Decreasing the heart rate should decrease bleeding. Wheezing is an adverse reaction from propranolol and should be monitored for after administration. A decreased in heart rate and blood pressure will help to decrease bleeding. Hematemesis is vomiting blood.1. Incorrect: Blood pressure is the force of blood flow against the walls of your arteries. Propranolol should decrease blood pressure, thus decreasing bleeding.2. Incorrect: Beta blockers inhibit renin release which can decrease the release of aldosterone. We should monitor for hyperkalemia, rather than hypokalemia.

The nurse is preparing to administer a dose of sacubitril/valsartan 24/26 mg by mouth. The nurse has not administered this medication before and is using a drug reference to review information about the medication. Which client and drug reference information supports the nurse's decision to withhold the sacubitril/valsartan? Exhibit Select all that apply 1. Bilateral crackles noted to posterior lung fields. 2. Potassium- 4.8 mEq/L (4.8 mmol/L). 3. Currently taking trandolapril 2 mg by mouth daily. 4. Concomitant use or use within 36 hours of ACE inhibitors. 5. ACE inhibitors increase risk of angioedema. 6. Decreased Hematocrit

3., 4., & 5. Correct: This client is currently taking trandolapril, which is an ACE inhibitor. The drug reference guide specifically said, "concomitant use (of sacubitril/valsartan) or use within 36 hours of ACE inhibitors" is contraindicated because giving with ACE inhibitors can increase the risk of angioedema. 1. Incorrect: Bilateral crackles noted to posterior lung fields. 2. Incorrect: Potassium- 4.8 mEq/L (4.8 mmol/L). This is within normal limits and would not require withholding the sacubitrin/valsartan. 6. Incorrect: This client's Hematocrit is 43%, which is normal. Normal values: Adult males: 42-52% (0.42-0.52). Adult women: 37-47% (0.37-0.47). Therefore, this would not influence the administration of the sacubitril/valsartan.

The nurse is discharging a client post right radial percutaneous transluminal coronarey angioplasty (PTCA) with stent insertion. Which instructions should the nurse give the client to reduce the risk of complications? Select all that apply 1. Do not use the wrist to lift more than 5 pounds (2.27 kg) for 24 hours. 2. Stop taking aspirin in one week. 3. Drink at least 8 glasses of water a day. 4. Wear loose fitting sleeves. 5. Do not shower or soak in a tub for one week. 6. Take short walks around your house.

3., 4., & 6. Correct: Drink eight to ten glasses of water to flush the contrast material from the client's system. The client should wear loose sleeves. We do not want any constriction to the surgical site. In general, the client will need to take it easy for the first two days after getting home. The client can expect to feel tired and weak the day after the procedure, but it is important to take walks around the house. This will help prevent blood clots. 1. Incorrect: The client should limit the use of the wrist. It is important to allow the artery to heal. So, no straining of the wrist. Do not use the wrist used in the procedure to lift more than 2 pounds (0.9 kg) for 24 hours. 2. Incorrect: Clients are maintained on aspirin indefinitely after percutaneous coronary intervention to prevent future thrombotic events. 5. Incorrect: The client can shower after the pressure dressing is removed (usually the day after surgery). The client should keep the area clean and dry when not showering.

What information should the nurse include when providing community teaching on burn prevention strategies? Select all that apply 1. Have chimney professionally inspected every 5 years. 2. Microwave a baby bottle rather than heating on the stove. 3. Clean the lint trap on the clothes dryer after each use. 4. Keep anything that can burn at least 3 feet (0.91 meters) away from space heaters. 5. Hold a hot beverage or hold a child, not both at the same time. 6. Home hot water heater should be set at a maximum of 120°F (48.8°C).

3., 4., 5., & 6. Correct: Lint that accumulates in the lint trap of a dryer can cause a fire, so the lint trap should be cleaned after each use. Space heaters need space at least three feet (0.91 meters) away from anything that can burn. A hot beverage can easily spill on a child by accident when trying to handle both the beverage and child at the same time. Home hot water heater should be set at a maximum of 120°F (48.8°C), especially when small children, the elderly, or diabetics are in the home. 1. Incorrect: A chimney should be professionally inspected every year prior to use. It should also be cleaned if necessary. 2. Incorrect. Never microwave a baby bottle. The formula inside the bottle can become scalding hot in the center.

What signs and symptoms does the nurse expect a client diagnosed with bacterial pneumonia to exhibit? Select all that apply 1. Asymmetrical chest expansion 2. Night sweats 3. Dyspnea 4. Tachypnea 5. Pleuritic chest discomfort 6. Increased tactile fremitus

3., 4., 5., & 6. Correct: The most common presenting signs and symptoms of pneumonia are cough, fever, chills, dyspnea, tachypnea, and pleuritic chest pain. If consolidation is present, increased tactile fremitus (vibration of the chest wall produced by vocalization) may be noted. 1. Incorrect: Asymmetrical chest expansion occurs if the client has a collapsed lung from a pneumothorax or hemothorax. 2. Incorrect: Night sweats is a common symptom of tuberculosis, not pneumonia.

A new nurse on a telemetry unit has been assigned a client admitted for treatment of congestive heart failure (CHF). When completing a cardiac output assessment, the nurse would evaluate what body function? Select all that apply 1. Skin turgor 2. Bowel sounds 3. Urinary output 4. Pupillary reaction 5. Peripheral edema 6. Level of consciousness

3., 5. & 6. Correct: Congestive heart failure occurs when the heart is unable to move fluid forward through the vascular system. The backup of fluid results in poor perfusion which presents a variety of signs and symptoms. The kidneys are vulnerable to altered levels of cardiac perfusion, which is reflected urinary output. Excess fluid that is circulated properly will accumlate in peripheral body tissues causing notable edema in ankles initially. Even the brain reacts to poor perfusion with an altered level of consciousness. These signs should be determined in a cardiac output assessment. 1. Incorrect: Skin turgor relates to superficial body moisture, not fluids in the vascular system. Skin turgor reflects hydration, not circulation. 2. Incorrect: Bowel sounds are generated by peristalsis within the gastrointestinal system. Though fluids can alter normal functioning in the intestines, cardiac output is not a factor in bowel sounds. 4. Incorrect: Reactions of the pupils is a function of both sympathetic and parasympathetic nervous systems. Caridac output does not impact the nervous system or pupillary responses.

Labetalol has been prescribed for a client in the emergency room. Prior to administering this medication, what assessment should the nurse perform? 1. Listen to the client's breath sounds. 2. Check the client's temperature. 3. Monitor for peripheral edema. 4. Auscultate the apical pulse rate.

4 Correct: The therapeutic effect of labetalol, which is a beta blocker, is to lower the blood pressure and decrease the heart rate. Apical pulse should be assessed for 1 full minute. If pulse is less than 60 the medication is held and the healthcare provider should be notified. 1. Incorrect: Indirectly a beta blocker could affect breath sounds but assessing breath sounds is not as important as taking the client's apical pulse. Beta blocks should be used cautiously in clients with a history of COPD or asthma these could cause airways to constrict. 2. Incorrect: Labetalol does not affect the client's temperature. This is not a side effect of labetalol. 3. Incorrect: Indirectly a beta blocker could affect the amount of peripheral edema, however, assessing for peripheral edema is not as important as taking the client's apical pulse.

What signs/symptoms would the nurse expect to assess in a client diagnosed with Guillain-Barre' Syndrome? Select all that apply 1. Opisthotonos 2. Seizures 3. Paresthesia 4. Hemiplegia 5. Hypotonia 6. Muscle aches

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

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Clean client's halo fixation insertion sites with hydrogen peroxide. 2. Insert acetaminophen suppository in client's rectum. 3. Reapply pneumatic compression device to client's legs. 4. Check client's gag reflex prior to feeding. 5. Set up suction equipment in client room. 6. Reposition client every 2 hours.

3., 5., & 6. Correct: The UAP is trained on use of routine equipment such as pneumatic compression devices and can reapply the device to a client. Gathering needed equipment and supplies is within the scope of duties for the UAP. Repositioning a client every 2 hours is within the UAP's ability and can be assigned by the nurse. 1. Incorrect: The UAP can provide routine hygiene. The nurse would be responsible for wound care, including halo insertion pin site care. This requires skill beyond the UAP's knowledge. 2. Incorrect: The UAP cannot administer medications. 4. Incorrect: The UAP cannot assess or evaluate a client. The RN most do this part of the nursing process.

The charge nurse has received word that a mass casualty has occurred and beds are needed in the hospital. This will require discharging some current clients. Which client would be appropriate to seek permission from the healthcare provider to be discharged? Select all that apply 1. Client admitted with chest pain and has an elevated Troponin level. 2. Client with blood glucose of 500 mg/dL and pH of 7.3 receiving IV insulin. 3. Client admitted with hemothorax but no chest tube drainage in last 14 hours. 4. Client who underwent a laminectomy for spinal stenosis 12 hours earlier. 5. Elderly client who fell and is developing increased confusion.

3., and 4. Correct: These clients are the ones that would be considered the most stable and therefore, could be safely discharged. The client who had the hemothorax and has not had any drainage for 14 hours indicates that the hemothorax has resolved. The chest tube could be safely removed for the client to be discharged. Clients who have laminectomies often are released home the same day as the surgery, if there are no complications and the condition is stable. This may seem early to discharge a client who had back surgery, but the clients who need to be admitted would be considered unstable and would be a priority over this client. 1. Incorrect: This client would be considered unstable and therefore not a candidate for discharge. This client may be having a MI as indicated by the presence of chest pains and the elevated Troponin level. Remember, Troponin is one of the most specific cardiac biomarkers for indicating myocardial damage. 2. Incorrect: This client is in diabetic ketoacidosis (DKA) and considered unstable. This client is in need of continued IV insulin and careful monitoring. Metabolic acidosis is an unstable condition. 5. Incorrect: Although you may think that it is normal for the elderly to have some confusion, this client may have a cerebral bleed following the fall and is considered unstable. If the client is found to not have a bleed or other complication from the fall and is determined to be stable, this would be the next client who would be considered for discharge.

A recently hired primary healthcare provider from India has started working at the local hospital. When receiving new phone prescriptions, the nurse is unable to understand the primary healthcare provider's thick accent. Which comment by the nurse is most likely to successfully resolve the issue? 1. "I'll have to get someone who can understand you." 2. "I can't understand you. You need to say it again." 3. "Can you please repeat that prescription again slowly? " 4. "I don't know what you are trying to say."

3.CORRECT: The issue involves difficulty understanding the verbal phone prescriptions rom the new primary healthcare provider. Any comment by the nurse must be both professionally worded and culturally sensitive. In this statement, the nurse is asking for the orders to be repeated and indicating the need to speak slowly. This does not place blame on the healthcare provider but does suggest a process to resolve the situation in a professional manner. 1. INCORRECT: This response is not the best. It may imply cultural insensitivity and that the inability to communicate is solely the fault of the primary healthcare provider. 2. INCORRECT: This may be a truthful statement, but it is not professionally stated. This phrasing by the nurse suggests that the problem is the fault of the primary healthcare provider. Additionally, the manner in which the nurse asks the prescription to be repeated sounds abrupt and demanding. 4. INCORRECT: There is no attempt by the nurse to resolve the situation with any suggestions, which is both culturally insensitive and unprofessional. A tone of frustration would not help the nurse to clarify the prescription.

The nurse is caring for a client in the emergency department. The primary healthcare provider prescribed penicillin 100,000 units IM. The drug label reads penicillin 300,000 units/mL. The nurse would administer how many mL of this medication? Round answer using two decimal points.

300,000 units : 1 mL = 100,000 units : x mL 300,000 x = 100,000 x = 0.33

A client who is scheduled for a total hip replacement surgery in the morning begins to verbalize anxiety related to the surgery. Arrange the client's comments in order as the client's anxiety advances beginning with mild to panic anxiety. 1. "Having trouble thinking about anything, but the surgeon cutting on my hip." 2. "My Dad died on the operating table, and I keep thinking I will die too." 3. "I know those hip exercises after the surgery are painful." 4. "Can I wear my wedding ring during the surgery?"

4, 3,1,2 The client is experiencing mild anxiety when asking a question about whether their wedding ring needs to be removed during surgery. The client is concerned about the ring, and is able to ask a direct specific question. Mild anxiety includes feelings of worrying and apprehension. Expressing a negative concern about their ability to complete the hip exercises after surgery is an example of moderate anxiety. The client is worrying about the hip exercises which is causing an increase in the anxiety level. The client is worried about the surgeon cutting on their hip. The physical action of cutting the hip is very troubling for the client. The client's continuous worrying is causing the client to have decreased ability to concentrate. This action indicates an increase in their anxiety level to severe. The client is expressing panic anxiety with the statement of feelings of impending doom. If the client's father had died on the "operating table", then there is a possibility that the client will also die during the surgery.

A client who is sitting in a chair begins to have a tonic-clonic seizure. In what order should the nurse intervene? 1. Position client on side. 2. Administer prescribed antiepileptic medication. 3. Push aside any furniture. 4. Ease client to the floor.

4,1,3,2 When a client has a seizure, the priority is safety. The nurse must protect the client from injury. This client is sitting in a chair when the seizure occurs. So, the first action by the nurse would be to ease the client to the floor. Otherwise, the client could fall. Second, the nurse should position the client onto the side. This will protect the client's airway. With the client on their side, the risk of aspiration is decreased, and the tongue will not become an obstruction. Third, move furniture out of the way. During a seizure, the client's extremities may move around violently striking furniture near. After making certain the client is safe, administer any prescribed antiepileptic medications. This is usually prescribed when a seizure lasts longer than 2 minutes.

n what order should the nurse assess assigned clients following shift report? Place in priority order. 1. Client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. 2. Client two days post thyroidectomy who has a negative Trousseau's sign. 3. Client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22. 4. Client diagnosed with Addison's disease who is lethargic and has a BP of 86/48, P 120, and R 24.

4,2,3,1 All these clients have an endocrine problem. So, now you must decide in what order to assess each of these clients. The first client the nurse needs to assess is the client diagnosed with Addison's disease who is lethargic and has a BP of 86/48, P 120, and R 24. Do you see shock (Addisonian Crisis)? You should. This BP is too low. You don't even have to know anything about Addison's disease to know this client is critical and could die if intervention is not rapid. The second client the nurse needs to see is the client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. The client's airway is stable since the client is intubated, however, the nurse needs to monitor this client frequently to ensure the airway remains patent. The third client that should be assessed by the nurse is the client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22. Look at these blood gases. Normal. What is iatrogenic? Caused by medical treatment: symptoms, ailments, or disorders induced by drugs or surgery. Most likely this client developed Cushing's due to steroid administration for the cancer. The fourth client the nurse should assess is the client two days post thyroidectomy who has a negative Trousseau's sign. A negative Trousseau's is a good thing. This client is stable two days postop.

Four clients arrive for their appointment at a diabetic clinic. In what order should the nurse see the clients? 1. Client scheduled for a dressing change to foot ulcer. 2. Client eating a simple-carb snack due to weakness. 3. Client to receive dietary education. 4. Client reporting a headache and has a fruity breath.

4,2,3,1 The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. Remember, pick the killer answer first! This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). What was the hint? Fruity breath. The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. This is a diabetic clinic. This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. The third client would be the one needing a dressing change. Nothing life threatening, but an assessment needs to be made regarding the ulcer. The last client would be the one needing dietary education. Nothing life threatening. This client can wait until the others are treated.

Which clients would be appropriate for the RN to assign to the LPN/VN? Select All 1. A client admitted for lithotripsy. 2. A client diagnosed with severe anemia. 3. A client with partial thickness burns over 35% of the body. 4. A client diagnosed with cystitis who has been prescribed antibiotics intramuscularly. 5. A client who needs enemas to decrease bacteria in the GI tract.

4,5

The nurse asks if the client has an advance directive. The client responds by saying, "What is an advance directive?" What is the nurse's best response to the client's question? Select all that apply 1. Specifies your wishes regarding your personal effects and finances should you become unable to make decisions. 2. Specifies your wishes regarding healthcare and your finances should you become incapacitated. 3. Similar to a will, it specifies your wishes for burial should you die during hospitalization. 4. Specifies your wishes regarding healthcare and treatment options should you become incapacitated. 5. The person signing the advanced directive must be competent.

4. & 5. Correct: An advance directive is a legal document prepared by a competent individual that specifies what treatments, if any, the client desires should the client become incapacitated or unable to make informed healthcare decisions in the future. The person signing the advance directive must be able to understand and agree with the document. 1. Incorrect: An advance directive does not address client personal effects and finances. These might be included in a last will and testament but are not part of an advance directive. 2. Incorrect: An advance directive does not address client personal effects and finances. These might be included in a last will and testament but are not part of an advance directive. 3. Incorrect: An advance directive does not address burial wishes.

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. Slightly swollen eyelid 2. Slight discomfort of the eye 3. "Bloodshot" 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.

The emergency room nurse is assessing a client reporting severe abdominal pain for several hours prior to arrival at the hospital. Assessment findings include slight mottling of the lower extremities and a pulsating mass near the umbilicus. Which actions should the nurse implement immediately? Select all that apply 1. Position client on the left side. 2. Apply warm blankets to legs. 3. Administer I.M. pain medication. 4. Alert the operating room staff. 5. Notify the primary healthcare provider. 6. Palpate mass to determine size.

4. & 5. Correct: The client's symptoms indicate the presence of an aortic abdominal aneurysm that may be dissecting (rupturing) at this time. This is a life-threatening emergency and the client will need urgent surgery to survive. The nurse should immediately notify the healthcare provider and alert the operating room staff of impending surgery. 1. Incorrect: These are the classic symptoms of a dissecting abdominal aneurysm, a life-threatening situation requiring immediate surgery. Positioning the client on either side is contraindicated as that action may cause further internal bleeding, complete rupture of the aneurysm, or death. 2. Incorrect: Mottling of lower extremities accompanied by severe abdominal pain suggests a dissecting abdominal aneurysm. The discoloration of lower extremities indicates compromised circulation secondary to interrupted blood flow because of the aneurysm. This client would not benefit from warm blankets but rather needs immediate surgery to survive. 3. Incorrect: Pain medications in general are not administered until an exact diagnosis is confirmed, since relieving pain would mask those signs or symptoms needed to verify the problem. While the client may be given medications at some point, this is not the life-saving action the nurse must take immediately. 6. Incorrect: The client's symptoms are suggestive of a dissecting abdominal aneurysm, a life-threatening emergency requiring immediate surgical intervention. It is never acceptable for the nurse to palpate an abdominal mass, particularly a pulsating mass, since this would likely cause complete rupture of the blood vessel and immediate death.

The nurse is evaluating an elderly bedridden client for possible fecal impaction. What sign/symptom should the nurse report as most indicative for a fecal impaction? 1. Rigid, board-like abdomen 2. Absence of any bowel sounds 3. Diarrhea with severe cramping 4. Constipation with liquid seepage

4. CORRECT. A client may have several symptoms with a fecal impaction; however, the most classic symptom which the nurse should report is the presence of constipation in the presence of liquid fecal seepage from the rectum. The client may also report abdominal distention with a feeling of fullness, cramping or even painful defecation. 1. INCORRECT. Although the client may report abdominal pain, a rigid, board-like abdomen is indicative of peritoneal inflammation such as peritonitis. As pain increase, the abdominal muscles respond by becoming rigid, hence giving the board-like appearance. 2. INCORRECT. A complete absence of bowel sounds is indicative of other bowel issues, such as a paralytic ileus, which occurs when peristalsis has completely stopped. That is not the case with an impaction. 3. INCORRECT. Diarrhea, especially with cramping, may be attributed to a variety of illnesses, including gastroenteritis, Crohn's disease or even ulcerative colitis. Additionally, diarrhea is not the same as liquid seepage.

Dietary teaching has been initiated for a client newly diagnosed with acute diverticulitis. The nurse knows that further instruction is necessary when the client makes what statement? 1. "I must include a lot of fluid in my daily routine." 2. "I need to take my antibiotics at the same time daily." 3. "Rest and mild exercise are important for my recovery." 4. "Decreasing fiber in my diet can help prevent recurrences."

4. CORRECT. Diverticula are small, bulging pouches that can form in the lining of the digestive system, most often the lower portion of the colon. Diverticulitis is an inflammation in those pouches, which fill with retained material causing infection and inflammation. To diminish the chances of an exacerbation, the client is taught to increase fiber in the diet. This client's comment indicates the need for further instruction. 1. INCORRECT. A client with diverticulitis needs large quantities of fluid daily to prevent dehydration and to avoid possible bowel blockage. Sluggish bowels also increase the potential for bacterial growth and a recurrent infection. This statement is accurate and does not require additional teaching. 2. INCORRECT. Most clients hospitalized with diverticulitis will continue to take oral antibiotics for a period of time after discharge. Consistency with medication is always important to maintain adequate blood levels of the antibiotic. The client has made an accurate statement so no further teaching needed. 3. INCORRECT. Once the client is discharged home, rest will be important to recovery. However, a mild form of daily exercise, such as short walks, can help with recovery by boosting the body's own immune system. It is obvious the client comprehends the nurse's teaching and will not require further instruction here.

An Orthodox Jewish client receives the following lunch tray. What is the nurse's priority action? Exhibit: Spaghetti and meatballs in sauce Tossed salad with vinegarette dressing Hot rolls with butter Fruit cocktail Milk - coffee 1. Nothing, since this is a healthy and acceptable lunch. 2. Ask the client to eat the acceptable food and leave the remaining food on the tray. 3. Remove the tossed salad so the client can eat the rest. 4. Call dietary to provide an acceptable meal for the client.

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

The nurse is developing the plan of care for a newly admitted client diagnosed with schizophrenia. What goal would the nurse consider a priority for this client? 1. Schedule alone time for client to relax. 2. Frequently reorient the client to surroundings. 3. Encourage participation in all social activities. 4. Assign same staff to provide client care daily.

4. CORRECT. Schizophrenia is a group of psychotic disorders characterized by thought disturbances, bizarre behaviors and social withdrawal. Because of the numerous emotional and psychologic dysfunctions, there are many possible goals. However, the priority objective is to help the client develop a trusting relationship in order to achieve other goals. Assigning the same staff to provide care daily is the first step toward that objective. 1. INCORRECT. Clients with schizophrenia tend to self-isolate due to paranoid thoughts or hallucinations. Social withdrawal is a problem with these individuals and should not be encouraged by the nurse. Relaxation is not a priority goal for this client. 2. INCORRECT. This client was just admitted with schizophrenia. Getting this disorder under control will take some time, requiring both medications and therapy. Reorienting the client to the surroundings frequently is important but not the priority at this time. 3. INCORRECT. During the initial treatment period, the client may display hostility or angry, defensive behaviors which make group activities inappropriate. Eventually the client can be encouraged to participate in reality-based events but not in this early phase.

A client awaiting discharge for a broken left tibia is to be sent to physical therapy for crutches and crutch walking. The client reports having brought a pair of crutches borrowed from a family member. What is the most appropriate action for the nurse to take now? 1. Cancel physical therapy and allow client to leave. 2. Ask client to stand with crutches to check the size. 3. Tell client insurance will not permit use of old crutches. 4. Send client with crutches to physical therapy for evaluation.

4. CORRECT. The physical therapy department is best qualified to assist a client in adjusting to the use of crutches prior to discharge. Because the client wants to use older crutches, it is even more important for a physical therapist to determine whether it is safe for the client to do so. Physical therapy can evaluate the condition of the old crutches, the client's ability to manage that equipment and to walk safely with those crutches. 1. INCORRECT. It is permissible for a client to use previously owned medical equipment. However, the stability of that equipment and the client's ability to use the equipment safely must be evaluated by physical therapy. Cancelling physical therapy would also violate the physician's orders and place the client at risk for injury upon discharge. 2. INCORRECT. While the nurse may be able to adjust the old crutches to the client's height, crutch safety and walking should be evaluated by physical therapy to be certain the previous equipment is appropriate. 3. INCORRECT. Insurance does not designate whether assistive medical devices can be reused by clients or if a new device must be purchased. It is cost effective to reuse durable medical equipment if it is appropriately suited to the client's current needs.

The nurse is instructing expectant first-time mothers about the process of rooming-in while at the hospital. After discussing security protocols, one client asks the nurse what to do if no staff is available when toileting or showering assistance is needed. The nurse knows teaching was successful when another client responds with what statement? 1. "Only hand the baby to individuals wearing proper hospital I.D." 2. "Ask family member to watch infant while you're in the bathroom." 3. "Showering is not necessary since discharge is within 24 hours." 4. "Push baby in bassinet with you into bathroom if no one available."

4. CORRECT. There are many safety and security measures implemented to diminish the potential for newborn abductions. At no time should a newborn ever be left alone, even in the mother's room. In the unlikely event no authorized staff can assist the client in the bathroom, the newborn should be wheeled by the mother into the bathroom and kept in view at all times. 1. INCORRECT. The wearing of an official facility identification badge does not guarantee security or even whether the individual is actually an employee. Because of the potential for fake I.D.'s, the newborn should never be handed to anyone just because they are wearing facility identification. 2. INCORRECT. Having to rely on family anytime the mother needs to use the bathroom is impractical and inconvenient since family may not always be present or available. The mother and infant are the responsibility of staff. A more timely solution is needed. 3. INCORRECT. Not all mothers are discharged within 24 hours, depending on the mode of delivery and condition of the client. More importantly, length of time in facility does not negate the mother's right to have a shower any time if prescribed.

A homecare client with terminal cancer is taking morphine sulfate and reports the current dose is no longer relieving the pain. What would the nurse tell the client about the increased discomfort? 1. The pain medication will need to be taken consistently around the clock. 2. A different pain medication will need to be prescribed since addiction has occurred. 3. As the cancer spreads, the pain medication will no longer help. 4. A tolerance to the current dose has occurred, so the dose will need to be increased.

4. CORRECT. Tolerance occurs when a client no longer experiences the same effect from a specific dose of medication and requires a larger dose to achieve the desired effect. The client has been using morphine for pain control and is no longer experiencing the same level of relief. This is an expected result of long term use with certain medications. 1. INCORRECT. While inconsistent scheduling of medication doses can cause blood levels of the morphine to fluctuate, it is unlikely this client would skip or miss a dose to treat on-going cancer pain. 2. INCORRECT. Addiction is a behavioral/physical compulsion to utilize a particular drug regardless of its negative consequences, side effects, cost, loss of family, friends and employment. An addicted individual craves the drug both psychologically and physically, and does not use the medication for its intended purpose. 3. INCORRECT. As pain worsens and the intolerance to the morphine increases, the dosage can also be increased so that the client does not suffer in pain.

A client is seen at the clinic two weeks after starting amitriptyline. The client reports improved sleep patterns and appetite, but no change in feelings of sadness or depression. What comment by the nurse is most appropriate? 1. "Would you like me to ask the doctor to increase your dose?" 2. "You might need to be changed to a different medication." 3. "Tell me what type of situations make you feel depressed." 4. "Some medications take a little longer to improve moods."

4. CORRECT. Tricyclic antidepressants such as amitriptyline often take three to four weeks before the client experiences maximum benefit. The medication has already begun to alter some of the client's symptoms as evidenced by reports of better sleep patterns and improved appetite. The nurse is both reassuring and educating the client about the medication. 1. INCORRECT. Asking the client about an increase in medication dosage is not appropriate since the client is not knowledgeable about the drug actions. The nurse should determine what, if anything, to discuss with the primary healthcare provider after client assessment. 2. INCORRECT. The client has only been taking amitriptyline for two weeks and acknowledges some signs of improvement already. It is premature to assume another medication would be needed. 3. INCORRECT. Though the nurse is presenting an open-ended statement regarding the client's on-going symptoms of depression, this comment focuses on the negative rather than the positive effects occurring with this medication.

A school-aged child is being admitted for probable viral meningitis. What arrangement does the nurse need to make in order to prepare for this client? 1. Private room. 2. Negative air-flow room. 3. Droplet precautions including mask. 4. Needs standard precautions only.

4. CORRECT. Viral meningitis is caused by a group of enteroviruses, such as those that also cause mumps or measles. School-aged clients generally fare better than very young children or infants. The Center for Disease (CDC) has determined that standard precautions are adequate for older children and adults. 1. INCORRECT. A private room would be appropriate for bacterial meningitis and other highly contagious illnesses. This is not needed in the case of viral meningitis. 2. INCORRECT. Negative air-flow is needed for serious illnesses such as active tuberculosis, SARS, Ebola or even certain types of chickenpox. Such a room would not be necessary for viral meningitis. 3. INCORRECT. If there is close contact with a person who has viral meningitis, you may become infected with the virus that made that person sick. However, you are not likely to develop meningitis. That's because only a small number of people who get infected with the viruses that cause meningitis will actually develop viral meningitis. Standard precautions is the best way to prevent this virus.

A client returns from post anesthesia care unit (PACU) following a mastectomy with a Jackson-Pratt drain in place. What action by the nurse is important? 1. Empty drain every eight hours. 2. Irrigate drain with NS every shift. 3. Drape tubing above breast incision. 4. Empty and compress bulb when 2/3 full.

4. CORRECT: A Jackson-Pratt drain is not connected to wall suction, but instead uses gravity and compression to create suction. For maximum efficiency, the bulb must be emptied at only 2/3 capacity. If the bulb becomes filled, suction fails, and fluid will build up in the tissues, possibly leading to wound dehiscence. 1. INCORRECT: The purpose of a surgical drain is to prevent the buildup of fluid under the incision, thus decreasing the chance of dehiscence. Emptying the drain is based on the amount of fluid in the bulb, not timed by shift. 2. INCORRECT: A drainage device connected to the body is meant to pull liquid from inside the body, and therefore is never irrigated. Doing so would increase the chance of infection, even if using sterile normal saline. Pushing fluid into a drain could damage the incision, or even lead to dehiscence. 3. INCORRECT: Any drain or tubing inserted into the body should always be draped below that area or system of the body to improve gravity drainage. The tubing of the Jackson-Pratt drain must hang below the level of the incision.

A 20 year old client has been admitted to the hospital with a diagnosis of preeclampsia. The charge nurse has only semiprivate rooms available. What roommate would be most appropriate for this client who is being admitted? 1. An adolescent primigravida with many visitors. 2. A 25 year old post induction for fetal demise. 3. A 35 year old awaiting discharge after a total abdominal hysterectomy (TAH). 4. A 30 year old post dilation and curettage (D&C) who enjoys knitting.

4. CORRECT: A client with preeclampsia will be experiencing stress and elevated blood pressure. There is a risk of seizures, and therefore a calm, relaxed environment would provide the most therapeutic setting for the client. The 30 year old client is ideal because knitting is a quiet activity. Additionally, a D&C is a relatively uncomplicated procedure and this client will most likely soon be discharged, leaving the preeclampsia client alone in that room. 1. INCORRECT: Although the client is close in age to the adolescent, the teenaged primigravida has many young visitors which would create noise or confusion in the environment. Since this client is suffering from preeclampsia, a quiet environment is necessary to prevent other complications such as seizures. This adolescent would not be the best roommate. 2. INCORRECT: The client is admitted with a diagnosis of preeclampsia, which means elevated blood pressure, edema and the possibility of seizures. A quiet calm environment would be crucial for this client. The 25 year old client is close in age; however, that client has experienced a fetal demise and delivery of that fetus. There will most likely be grieving, multiple family members, and tension in that environment which would not be helpful to the client with preeclampsia. 3. INCORRECT: Though there is a large age difference, that issue does not impact whether this client would be an appropriate roommate. A client with preeclampsia needs a restful, calm environment to prevent further complications. Depending on the reason for the total abdominal hysterectomy (TAH), this client may require special teaching, referrals for further care and treatment, or emotional support for an unexpected diagnosis. The charge nurse knows this may be too hectic of an environment for the client with preeclampsia.

The nurse is reviewing a safety contract with a client who is suicidal. However, the client declines to sign the safety contract at this time. What action must the nurse take? 1. Check that all windows are locked and the doors secured. 2. Secure the room by removing potentially harmful objects. 3. Place client in a chair at nursing station until contract is signed. 4. Assign a staff member to stay with client, even in the bathroom.

4. CORRECT: A safety contract states the client will not do any self-harm in a specified length of time or without calling the nurse. If there is a refusal to sign such a contract, the client cannot be alone even when using the bathroom. Safety is always the priority concern for a suicidal client. 1. INCORRECT: Although facilities have specific safety precautions for doors and windows, it violates fire safety codes to lock exits. There is no indication this is a psychiatric facility but safety regulations apply to all client facilities. 2. INCORRECT: It is impossible to "secure" any room completely. If a client wishes to bring self-harm, any object can become lethal, even a soft pillow. 3. INCORRECT: Placing a client in a chair for an unspecified length of time is punitive and verges on abuse. This client may never sign a safety contract. Also, the chaos of the nursing station could further upset the client.

A terminal client begins reminiscing about the past, expressing grief and regret over life choices. What response by the nurse would best help the client cope at this time? You answered this question Correctly 1. "You can't change the past so try not to dwell on it." 2. "Would you like me to call a priest for you to talk with?" 3. "You still have time to make amends if you want." 4. "I can sit here with you while you continue to talk."

4. CORRECT: Anytime a client expresses the desire to talk, the nurse should respond with an open-ended response, encouraging the client to continue to verbalize in a non-judgmental environment. More importantly, the nurse should remain with the client, even if there is no talking, to provide visual comfort. 1. INCORRECT: This non-therapeutic response denies the client's right to review past events or express feelings, which is a normal reaction at end of life. The nurse's closed response does not provide the client with the opportunity to verbalize. 2. INCORRECT: The nurse is ignoring the client's need to talk and is transferring care away to another individual, even if that individual is a clergyman. This is an incorrect action. 3. INCORRECT: While the client may regret some life choices, there is no mention of the desire or need to correct the past. The nurse is making an assumption.

A client with a history of deep vein thrombosis (DVTs) is being instructed on how to apply compression stockings prior to discharge. What statement alerts the nurse the client may be noncompliant when at home? 1. "I will follow the special diet in order to lose weight." 2. "I should walk a little every few hours after sitting." 3. "My husband can help remind me not to cross my legs." 4. "The stockings are too difficult to put on every morning."

4. CORRECT: Compression stockings are used to prevent the formation of blood clots, reduce the diameter of distended veins and decrease stasis. Usually these stockings are ordered to be applied upon rising in the morning and removed at night, depending on the disease process. The client's comment suggests the difficulty of putting the hose on may lead to not wearing the stockings consistently. 1. INCORRECT: This statement by the client indicates a positive attitude about the need to lose weight and the intention of following the prescribed diet. Obesity is one of several main factors that can lead to the development of DVTs. 2. INCORRECT: Prolonged sitting, or even lying down, can increase the incidence of blood clots or DVTs. If the client does a lot of sitting during the day, it is advisable to walk around every few hours to reduce stasis. The client is acknowledging the need to increase mobility regularly, which is an indication of compliance. 3. INCORRECT: Placing pressure directly on vessels by crossing the legs compresses both veins and arteries, thus increasing the potential for blood clots or dislodging an unknown clot. The client has acknowledged the need to keep legs uncrossed and the benefit of having family provide reminders.

A client is to be discharged following treatment for hepatitis A. The nurse knows teaching was successful when the client makes what statement? 1. "I should never eat fresh salad in a restaurant." 2. "I must wait two years before traveling abroad." 3. "I will need blood work once a month for a year." 4. "I will be able to donate blood when I am well."

4. CORRECT: Hepatitis A is a virus acquired from food or water contaminated with fecal material, causing inflammation in liver cells. Though some antibodies will remain in the blood permanently, an individual can donate blood once fully recovered from the illness. 1. INCORRECT: Hepatitis A can be spread in several ways, including ingestion of food or drink that is contaminated with fecal material. However, there is no need to avoid fresh salad or vegetables from a reputable restaurant where food is appropriately and safely prepared. 2. INCORRECT: Hepatitis A generally resolves within a few weeks, sometimes without any treatment. Even if the illness was acquired while traveling, there is no need to avoid overseas travel once the client has recovered. 3. INCORRECT: Hepatitis A shows symptoms in 2 to 4 weeks, and the client is usually recovered within several weeks or a month. Though the primary healthcare provider may check blood work for the presence of specific antibodies, the client does not need monthly bloodwork for a year.

A client arrives at the crisis center and reports stopping daily lithium because of pregnancy. What response by the nurse is most accurate? 1. "Are you positive that you are actually pregnant?" 2. "Lithium is perfectly safe throughout pregnancy." 3. "The psychiatrist can change you to another medication that is safe." 4. "It may be worse to suddenly stop the medication than to take the medication."

4. CORRECT: Lithium is most often used to treat manic-depression. Suddenly stopping the medication could cause the client to relapse, experiencing worse symptoms than previously. It may also be more difficult to get those symptoms under control again if the client has stopped this drug suddenly. The client and primary healthcare provider would need to weigh the benefits of the medication vs the possible birth defects attributed to the use of lithium during pregnancy. 1. INCORRECT: While this is a valid question by the nurse, there is a greater concern at this point. The client's pregnancy status can be verified at any time. 2. INCORRECT: This statement by the nurse is not correct. Specific birth defects have been attributed to the use of lithium during pregnancy. 3. INCORRECT: The psychiatrist would need to be notified that client has stopped the medication. However, there are very few medications for bipolar disorder that would also be completely safe during pregnancy.

The pediatric nurse is assessing a child following an appendectomy. What is the nurse's main priority following surgery? 1. Obtain vital signs every four hours. 2. Assess the need for pain medication. 3. Tally intake and output every eight hours. 4. Auscultate lung sounds every four hours.

4. CORRECT: No matter what type of surgery, recall that the effects of anesthesia and intubation, if performed, can lead to complications, particularly in children. The potential for atelectasis and pneumonia follows surgery; therefore the client is encouraged to cough and deep breathe to minimize these risks. Auscultating lung sounds frequently post-op is crucial. 1. INCORRECT: Although vital signs are important, initially the nurse should check vitals every half hour to one hour. Despite the frequency, another assessment is even more important. 2. INCORRECT: It is crucial to medicate a post-operative client; however, pain medications should never be administered until after the initial assessment as pain medication will alter important symptoms the nurse needs to determine any complications. 3. INCORRECT: Standard intake and output is tallied once a shift, or every eight hours. Though this information is vital to determine hydration and function of the kidneys, it is not the nurse's main priority.

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

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

A client scheduled for an amniocentesis expresses concerns about the procedure to the nurse, despite having signed the consent form. What statement by the nurse would be most appropriate for the client? 1. "Don't worry, it's a very simple procedure." 2. "You have already signed the consent form." 3. "I will tell the doctor you need to talk more." 4. "Can you tell me what most concerns you?"

4. CORRECT: The client is obviously having second thoughts and needs further clarification or discussion. Even though a consent form was signed, the client has the legal right to withdraw that consent at any time. This open-ended question by the nurse is an appropriate approach to encourage the client to express concerns, allowing the nurse to gather further information and formulate a suitable plan to proceed. 1. INCORRECT: A nurse should not use the words "don't worry" to a client. Doing so dismisses both the client's feelings and the right to request further information. This is not a "very simple procedure", and has definite, potentially serious complications. This comment by the nurse does not employ any appropriate therapeutic communication techniques. 2. INCORRECT: This comment by the nurse is not true, since a client can withdraw consent for a procedure at any time, including just before the actual procedure. The client is expressing concerns about the amniocentesis now. "Patient Rights" always assure clients the ability to question any and all proposed treatments at any time. 3. INCORRECT: Since the client needs more information, it would be important to notify the primary healthcare provider. However, it is not appropriate on the NCLEX to transfer care of the client to someone else initially. The client is anxious and worried; therefore, the nurse should use therapeutic communication techniques to encourage the client to talk.

client scheduled for an amniocentesis expresses concerns about the procedure to the nurse, despite having signed the consent form. What statement by the nurse would be most appropriate for the client? 1. "Don't worry, it's a very simple procedure." 2. "You have already signed the consent form." 3. "I will tell the doctor you need to talk more." 4. "Can you tell me what most concerns you?"

A client with a history of angina has returned to the unit following a cardiac catherization. What nursing action has the highest priority? 1. Obtain vital signs every thirty minutes. 2. Assess pedal pulses every ten minutes. 3. Place the call bell within client's reach. 4. Keep affected extremity immobilized for 6 hours.

4. CORRECT: The greatest risk following a cardiac catherization is the potential for hemorrhage, most often from the insertion site. Therefore, the affected extremity must remain straight and immobilized for 4-6 hours after the procedure. 1. INCORRECT: The frequency of vital signs is determined by facility protocol, but generally vital signs are obtained every ten minutes for the first half hour, then every fifteen minutes for another half hour. While vital signs provide valuable information to compare to baseline, another action is more important. 2. INCORRECT: It is vital to assess pedal pulses in order to verify circulation following a catherization. The frequency is based on facility protocol. However, this action is not the highest priority. 3. INCORRECT: Because the client is on bed rest, it is crucial for the client to be able to summon staff when needed. Despite the importance of this action, there is an even more important action.

Prior to removal of cataracts, the client is to receive eye drops in both eyes. The nurse knows what action takes priority? 1. Remove any exudate around eyes with warm water. 2. Instill exact number of drops into lower conjunctival sac. 3. Instruct client to look upward when drops are instilled. 4. Avoid dropping the medication directly on the cornea.

4. CORRECT: The most important safety consideration when instilling eye drops is to avoid dropping the medication directly onto the cornea. The extreme sensitivity of the cornea before, and after, eye surgery could cause serious eye problems if meds were dropped onto the cornea. 1. INCORRECT: It is important to clean away any exudate prior to instilling eye drops to maintain aseptic technique and decrease chance of infection. Though this is an important action, there is another task which takes priority. 2. INCORRECT: Instilling the exact number of drops is appropriate when implementing written prescriptions from the primary healthcare provider. This is an important nursing action but not the priority. 3. INCORRECT: Instructing the client to look upward helps prevent drops from running out of the eye but there is another issue more important.

A preschool child has been rushed to the emergency room after ingesting an undetermined amount of chewable baby aspirin. What action should the nurse take immediately? 1. Inject subcutaneous dose of vitamin K. 2. Induce vomiting with ipecac. 3. Initiate large bore IV line. 4. Insert a nasogastric tube.

4. CORRECT: The most urgent need in an overdose situation is to neutralize or inactivate the drug and/or poison. Activated charcoal is the treatment of choice for aspirin. In a child this young, the only way to instill the charcoal is via NG tube, which will also decrease the chance of aspiration. 1. INCORRECT: Vitamin K is used as an antidote to reverse the effects of excessive warfarin. Although Vitamin K is used to decrease bleeding, it is not an appropriate or effective intervention for baby aspirin. 2. INCORRECT: Inducing vomiting with syrup of ipecac is no longer considered an acceptable intervention for poisoning. Inducing vomiting increases the chance for aspiration and electrolyte imbalances. 3. INCORRECT: Although an IV site will be important for fluid resuscitation, initiating an intravenous line is not the nurse's first priority.

The nurse is presenting a seminar to expectant teen parents regarding infant car seat safety. What statement from a teen parent indicates to the nurse that teaching was successful? 1. "It's okay to place the car seat up front as long as it faces backwards." 2. "The baby has to stay rear facing until at least 40 pounds or 40 inches." 3. "Regular seat belts can be used if the child does not like the booster seat." 4. "An infant must stay in the backseat, facing backward, till at least a year old."

4. CORRECT: The nurse is looking for a statement that indicates the teen parents understand the proper use of infant car seats. Although there are some variations from state to state, the National Safety Council advises that infants should be in a rear-facing car seat in the back seat of a vehicle until at least age one year. This comment indicates the parents understand the teaching clearly. 1. INCORRECT: An infant or child car seat can never be placed in the front seat at any time, regardless of what direction it may face. Further teaching is definitely indicated. 2. INCORRECT: A child of 40 pounds or forty inches is of pre-school age, usually around 3 to 4 years old. This is too old for a rear-facing car seat. The issue of height and weight is more useful when determining whether a child can safely move from a car seat to a booster seat. The parents did not understand the instruction. 3. INCORRECT: The choice of booster seat versus regular car seat belts is not based on whether the child likes, or is comfortable, in using either type of restraints. The most accepted guideline for child safety is that children under the age of 8 years old should be in either a child's car seat or booster seat. Further teaching is needed.

An elderly client is to be ambulated for the first time following a hip replacement. The client refuses to get out of bed, indicating an extreme fear of falling. What statement by the nurse is most therapeutic? 1. "Don't be afraid because I will not let you fall." 2. "Your doctor says you must walk twice today." 3. "I'll get another nurse to help so you won't fall." 4. "What worries you most about getting out of b

4. CORRECT: The nurse needs to focus on the client's psychological as well as physical needs. An open-ended question or statement encourages the client to elaborate and share concerns that the nurse needs to address. It would be inappropriate to force the client to participate in an activity that causes extreme fear and distress. 1. INCORRECT: The nurse is dismissing the client's right to experience a specific emotion, rather than actively seeking the reason behind those feelings. The nurse is not utilizing appropriate communication techniques. 2. INCORRECT: This tactless response focuses on the orders provided by the primary healthcare provider, rather than the client's expressed concerns. Such a comment by the nurse is non-therapeutic because it ignores the client's psychological needs. 3. INCORRECT: Although the nurse offers a solution to the client, there is no chance for the client to verbalize feelings and concerns. It is more important to present the client with the therapeutic opportunity to discuss fears.

Two cognitively impaired siblings are clients in the same hospital room. During rounds, the nurse notes they have removed identification bracelets. Because of similar appearance, the nurse is unable to identify the correct client for blood work. What would be the most reliable method for the nurse to use to properly identify these clients? 1. Draw blood to type and crossmatch and compare with chart. 2. Call the primary healthcare provider to identify each client. 3. Ask nurses on the next shift to try to identify the clients. 4. Notify family to come in and identify clients in person.

4. CORRECT: The only way to definitely identify a client with no identification bracelet who is unable to identify self is to have immediate family verify the client in person. When the family member arrives and verifies the client, the hospital must apply a new ID bracelet in the presence of the family for added security. 1. INCORRECT: Even typing and cross-matching to determine the blood type does not guarantee a correct identification. Additionally, both clients may have the same type blood since they are siblings. 2. INCORRECT: A primary healthcare provider would not necessarily be able to identify a specific client. Having hundreds of clients would make it more difficult to remember individuals correctly. It is unlikely that the healthcare provider could correctly indicate which client needed blood work. 3. INCORRECT: This is the least effective approach to properly identify the clients. Certainly, nurses spend more time with clients than other healthcare individuals, but asking another nurse to make this type of identification is still extremely risky and unreliable.

Two days after a client has a chest tube inserted, the nurse notes constant bubbling in the water seal chamber. What action should the nurse take? 1. Do nothing since this is normal. 2. Decrease the amount of suction. 3. Replace CDU unit with another one. 4. Notify primary healthcare provider.

4. CORRECT: The water seal chamber is the middle of the three chambers and helps to create the one-way flow of drainage and air from the client to the CDU. The water seal chamber should bubble only intermittently when the client coughs, sneezes or breathes, creating a fluctuation of the water known as "tidaling". Constant bubbling in that chamber indicates an air leak somewhere in the system. Because the nurse cannot fix this independently, the primary healthcare provider must make that determination. 1. INCORRECT: The water seal chamber helps create the one-way flow of drainage and air from the pleural space to the CDU. Constant bubbling in that chamber is not normal. 2. INCORRECT: Constant bubbling in the water seal chamber is not controlled by the amount of suction. Decreasing suction would not alter the type of bubbling in the middle chamber. 3. INCORRECT: Though the nurse may discover damage to the CDU unit itself, simply replacing the unit with a new one may not correct the problem in the water seal chamber.

A nurse has received morning report on multiple clients. What client should the nurse assess first? 1. Client on 2/L min, of oxygen by nasal cannula with pneumonia. 2. Client with Crohn's disease reporting two semi-loose stools. 3. Client one day post-appendectomy reporting abdominal cramps. 4. Client on heparin drip reporting bleeding gums when brushing teeth.

4. CORRECT: This client is currently on a heparin drip, possibly for a DVT. Bleeding gums sometimes occurs in those who brush teeth too vigorously; however, bleeding in a client on a heparin drip could indicate a serious side effect. This client should be seen immediately. 1. INCORRECT: It is not unusual for a client with pneumonia to need supplemental oxygen by nasal cannula and 2L/min, is a very small amount. Although this client will definitely need a respiratory assessment, there is no indication that any complications are occurring. This client is not a priority. 2. INCORRECT: Crohn's disease is an auto-immune process in which inflammation of the large and small bowel causes pain and diarrhea. Reporting loose stools would not be unexpected for this client; therefore, this client would not need to be the first assessment. 3. INCORRECT: One-day after an appendectomy, it would not be unusual for a client to have some abdominal pain or cramping. Although the nurse will need to assess for bowels sounds and inspect the dressing, this client is not a priority.

A client being treated for major depressive disorder arrives at group therapy for the first time in a week wearing clean clothes after showering. What response by the nurse would be therapeutic? 1. "Why are you all dressed up for group?" 2. "Maybe you could add makeup tomorrow." 3. "You must feel better after finally showering." 4. "You look really nice in that flowered jacket."

4. CORRECT: When a depressed client has a sudden change in behavior or attitude, the nurse must cautiously evaluate any meaning behind such abrupt behavior. The best way to proceed is to engage the client in an interactive conversation by utilizing therapeutic techniques. This nursing comment provides positive affirmation of the client's actions by drawing attention to the choice of clothing. Open-ended statements provide a safe environment for building rapport and client interaction. 1. INCORRECT: Demanding an explanation for behavior is always non-therapeutic. Most often, the client will have no response or even understanding of the behaviors and can become frustrated trying to respond. Additionally, this question could be interpreted as disapproving of the clothing, causing the client to return to previous behaviors. 2. INCORRECT: The nurse is suggesting the client's attempts to improve self are less successful by inferring that makeup should be applied. This comment is not therapeutic, nor does it acknowledge the positive initial actions taken by the client. Rather than encouraging, such a response by the nurse is negative and not constructive. 3. INCORRECT:. While this statement does acknowledge the client has showered, the word "finally" has a negative connotation, suggesting the client has neglected personal care for an unacceptable amount of time. Such a comment by the nurse is non-therapeutic and discourages communication.

A client is brought to the after hours clinic with a stab wound to the left leg, reporting it as "accidental". The nurse notes the odor of alcohol and marijuana on the client. The nurse is aware that client privacy rights do not apply to what action? 1. The right to refuse photos of the wound. 2. The right to refuse a blood alcohol test. 3. The right to refuse a tetanus injection. 4. The right to refuse police notification.

4. CORRECT: When an individual sustains a stab wound, even if self-inflicted, medical personnel are required to notify the police or proper authorities in that jurisdiction. Each facility determines the proper procedure for reporting gunshot or stab wounds, but the injury must be reported immediately while the client is still in the clinic. 1. INCORRECT: A client has the right to refuse to have photographs taken by medical personnel, regardless of the circumstances. Even if the primary healthcare provider determines the client is presenting with "a rare disease", pictures remain within the client's right of refusal. This can be an issue, especially in surgical situations, if the client has not given permission prior to the procedure. 2. INCORRECT: A blood alcohol level can be requested by police or legal authorities, but in most cases, the client retains the right to refuse that blood work. However, there may be legal implications of refusing the test, including immediate arrest, so the client needs to be informed of those implications. 3. INCORRE

The nurse discovers that a client was given the wrong medication. After verifying the client is stable, an incident report is completed. What is the proper disposition of the report? 1. Send a copy of the report to the primary healthcare provider. 2. Notify the State Board of Nursing about the incident report. 3. Document that a report was completed on the client's chart. 4. Give the report to the hospital's risk management team.

4. Corect: The purpose of an incident report is to describe and document a particular event, injury, medication error, or other occurrence that affects a client or staff member. This report is then sent directly to the hospital risk management team for the express purpose of developing a plan or protocols to prevent a repeat occurrence. 1. Incorrect: Although the primary healthcare provider will need to be informed of the medication error and the client's current status, including vital signs, a copy of the incident report is not provided. 2. Incorrect: The State Board of Nursing is rarely notified about medication errors or the existence of an incident report. 3. Incorrect: The information documented on the main chart includes the client's current status and assessment specifics. It should also be documented that the primary healthcare provider was notified. However, there should not be any mention of the incident report on the client's chart.

The nurse is providing care to a client who is 12 hours post abdominal aorta aneurysm (AAA) repair. Which assessment finding by the nurse would indicate a possible complication? 1. Urinary output 360 mL since surgery 2. Temperature 100.2 degrees F (37.9 degrees C) 3. 2+/4+ pedal pulses 4. Mean arterial pressure 50

4. Correct. A normal range for mean arterial blood pressure is 70 to 110. A minimum of 60 is required to supply enough blood to nourish the coronary arteries, brain and kidneys. What is the complication you are worried about? Shock! 1. Incorrect. Normal UOP 30 mL x 12 hours = 360 mL 2. Incorrect. A slight increase in temperature postoperatively is not uncommon. 3. Incorrect. 2+/4+ is normal.

A client has been admitted for evaluation of severe anxiety and new onset panic attacks following the loss of a spouse. Which client factor would the nurse consider most important in developing a plan of care? 1. Available support system 2. Perception of the situation 3. Desire to return to work 4. Coping mechanisms

4. Correct. The plan of care for a client in crisis involves a complex combination of factors to achieve a positive outcome. However, the most important consideration is the client's own coping skills. Treatment and subsequent recovery is more successful when the client has the coping skills and is able to participate in the recovery process. 1. Incorrect. Although a good support system is crucial during any psychiatric or emotional crisis, this is not the most important aspect of a client's plan of care. The priority is the client. Available support systems is not the priority when developing a plan of care. 2. Incorrect. The client's own perception of the problem can enhance or detract from a successful outcome; however, there is another facet that is more critical to a client's positive outcome. The client's coping mechanisms can affect their perception of the situation. 3. Incorrect. Having a goal, such as returning to employment, is important to the client's recovery, but by itself is not enough to ensure a positive outcome for a client. Returning to work is not the priority with new onset panic attacks.

The nurse is caring for a client who has been intubated and placed on a ventilator. The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a respiratory rate of 40; arterial line BP 98/44; oxygen saturation 82%; cardiac monitor sinus tachycardia at 138. What action should the nurse take first? 1. Turn off alarm, then check ventilator settings. 2. Increase FiO2 setting to 100%. 3. Hyperventilate client, then suction ET tube. 4. Auscultate lung sounds.

4. Correct. When an alarm sounds, the first action by the nurse should be to assess the client. In this situation, assessment of lung sounds, chest movement, and respiratory effort should indicate which respiratory complication the client may be experiencing. Depending on the assessment findings, the other actions may be necessary. Excessive positive pressure can result in lung complications, including a pneumothorax. This could quickly progress to a tension pneumothorax. Therefore, the nurse should consider any sudden changes in oxygen saturations and signs of respiratory distress as life threatening. Immediate assessment of the client is warranted with actions taken based on the findings. 1. Incorrect. Depending on the assessment findings, this action may be necessary. Check the ventilator after checking the client. The ventilator is checked following the client assessment to assure that it is working properly and that the settings are appropriate. 2. Incorrect. Depending on the assessment findings, this action may be necessary. The goal of mechanical ventilation is optimal gas exchange by maintaining oxygen delivery and alveolar ventilation. The lowered oxygen saturation could be the result of the underlying illness, but since there was an abrupt change, mechanical factors should be considered as well. The nurse would need to institute other measures to promote gas exchange in addition to consideration of increasing the fraction of inspired oxygen. 3. Incorrect. Depending on the assessment findings, this action may be necessary. Ventilation use increases the production of secretions, regardless of the initial reason for ventilating support. The client must be assessed first for the presence of secretions by auscultating the lungs bilaterally. If excessive secretions are present, suctioning should be performed with caution to prevent damage to the airway mucosa.

A child with acute lymphocytic leukemia (ALL) is receiving chemotherapy through a single lumen Groshong catheter. During the infusion, the child reports nausea and has vomited. The primary healthcare provider has prescribed ondansetron IV. What action should the nurse take? 1. Ask primary healthcare provider for an oral antiemetic. 2. Give ondansetron IVPB with the chemotherapy. 3. Wait until chemotherapy is complete to infuse ondansetron. 4. Stop chemotherapy temporarily and flush line to give ondansetron.

4. Correct: A Groshong catheter is implanted when other venous access sites are no longer useable. The child has begun to react to the chemotherapy and needs medicated now. Because this implanted device has only one lumen, the nurse must stop the chemotherapy infusion temporarily, flush the port, administer the ondansetron, flush again and restart the chemotherapy infusion. 1. Incorrect: Because this client is vomiting, changing the medication to the oral route would not be effective. The medication takes longer to work if given orally, which means the client may vomit again before the medication activates, losing part of the dose. 2. Incorrect: Chemotherapy infusions should not be mixed with other categories of drugs, such as an antiemetic, because of the possibility of drug interactions. Certain chemical mixtures could also cause precipitates to form in the tubing, which is dangerous to the child. 3. Incorrect: The child is experiencing nausea and vomiting at this time. Waiting togive the antiemetic until after the chemotherapy is completed causes the child to suffer needlessly. The nurse should take action immediately to alleviate symptoms.

The lactation consultant is preparing to make rounds on the breastfeeding clients on the Labor, Delivery, Recovery, Postpartum (LDRP). Which client should the consultant see first? 1. The mother who is nursing her newborn every 2-3 hours for 15-20 minutes at a time. 2. The mother who stated that her newborn sucks in short bursts and has audible swallowing. 3. The mother who reported blisters on her nipples and pain whenever the newborn latches on. 4. The mother who stated that her baby was so good that she has to wake him for each feeding.

4. Correct: A baby who is so sleepy that he doesn't wake on his own for feeding is at high risk for dehydration and malnourishment. This newborn needs further evaluation and close monitoring to prevent serious complications. 1. Incorrect: This is a normal finding for a breastfeeding mother and is not the priority concern for the consultant.2. Incorrect: This is a normal finding for a breastfeeding mother and is not the priority concern for the consultant. 3. Incorrect: Blisters and pain are concerns that need to be assessed, but the sleepy baby situation has first priority. This would be the next client for the consultant to see, but not the first.

The nurse is talking to the parent of a 3 year old child who was constipated 1 week earlier. The child is on a regular diet. What statement by the parent indicates to the nurse that the prescribed treatment for constipation has been effective? 1. "My child drinks 1000 mL of fluids daily." 2. "My child is eating more fruit every day." 3. "I administered the prescribed oil-retention enema 6 days ago to my child." 4. "My child has had a soft, formed, brown stool every day for 6 days without straining."

4. Correct: A client is assessed as constipated when they have hard stools, difficulty passing the stool, and incomplete passage of stool. The desired outcome of constipation therapy is for the child to have soft, formed, bowel movements. The mother states that the child has had soft, formed, brown stools every day for the last 6 days. 1. Incorrect: Can you evaluate the effectiveness of the treatment plan by the parent describing how much fluid the child consumes in 24 hours? No. This is an action based on the need to increase the fluid intake to help decrease constipation. This is not an evaluation of the prescribed treatment for constipation. 2. Incorrect: This statement is a description of the classification of food that the child is eating. The effectiveness of the prescribed plan for the constipation is not addressed. 3. Incorrect: The mother is describing the completion of a prescribed treatment. The results of the enema are not listed, and it does not evaluate the prescribed treatment for constipation.

client is admitted with irritable bowel syndrome (IBS) and shingles. The nurse is discussing the client assignments with the charge nurse. Which staff member should not be assigned to this client? 1. The nurse with a history of roseola. 2. The unlincesed assitive personnel (UAP) with no history of roseola. 3. The UAP with a history of chicken pox. 4. The LPN/VN with no history of chicken pox.

4. Correct: A nurse who has not had chicken pox could contract it and should not be assigned a client with shingles. Those who have not developed antibodies to the varicella zoster virus are susceptible to chicken pox. Chicken pox and shingles are both from the varicella virus. 1. Incorrect: Roseola is a rose colored rash and would not have any effect on the assignment. It is a generally mild infection that usually affects children by age 2, and rarely adults. It is caused by 2 strains of herpes virus, rather than the varicella virus. 2. Incorrect: Roseola is a rose colored rash and would not have any effect on the assignment. It is a generally mild infection that usually affects children by age 2, and occasionally adults. It is caused by 2 strains of herpes virus, rather than the varicella virus. There is no relationship between roseola and shingles. 3. Incorrect: Shingles is caused by a reactivation of the varicella-zoster virus (which causes chicken pox). Those who have not developed antibodies to the varcella-zoster virus are susceptible to chicken pox. Therefore, the UAP who had chicken pox could be assigned this client.

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 client's 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 he restraints. Also the client may perceive the restraints as a threat.

Which client should the nurse see first? 1. Primigravida on IV magnesium sulfate with deep tendon reflexes of 2+ 2. Multigravida on po terbutaline with a pulse rate of 110/per minute 3. Primigravida on IV oxytocin with contractions every 3-4 minutes 4. Multigravida on po methyldopa with a blood pressure of 142/90.

4. Correct: A systolic blood pressure of ≥ 140 mmHg or a diastolic BP of ≥ 90 mmHg indicates hypertension. This client is already on methyldopa, which is an antihypertensive medication. Her hypertension is worsening and may compromise fetal well being. 1. Incorrect: + DTRs are normal. Clinical signs of safe dosage of magnesium sulfate include normal deep tendon reflexes. Adverse effects include depressed reflexes. 2. Incorrect: Maternal tachycardia (up to 120 bpm) is expected when on this medication. Terbutaline is a beta adrenergic agonist could have significant cardiovascular effects. 3. Incorrect: The desired contraction pattern with oxytocin is 3 in 10 minutes. A contraction every 3-4 minutes would equal 3 contractions in 10 minutes. The dosage of the oxytocin is individualized until the desired contraction rate is achieved.

Which statement by a client would indicate to the nurse that education about alendronate has been successful? 1. "It is recommended that I recline for 15 minutes after taking my medication." 2. "Food should be eaten immediately after taking alendronate." 3. "My medication tablet should be chewed for rapid absorption." 4. "I should drink a full 8 ounce glass of water with my medication."

4. Correct: Alendronate is a biophosphonate drug used in the treatment of osteoporosis and other bone diseases. The client should take each tablet in the morning with a full glass of water (6-8 ounces or 180-240 ml) at least 30 to 60 minutes before the first food, beverage or medication of the day, to increase absorption. 1. Incorrect: After taking alendronate, the client should remain upright (sitting or standing) for 30-60 minutes. The client should not lie down until after eating. These actions help to decrease the likelihood of esophageal and GI associated side effects. 2. Incorrect: The client should wait at least 30-60 minutes before eating, drinking or taking any other medication, to increase absorption. 3. Incorrect: The client should not chew the medication tablet, mouth ulcers can occur when alendronate is chewed or dissolved in the mouth.

A tour bus is involved in an accident, sending several clients to the emergency room (ER) for treatment. An unconscious client with multiple internal injuries requires immediate surgery. When itemizing the client's belongings, the nurse finds a wallet containing four thousand dollars. What is the appropriate method for the nurse to secure the money? 1. Place wallet inside client's pants and then in belongings bag. 2. Secure the money in an envelope in the ER narcotics drawer. 3. Sign money over to the hospital CEO until client is discharged. 4. Tally cash with 2nd nurse, document and lock in hospital safe.

4. Correct: All personal valuables in the possession of an unconscious client, including money or jewelry, must be tallied in the presence of two nurses and then documented in the client's main chart. Valuable items such as watches, rings or necklaces must also be secured until a family member is contacted, or the client is able to designate disposition of same. With large amounts of cash, a passport or other such important items, it is vital to account for and secure those items until returned to client or family. When dealing with money, two nurses must count the cash and document the total on the client's chart. The funds are then locked in the main hospital safe until the client is discharged or delegates a family member to retrieve same. 1. Incorrect: Even though the client's belongings bag is personal property, it is not a secure location. The bag is usually kept in the client's room or closet which does not provide security for a large amount of money. 2. Incorrect: While locking the cash into the ER narcotics drawer may be a temporary solution during care of the client, this is not an adequate long-term solution. The client will be sent to the operating room, and then admitted to a room. The money is personal property which should remain with the client in a secured manner. 3. Incorrect: Entrusting the funds to a single individual, even the facility CEO, is not the appropriate method of securing valuables.

An alcoholic client was admitted to the medical unit with substance-withdrawal delirium. Two days later, the client decides to leave the hospital against medical advice. What is the priority nursing intervention at this time? 1. Hide the client's clothes so that he 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 will provide an opportunity to attempt to fix the problem and possibly revise the client's decision. 1., 2. & 3. Incorrect: Confining a client against his or her wishes, except in an emergency situation, may be considered 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 against his or her will, and retaining in mechanical restraints a competent voluntary client who demands to be released.

Which client should the nurse recognize as being at greatest risk for the development of cancer? 1. Smoker for 30 plus years 2. Body builder taking steroids and using tanning salons 3. Newborn with multiple birth defects 4. Older individual with acquired immunodeficiency syndrome

4. Correct: Cancer has a high incidence in the immune deficiency client and in the older adult with both of these risk factors together, this one is the highest risk for cancer. 1. Incorrect: Although smoking is a known environmental carcinogen, this one risk factor alone is not the highest risk. 2. Incorrect: These are known environmental carcinogens, but do not rank as highly as aging and immune deficiency. 3. Incorrect: Birth defects are not a risk factor for cancer.

A child who fractured the ulna and radius following a fall is experiencing itching under the cast. What would be an appropriate nursing intervention to help alleviate the itching? 1. Apply a small amount of hydrocortisone cream with a cotton tip applicator. 2. Use a soft, sterile, cotton tip applicator to gently rub area under the cast. 3. Apply warm, dry heat to the outside of the cast with a lightweight heating pad. 4. Circulate air under the cast utilizing a blow dryer on the cool setting.

4. Correct: An acceptable, safe way to try to alleviate itching is to use a blow dryer on the cool setting to circulate air under the cast. This is the only safe option provided. 1. Incorrect: Although you may be thinking that hydrocortisone cream is an antipruritic, keep in mind the safety aspects of cast care. Nothing should ever be placed underneath the cast. Because of the risk of skin breakdown, the parents and child should be cautioned to not attempt to place any medication or object under the cast. 2. Incorrect: Remember safety! Skin breakdown could occur, even when using a "soft" object. Never place anything under the cast to try to reduce itching. 3. Incorrect: Applying heat to the cast would most likely increase the itching and could create moisture under the cast. The use of heat on the cast should be avoided.

A client is awake in the recovery room following a cardiac catheterization performed through the left radial artery. During the assessment, the nurse notes severe swelling of the left upper arm with a diminished left radial pulse, indicating an internal arterial hemorrhage. The cardiologist states the client will require immediate surgery to repair the leaking artery. The nurse understands what fact about the current consent form? 1. Can be assumed since it's an emergent situation. 2. Should be signed by client who is currently awake. 3. Is not needed since client consented to catheterization. 4. Must be approved by family or a spouse.

4. Correct: An additional procedure requires a new consent form which describes specifically what the cardiologist plans to do. Even though the client is awake, residual sedation from the catheterization makes it necessary for a family member or spouse to sign the consent form. 1. Incorrect: Emergent situations are those in which the client's life or limb is threatened. That type of consent is called "implied" consent; however, despite the seriousness of the situation, implied consent is not valid in this case. 2. Incorrect: Though awake following the catheterization, the client is considered impaired because of the sedation used during the catheterization. Even if the client understands what is occurring, a signature by the client is not considered legal at this time. 3. Incorrect: Once the surgery and potential risks are explained to the client, a consent form is completed specifically describing the procedure to be performed by the cardiologist. That form does not cover any additional procedures, even if directly connected to the original surgery.

The nurse asks if the client has an advance directive. The client responds by saying, "I have heard of advance directives, but I do not have one. What is an advance directive?" Which response by the nurse is appropriate? 1. Specifies your wishes regarding your personal effects and finances should you become unable to make decisions. 2. Specifies your wishes regarding healthcare and your finances should you become incapacitated. 3. Similar to a will, it specifies your wishes for burial should you die during hospitalization. 4. A form of a living will. It specifies your wishes regarding healthcare and treatment options should you become incapacitated.

4. Correct: An advance directive is a legal document prepared by a competent individual that specifies what treatments, if any, the client desires should the client become incapacitated or unable to make informed healthcare decisions in the future. The document includes wishes regarding resuscitation measures, withdrawing treatment and life support, and end-of-life care. 1. Incorrect: An advance directive does not address client personal effects and finances. These might be included in a last will and testament, but are not part of an advance directive. 2. Incorrect: An advance directive does not address client personal effects and finances. These might be included in a last will and testament, but are not part of an advance directive. 3. Incorrect: An advance directive does not address burial wishes.

A nurse caring for a client diagnosed with osteomyelitis instructs an experienced unlicensed assistive personnel (UAP) to obtain vital signs on the client. Which value should the nurse tell the UAP to report immediately? 1. Heart rate 98/min 2. Respirations 22/min 3. Blood pressure 138/82 4. Temperature 101°F (38.3°C)

4. Correct: An elevated temperature indicates infection and inflammation and should be reported to the healthcare provider. The client may need IV antibiotics. 1. Incorrect: This is within normal limits. 2. Incorrect: Although slightly above normal (16-20/min), this respiratory rate does not indicate a problem for this client. 3. Incorrect: This is within normal limits.

The family of an elderly client are concerned about emotional well-being since the loss of the spouse two years ago. What alternative therapy could the nurse recommend for this client? 1. Massage 2. Bioelectromagnetics 3. Accupressure 4. Animal-assisted therapy

4. Correct: Animal-assisted therapy is the use of specifically selected animals as a treatment modality in health and human service settings. It has been shown to be a successful intervention for people with a variety of physical or psychological conditions. The contributions companion animals make to the emotional well-being of people include providing unconditional love and opportunities for affection; achievement of trust, responsibility, and empathy toward others; a reason to get up in the morning, and a source of reassurance. 1. Incorrect: Massage therapy is the scientific manipulation of the soft tissues of the body. It is believed to aid the body to heal itself. 2. Incorrect: This uses electromagnetic fields to affect the functioning of cells, tissues, organs and systems. 3. Incorrect: Acupressure is a treatment rooted in the traditional Eastern philosophy of life energy, that flows through the body along pathways. It opens up blocked pathways to relieve pain.

What should the nurse include in the plan of care for a child who is receiving chemotherapy for a diagnosis of leukemia? 1. Place the child in a negative pressure isolation room. 2. Administer prophylactic intravenous (IV) antibiotics. 3. Avoid high protein food intake. 4. Teach family and visitors handwashing techniques.

4. Correct: Any client on chemotherapy should have good infection control measures in place such as handwashing by all who they encounter.1. Incorrect: If the client is immune suppressed, place them in a positive pressure isolation room. A negative pressure room primarily keeps its air inside the room with controlled venting only; whereas a positive pressure room keeps unfiltered air from outside the room out of the room all together. In a hospital, clients with communicable diseases, especially airborne ones, are kept in isolation rooms. In order to ensure the safety of other clients, staff and visitors, it is important that the isolation room contain negative air pressure. This will keep any germs from entering the general airflow and infecting other people. Positive pressure isolation rooms are designed to keep a vulnerable client in isolation safe from contamination from the outside. The air pressure in the room is greater than that outside of it, so it pushes potential infection agents or chemicals away from the client. The most common application is in rooms for client who have compromised immune systems. For these individuals, it is important that no common pathogens, even those that are harmless to healthy people, enter the room. For positive pressure isolation rooms, an anteroom is recommended and incoming air is filtered through both HEPA filters and ultraviolet germicidal irradiation systems, which kill bacteria by exposing them to ultraviolet light. 2. Incorrect: This would be appropriate if there was evidence of a bacterial infection. Just because chemotherapy is being administered does not mean the client has an infection. 3. Incorrect: This client would likely need a high protein diet to meet the nutritional demands of the body during chemotherapy. We need protein for growth, to repair body tissue, and to keep our immune systems healthy. When the body doesn't get enough protein, it might break down muscle for the fuel it needs. This makes it take longer to recover from illness and can lower resistance to infection. People with cancer often need more protein than usual. After surgery, chemotherapy, or radiation therapy, extra protein is usually needed to heal tissues and help fight infection.

The charge nurse is orienting a new nurse to the pediatric unit. Which teaching related to assessment is appropriate? 1. One assessment should be done daily on each client by the charge nurse. 2. An assessment should be done daily on each client at the beginning of the shift. 3. Assessments of clients should be updated as the nurse provides care to clients. 4. Assessments of clients should be done at the beginning of the shift and updated as nursing care is provided.

4. Correct: Assessment is ongoing; however, for each shift a baseline assessment should be done so the nurse can verify or make judgment regarding other findings throughout the 24 hour day. It is best to get the baseline as soon as possible once the shift begins, and update or reevaluate during the shift. This option actually incorporates the other 3 options making it the correct option. 1. Incorrect: Must include ongoing updated assessments, not just one assessment. These can be done by the assigned RN, not the charge nurse.2. Incorrect: Must include ongoing updated assessments, not just at beginning of shift.3. Incorrect: Must include initial beginning of shift assessment.

A client 34 weeks pregnant is scheduled for a visit at the prenatal clinic one week after receiving an injection of prenatal betamethasone due to the potential for premature labor. The client had been resting at home all week, as ordered. What assessment finding by the nurse should be reported to the primary healthcare provider immediately? 1. Blood pressure of 92/50 2. Fasting blood sugar of 75 3. Tympanic temperature of 100º F 4. Muscle weakness with cramping

4. Correct: Betamethasone is a corticosteroid used to speed up lung maturation in premature infants by stimulating the synthesis and release of surfactant into the fetal lungs. Excess amounts of such corticosteroids increase the body's stress response, leading to tachycardia, swelling in joints, an imbalance in electrolytes and even muscle wasting. Muscle weakness, especially with cramping, should be evaluated immediately by the primary healthcare provider. 1. Incorrect: Although this blood pressure is very low, especially in the third trimester, there is no information regarding the client's baseline. Though the nurse will need to evaluate this BP reading, there is a more urgent issue with the client. 2. Incorrect: A fasting blood sugar of 75 is within the normal range of 70 to 110. No need to report this information to the primary healthcare provider. 3. Incorrect: A pregnant female can quickly become dehydrated late in the third trimester due to excessive urination, resulting in a slightly elevated temperature. Though 100 degrees Fahrenheit is not exceedingly high, this will need further investigation. However, another symptom is of greater concern.

The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about nutrition and maintaining body weight. Which instruction is most important for this client? 1. Do postural drainage just before meals. 2. Consume fluids only at meal times. 3. Prepare meals high in carbohydrates. 4. Plan rest periods before and after meals.

4. Correct: Both ingestion and digestion require a great deal of energy expenditure for clients. Resting prior to eating helps decrease dyspnea, allowing the client to complete an entire meal. Relaxing afterwards compensates for the increased blood flow sent to the gastrointestinal system during digestion, again minimizing respiratory effort. Frequent rest periods throughout the daily are vital for COPD clients. 1. Incorrect: Postural drainage techniques help COPD clients loosen and expel excessive mucus that builds up from inflammation within the lung tissue. Because of specific therapy positions, including those in which the client faces head down, there is the chance of wheezing or vomiting. This can lead to aspiration or infection. The best time to complete chest therapies is at least an hour before or two hours after a meal. 2. Incorrect: Fluids help to thin excessive mucous secretions typical in chronic obstructive pulmonary disease. Also, if the client is using oxygen, the mucous membranes will quickly dry out. COPD clients are encouraged to drink at least 64 ounces of caffeine free liquids throughout the day, rather than just at mealtime. 3. Incorrect: Because dyspnea interferes with eating, weight loss and malnutrition are areas of concern for clients with COPD. Small frequent meals high in protein are important to maintain nutrition and improve the immune system.

An infant has been prescribed Bryant's traction for a diagnosis of developmental dislocated hips (DDH). At what degree of hip flexion should the nurse maintain the infant's hip for proper traction alignment? 1. 15 2. 30 3. 45 4. 90

4. Correct: Bryant's traction is used for DDH. The child's body and the weights are used as tension to keep the end of the femur in the hip socket. Traction helps position the top of the femur into the hip socket correctly. This is accomplished with 90 degrees of hip flexion. 1. Incorrect: Fifteen degrees of flexion is not adequate to keep the femur end in the hip socket. 2. Incorrect: Thirty degrees of flexion is not adequate to keep the femur end in the hip socket. 3. Incorrect: Forty-five degrees of flexion is not adequate to keep the femur end in the hip socket.

A client with cirrhosis is being treated with bumetanide 1 mg daily for the management of ascites. What should the nurse assess for related to the effects of this medication? 1. Hyperbilirubinemia 2. Hypercalcemia 3. Hypoaldosteronism 4. Hypokalemia

4. Correct: Bumetanide is a K+ depleting diuretic. Potassium is lost primarily through the kidneys; therefore, when the urine output increases with the use of a diuretic, more potassium can be lost and the client is at risk for hypokalemia. 1. Incorrect: Hyperbilirubinemia may be present with cirrhosis but is not related to the effects of bumetanide. Don't let the presence of ascites convince you that this question is asking about a liver problem. 2. Incorrect: Although loop diuretics, such as bumetanide, can cause a slight increase in the excretion of calcium, which would lead to hypocalcemia, compensatory mechanisms generally are able to keep the calcium levels within normal range. 3. Incorrect: Bumetanide does not cause hypoaldosteronism. This is an aldosterone problem.

The nurse is preparing to initiate postmortem care. Which postmortem care interventions would the nurse implement? 1. Identify the client by the name on the client's armband. 2. Remove tubes and indwelling lines after cleansing the body. 3. Insert the dentures after the family has viewed the body. 4. Maintain body preparation according to the client's religious beliefs.

4. Correct: Care of the body after death should be reflective of the client's personal, religious, or cultural practices. 1. Incorrect: The client should be identified by 2 identifiers such as the name and birthday, name and medical record number. 2. Incorrect: The tubes and indwelling lines should be removed prior to cleansing the body. Safety standard precautions should be initiated during the removal procedure. 3. Incorrect: After cleansing the body the dentures should be inserted to maintain facial shape. The family can view the body after the dentures are inserted.

The postanesthesia care unit has received several postoperative clients. While encouraging the clients to cough and deep breathe, the nurse realizes that coughing poses the greatest risk to which client? 1. A female with an abdominal hysterectomy 2. A male who had a right upper lobectomy 3. An adolescent with an open appendectomy 4. An elderly client who had cataract removal

4. Correct: Cataract removal involves replacing the eye's lens with an artificial lens that is permanently sutured into place. Coughing would increase intraocular pressure in this client and risk dislodging the lens and eye sutures. The nurse needs to monitor and prevent additional potentially harmful actions such as sneezing, vomiting, bending over, or straining. 1. Incorrect: Coughing is a potential complication following any surgery in which there are external sutures. However, a priority post op action is to encourage the client to cough and deep breathe to prevent possible atelectasis; therefore, the nurse must instruct this client to splint the lower abdomen prior to taking deep breaths and coughing. This client is not at the highest risk. 2. Incorrect: Any type of thoracic or cardiac surgery places the client at high risk for pneumonia or atelectasis. Deep breathing is particularly important for this client. The nurse will definitely need to encourage this client to cough and deep breathe while assisting with splinting the surgical incision. This client would be at a greater risk by NOT coughing. 3. Incorrect: An open appendectomy indicates this was not done laparoscopically, but rather that this client will have abdominal sutures. Despite this fact, the client must be encouraged to cough and deep breathe to prevent complications. The nurse will instruct the client to splint the lower abdomen to protect the suture line while coughing and deep breathing.

A pregnant woman who has just been admitted to the labor and delivery room states that her "water just broke". What should the nurse do immediately? 1. Confirm that fluid is amniotic fluid with a pH test strip 2. Obtain maternal vital signs 3. Observe amniotic fluid color 4. Check fetal heart rate (FHR) pattern

4. Correct: Check the FHR immediately following the rupture of membranes. Changes in FHR pattern such as bradycardia or variable decelerations may indicate prolapsed umbilical cord. 1. Incorrect: The first thing the nurse should do is check FHR pattern. Changes in the FHR, such as bradycardia or variable decelerations could indicate prolapsed cord. Interruption of the blood flow through the cord interferes with oxygenation and is potentially fatal. 2. Incorrect: FHR is the priority as a change could indicate prolapsed cord. If the umbilical cord slips downward after the membranes rupture. it can become compressed which would be indicated by changes in the FHR, not the maternal vital signs. 3. Incorrect: The nurse should observe the amniotic fluid color after checking the FHR.

A community health nurse is assessing a migrant farmer who raises chickens. The nurse notes the client has developed a cough, fever, dyspnea, and hemoptysis. What infection should the nurse suspect? 1. Lyme disease 2. Toxoplasmosis 3. Tuberculosis 4. Histoplasmosis

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

What should the chemotherapy infusion nurse recognize as the major barrier of chemotherapy success in treating cancer clients? 1. Inadequate knowledge of the side effects of chemotherapy 2. Difficulty obtaining an IV access 3. The development of alopecia 4. Toxicity to normal tissues

4. Correct: Chemotherapy is toxic to both cancerous and non-cancerous cells. Widespread destruction of non-concancerous "normal" cells can limit the use of chemotherapeutic agents.1. Incorrect: Inadequate knowledge can be addressed and is not considered a major barrier for chemotherapy treatment.2. Incorrect: Implantable ports are most often used for chemotherapy administration and eliminate the difficulty of obtaining a repeated peripheral IV site.3. Incorrect: Alopecia is an adverse effect of chemotherapy but does not affect the success of chemotherapeutic agents.

A nurse is caring for a client who has been prescribed clonazepam for 6 months. What education should the nurse provide to the client? 1. "Your glucose level should be monitored while prescribed clonazepam." 2. "You may experience dry skin periodically while prescribed clonazepam." 3. "Schedule appointments to have clonazepam administered intravenously." 4. "A long-term prescription of clonazepam should be discontinued gradually."

4. Correct: Client's on an extended prescription of clonazepam will precipitate physical withdrawal symptoms, if the prescription is abruptly discontinued. The physical symptoms can include nausea, feeling tired, and headache. 1. Incorrect: The action of clonazepam does not result in a negative feedback in the endocrine system. The glucose level does not need to be monitored while prescribed clonazepam. 2. Incorrect: Dry skin is not a side effect related to the actions of clonazepam. The integumentary system side effects related to the actions of clonazepam include rash, alopecia, and hirsutism. 3. Incorrect: The route of administration for clonazepam is by mouth, tablet and disintegrating tablet. Clonazepam is not approved to be administered by the intravenous route.

The nurse is caring for a client on the oncology unit. The client asks, "Why do I need this LifePort to receive my chemotherapy?" What evidence should the nurse consider when answering? 1. IV infusions can be more rapidly administered via an implantable IV port 2. Implantable IV ports are kept sterile and therefore do not become infected 3. Chemotherapeutic agents are more readily absorbed from implantable IV ports 4. Implantable ports are beneficial when long-term and/or multiple IV therapy is indicated.

4. Correct: Clients requiring long-term and/or multiple IV therapy benefit from implantable ports, because they reduces the number of IV sticks, preserve the integrity of peripheral veins, and provide a vessel with adequate blood flow. The part allows chemotherapy agents to be given in a larger vein, decreasing risk of tissue damage that can occur with peripheral administration. 1. Incorrect: Rate of administration is not an indicator for an implantable port, and chemotherapeutic agents are administered at a slower rate than most IV medications. Chemo agents should be given at the prescribed rate. 2. Incorrect: Infection is a concern for any implantable device. Sterile technique is used when accessing port. Inspection of the site is essential, in addition to monitoring vital signs and WBCs. 3. Incorrect: Rate of absorption is not affected by the type of central line or implantable IV port. Implantable ports promote safety and reduce problems during medication administration.

The hospice nurse has been assigned a new client who is being cared for at home by family members. Based upon the client's physical assessment, the nurse is aware that the client's death is imminent. What is the nurse's most important role in the care of the family at this time? 1. Providing care for the client, allowing the family to rest. 2. Providing education regarding the symptoms the client will likely experience. 3. Allowing the family to express their feelings and actively listening. 4. Communicating the client's impending death to the family while they are together.

4. Correct: Communicating news of the client's impending death to the family while they are together. The nurse's most important role in the care of the family is compassionate communication. The family needs to be informed about the situation so that they are prepared for the client's death and can provide support to one another.1. Incorrect: Providing respite time when death is imminent is not a priority. Family should be allowed to spend time with the client. They will, more than likely, want to be with the client in the last hours.2. Incorrect: When death is imminent, education of what to expect is appropriate, but does not take priority over compassionate communication. Compassionate communication is most important at this time.3. Incorrect: Silence and listening sends a message of acceptance and comfort. Although important, allowing for expression of feelings is not more important than preparing the client for the imminent death.

A newly married wife tells the nurse, "I told my husband that I may not know how to cook, but I can sure do the dishes!" Which defense mechanism is the client displaying? 1. Projection 2. Displacement 3. Sublimation 4. Compensation

4. Correct: Compensation is consciously or unconsciously overemphasizing a characteristic to compensate for a real or imagined deficiency. Making up for deficits in one area by excelling in another helps to raise or maintain the client's self-esteem. 1. Incorrect: Projection is attributing one's own thoughts or impulses to another person as if they had originated in the other person. This is unconsiously done and usually includes intolerable wishes and emotional feelings. 2. Incorrect: Displacement is shifting or transferring the emotional element of a situation from a threatening object to a non-threatening object. This could include transferring emotions from a person, object or situation to another person, object or situation. 3. Incorrect: Sublimation is redirecting a socially unacceptable impulse into socially acceptable behavior. Examples include strong aggressive or sexual drives.

The nurse is caring for a 5 year old client who is 12 hours post tonsillectomy. The client is pain free and has advanced to a soft diet. What is the priority nursing intervention? 1. Apply warm compresses to the throat. 2. Encourage gargling to reduce discomfort. 3. Position the child supine. 4. Monitor for frequent clearing of the throat.

4. Correct: Continuous swallowing and frequent clearing of the throat are signs of bleeding.1. Incorrect: This would increase blood flow, causing edema and bleeding, so this should not be done. 2. Incorrect: Gargling increases motion of throat and may cause bleeding. This is also something that could be a developmental challenge for a 5 year old. 3. Incorrect: The blood can drip down into the stomach and the client will wake up and vomit the old blood while lying flat. This puts the client at risk for aspiration so the nurse should place the client in a side lying position.

The nurse is caring for a client diagnosed with Obsessive Compulsive Disorder (OCD). Which statement, made by the client, would be the best indicator of improvement? 1. "My friends don't know I have OCD." 2. "I only do my hand washing to reward myself when I am good." 3. "I know my thoughts and behaviors aren't very normal." 4. "I have more control over my thoughts and behaviors."

4. Correct: Control is an issue for those with OCD. Appropriate goals for this client would be to control unwanted behaviors and thoughts. 1. Incorrect: Doesn't indicate control over behavior. Not telling their friends indicates the client is ashamed of disease and doesn't show improvement. 2. Incorrect: The behaviors are not reward for good behavior; they are utilized to decrease anxiety. Compulsions are ritualistic behavior that the individual feels driven to perform in an attempt to reduce anxiety. 3. Incorrect: Clients with OCD are aware their behavior is not normal, so this would not be an indicator of improvement. Obsessions are defined as thoughts, impulses or images that persist and recur, so that they cannot be dismissed from the mind.

The parents of a child hospitalized with cystic fibrosis have been given discharge instructions. The nurse knows that teaching has been successful when the parents make what statement? 1. "Our child will need to have a gluten free diet." 2. "The enzymes should be given at bedtime daily." 3. "Salt needs to be decreased in our child's diet." 4. "We need to prepare high calorie, high fat meals."

4. Correct: Cystic fibrosis is an inherited disorder in which abnormally viscous secretions affect the respiratory and digestive systems. Because the client is unable to absorb nutrients, several dietary adaptations are crucial, including frequent small meals along with digestive enzymes to help the client process food. The meals should be high calorie, high fat with increased amounts of sodium to help stabilize fluids. 1. Incorrect: A gluten free diet is not associated with cystic fibrosis. This special diet is generally required for clients with Celiac disease and certain food allergies, although clients with either of these diseases will need the addition of fat soluble vitamins A, D, E and K. This statement by the parents indicates the need for further teaching. 2. Incorrect: Pancreatic digestive enzymes, such as Creon or Pancreaze, must be given with every meal or snack in order to help the digestive system absorb nutrients properly. Because clients with cystic fibrosis need frequent small meals throughout the day, digestive enzymes must also be provided throughout the day with any food. 3. Incorrect: Clients with cystic fibrosis lose abnormally large amounts of salt in sweat, and the glands are unable to reabsorb needed sodium into the body system. Rapid dehydration is common due to decreased sodium levels, which are exacerbated during exercise or hot weather. These clients are encouraged to increase salt intake.

Which initial behavior by the client on a mental health unit demonstrates to the nurse that the client is assuming responsibility for anger management? 1. Plans to use exercise to work off anger. 2. Apologizes to those individuals to whom anger has been directed. 3. Develops a plan on how to react when feeling stressed. 4. Identifies stressors of past violent behavior.

4. Correct: Demonstrates client is assuming responsibility for anger management. 1. Incorrect: The client would have to identify precipitating factors first. 2. Incorrect: This does not indicate a change in behavior. It just shows that the client is aware of anger after the fact. 3. Incorrect: The client must identify stressors first.

Which comment by the mother indicates understanding of the diet needed to maintain health and adequate nutrition in the toddler? 1. "It is important to give my child low fat milk after one year of age". 2. "If the child won't eat new foods after three tries, he is not going to eat it". 3. "I think that the sooner one starts to give vitamins to children, the better". 4. "I try to provide whole grains, fruits, vegetables, and meat daily".

4. Correct: Depending on their age, size, and activity level, toddlers need about 1,000-1,400 calories a day. A health promotion strategy to help meet the nutritional needs of the toddler includes offering a wide variety of healthy foods and from all food groups based on the "my plate" food guide. 1. Incorrect: Fat should not be limited in the child under two years of age. In general, kids ages 12 to 24 months old should drink whole milk to help provide the dietary fats they need for normal growth and brain development. 2. Incorrect: Learning to eat new foods is a process that requires many attempts. Keep offering the food. 3. Incorrect: If children eat a wide variety of foods, it is unlikely that vitamin supplementation will be needed.

client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. Which preoperative prescription should the nurse question? 1. Administer tap water enemas until clear at 6 AM. 2. Nothing by mouth (NPO). 3. IV of D5 ½ NS at 75 mL/hour with a 20 gauge catheter. 4. Give magnesium citrate 296 mL at 3 PM today.

4. Correct: Did you notice the hint? Complete blockage of the large intestine. If you give the magnesium citrate, which is a laxative, what will happen? Nothing will get passed the complete blockage. The client would develop severe cramping. This could cause a medical emergency. 1. Incorrect: The client does need to be cleaned out below the tumor so that the primary care provider can see the area of concern and complete the biopsy. Since the enema would clean below the obstruction, the client would be able to expel the enema and any feces in this part of the colon. 2. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. This is an appropriate prescription. 3. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO.

The charge nurse is making assignments for the evening shift. Which client would be an appropriate assignment for a new LPN/VN graduate? 1. A middle aged adult admitted with syncope. 2. An adolescent with skin grafts to right hand. 3. A young adult receiving IV chemotherapy. 4. An elderly adult diagnosed with diverticulitis.

4. Correct: Diverticulitis is a bowel disorder of undetermined origin, characterized by pain to the lower abdomen, along with bloating, fever and diarrhea. Treatment may include hospitalization, antibiotics, liquid diet and bedrest. Because there is usually no bleeding involved, this would be an appropriate assignment for a new LPN/VN graduate. 1. Incorrect: A new admission requires assessments that must be completed by a registered nurse. Additionally, syncope could be an indication of a serious cardiac issue; therefore, this would not be a client suitable for the LPN/VN. 2. Incorrect: Although sterile wound care is within the scope of practice for an LPN/VN, skin grafts require special assessment techniques during dressing changes, in order to determine quality of tissue perfusion and potential for rejection. This client should be assigned to a more experienced nurse. 3. Incorrect: This client will need extensive assessments of multiple body systems while receiving I.V. chemotherapy, requiring an experienced registered nurse with knowledge of both chemo drugs and different types of cancer. This client would not be appropriate for a new LPN/VN.

Which risk factor should the nurse include when planning to educate a group of women about breast cancer? 1. Menopause before the age of 50 2. Drinking one glass of wine daily 3. Multiparity 4. Early menarche

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 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 time period between menarche and menopause increases.2. Incorrect: 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 is the priority nursing action for a pregnant client in labor who is having an epidural catheter inserted for pain management? 1. Perform a thorough skin prep of the insertion site. 2. Obtain the client's consent for the procedure. 3. Assure the client that residual effects of the procedure won't be felt. 4. Monitor maternal blood pressure.

4. Correct: Epidural anesthesia may result in distal vasodilation and a precipitous drop in maternal blood pressure, which will adversely affect placental blood flow. Evidence-based practice guidelines from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) suggests assessing the maternal blood pressure and fetal heart rate every 5 minutes during the first 15 minutes after initiation of epidural medication. 1. Incorrect: Preparing the insertion site is the responsibility of the primary healthcare provider. 2. Incorrect: Obtaining consent is the responsibility of the primary healthcare provider. This is not the priority nursing action. 3. Incorrect: Residual effects of epidural anesthesia include infection and headache. So this is an incorrect statement.

What information should the nurse include in teaching an oncology client the purpose of taking epoetin? 1. Emergency treatment of anemia. 2. Improves quality of life. 3. Used for the prevention of pure red cell aplasia (PRCA). 4. Decreases the need for transfusion.

4. Correct: Epoetin is prescribed to treat a lower than normal number of red blood cells (anemia) caused by chronic kidney disease in clients on dialysis, in HIV clients receiving zidovudine and in cancer clients receiving chemotherapy that develop anemia. Epoetin stimulates the bone marrow to produce more RBCs. 1. Incorrect: Epoetin does not work raoidly enough to be used for the emergency treatment of anemia (RBC transfusion). 2. Incorrect: Epoetin has not been proven to improve quality of life, fatigue, or sense of well-being in clients with cancer. 3. Incorrect: Pure red cell aplasia (PRCA) is a type of anemia that starts after treatment with epoetin or other erythropoetin medications.

What is most important for the nurse to monitor when administering intravenous erythromycin to a client? 1. Nausea and vomiting. 2. Clotting studies. 3. Premature atrial contractions. 4. Prolonged QT interval.

4. Correct: Erythromycin is a macrolide antibiotic that is linked to QT prolongation. Pharmacologic agents capable of prolonging the QT interval are capable of causing ventricular tachyarrhythmias. 1. Incorrect: This is a side effect but not as life threatening as a prolonged QT. 2. Incorrect: This medication does not alter clotting factors unless there is liver dysfunction, which is a contraindication of the medication. 3. Incorrect: PACs are not a common problem with this medication but prolonged QT intervals are, and the associated ventricular tachyarrhythmias are more life-threatening.

A client who has chronic renal failure has been prescribed synthetic erythropoietin for the prevention of anemia. Which assessment finding should be reported to the primary healthcare provider? 1. Hemoglobin level of 10 g/dl (1.6 mmol/L) 2. Blood pressure of 120/84 3. Constipation 4. Swelling of feet and ankles

4. Correct: Erythropoietin is generally well tolerated. Swelling of feet and ankles may indicate the beginning of a cardiovascular problem. Clients taking this drug are at risk for myocardial infarctions and risk of blood clots.1. Incorrect: The purpose of this drug is to increase hemoglobin levels. A level of 10g/dL (1.6 mmol/L) would be considered favorable even though still low. The client would still need the medication since anemia still exists. If hgb is above 12 g/dl (1.9 mmol/l), the level should be reported as the client does not need the med any longer. 2. Incorrect: An elevated blood pressure is one of the more common and major side effects. If elevated it should be reported, but this blood pressure is within normal limits.3. Incorrect: Constipation may be caused by iron preparations. Increasing fiber in the diet may improve that symptom. A common side effect of synthetic erythropoietin is darrhea.

The primary healthcare provider has prescribed ampicillin and ciprofloxacin piggyback in the same hour, every 6 hours. How will the nurse administer these medications? 1. Administer one of the medications every 4 hours and the other every 6 hours. 2. Administer the medications by combining them into 150 mL of normal saline (NS). 3. Administer the medications at the same time by connecting the secondary tubing to two separate ports on the primary tubing. 4. Administer the medications separately, flushing with normal saline (NS) between medications.

4. Correct: Even though two IV piggyback medications have been ordered at the same time, they can both be infused separately on time. It just takes planning. The nurse must follow the medication rights (right client, right medication, right route, right dose, right time). The antibiotics need to be administered one at a time and normal saline is used to flush the remaining medication of the first antibiotic before the second is administered. 1. Incorrect: The primary healthcare provider will prescribe the dosing schedule. Its beyond the scope of practice for the nurse to independently the dosing schedule. 2. Incorrect: The properties of each antibiotic are different. The two different antibiotics cannot be mixed together. 3. Incorrect: Administering the antibiotic into different parts of the IV tubing is the same as mixing the IVs together. Only one antibiotic should be administered at a time.

A paralyzed adolescent admitted for decubiti debridement has brought multiple personal electronics, including a laptop, cell phone and video game unit. The nurse notes the family has used extension cords to provide enough electrical outlets. What action by the nurse is most appropriate? 1. Inform family some of the electronics must be taken home. 2. Explain that extension cords are not permitted in a hospital. 3. Notify maintenance to install more outlets in the client room. 4. Ask client to have staff switch equipment in outlets as needed.

4. Correct: Extension cords are considered a safety hazard in the hospital setting, especially when provided by the family. The nurse has provided an alternative in order for the client to use personal equipment. Staff will assist the client to switch equipment when requested. 1. Incorrect: The nurse is violating the client's right to keep personal belongings while providing no alternative suggestion for the client. Additionally, the nurse has not addressed the use of extension cords in the hospital. 2. Incorrect: Though the nurse is making an accurate statement, no alternative plan has been offered to help meet the client's needs. 3. Incorrect: It is not possible to have maintenance perform construction in a room currently occupied by a client. Installing outlets for one client is not feasible.

Which action by the nurse is most likely to result in a possible breach of confidentiality of medical records? 1. Entering the data on clients only at computers in nurse's station. 2. Recording the client history of an abortion. 3. Sharing access controls like passwords with other healthcare professionals. 4. Leaving the computer terminal before logging off.

4. Correct: Failing to log out may allow persons not concerned with the care of the client to access private information. 1. Incorrect: Computers for entering data, may be moved from room to room by the nurse. This is a much better use of time and ensures comprehensive accurate data. 2. Incorrect: The medical record routinely contains sensitive information, so this does not breach confidentiality. 3. Incorrect: This should not be done but not as likely to result in breach of confidentiality since this is restricted to other healthcare professionals.

The nurse is teaching a group of clients who have osteoarthritis how to protect joints. What should the nurse include? Select all that apply 1. Use small joints and muscles. 2. Turn doorknobs clockwise. 3. Sit in a chair that has a low, straight back. 4. Push off with the palms of hands when getting out of bed. 5. Use hairbrush with extended handle.

4. Correct: Following cataract removal, a new lens is sutured in place, which slightly alters the corneal curve. Newer surgical approaches involve the use of a "suture-less glue" but that method is less common. Although the client's vision will eventually improve and stabilize, minor blurring may exist during the 6 to 12 week healing period. After that time, any remaining visual issues can be corrected with glasses. 1. Incorrect: Only the operative eye is protected by an eye patch during the healing process. The primary healthcare provider will remove that covering at the first post-operative checkup. Covering both eyes would pose a greater safety risk and decrease the client's self care abilities. 2. Incorrect: Pain following cataract surgery is the sign of a serious complication and should be reported to the surgeon immediately. Clients may experience a small amount of serous drainage or scratchy sensation, but should not have pain. 3. Incorrect: Implantation of a new lens causes a mild astigmatism that will be permanent. The client may still need to use corrective lenses, even if just for reading.

A client is admitted for management of ulcerative colitis. What sign/symptom would be of immediate concern to the nurse? 1. Tenesmus 2. Hyperactive bowel sounds 3. Ten bloody diarrhea stools in 8 hours 4. Abdominal guarding

4. Correct: Guarding is a completely involuntary response of the muscles. In other words, you have no control over it. It's a sign that your body is trying to protect itself from pain. It can be a symptom of a very serious and even life-threatening medical condition. 1. Incorrect: Tenesmus is the urge to move your bowels even if you've just emptied your colon. This is a common symptom of an ulcerative colitis flair and would not be of immediate concern to the nurse. 2. Incorrect: Hyperactive bowel sounds can mean there is an increase in intestinal activity. This may happen with diarrhea or after eating. This client has ulcerative colitis so hyperactive bowel sounds during a flare is expected. 3. Incorrect: The colon is ulcerated and unable to absorb water, so 10-20 bloody diarrhea stools are the most common symptom of ulcerative colitis and would not be of immediate concern to the nurse.

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. 2. Incorrect: The lower GI tract has a lot of magnesium; 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.

What electrolyte imbalance should the nurse monitor for in a client diagnosed with hyperosmolar hyperglycemic state (HHS)? 1. Hypocalcemia 2. Hypermagnesemia 3. Hyperkalemia 4. Hyponatremia

4. Correct: Hyperglycemia can cause dilutional hyponatremia, so Normal Saline is administered to replace both fluid and sodium lost through increased urinary output. 1. Incorrect: Calcium is not affected in the client who is in HHS. 2. Incorrect: HHS does not specifically cause hypermagnesemia. We do know that magnesium is lost through the kidneys, so hypomagnesemia is possible with uncontrolled diabetes. 3. Incorrect: Serum potassium levels are usually normal when the client arrives with HHS. The potassium will drop as the large volume of NS is administered with IV insulin. Then we worry about hypokalemia.

A client with end-stage kidney disease (ESKD) is admitted to the hospital with shortness of breath and has a serum potassium level of 5.5 mEq/L (5.5 mmol/L). What would be the priority nursing action? 1. Report the client has uremic fetor to the charge nurse. 2. Assign the client to the room closest to the nurse's station. 3. Provide the client with assistance with dressing and bathing. 4. Administer sodium polystyrene sulfonate 15 grams/60mL by mouth.

4. Correct: Hyperkalemia is the most immediate life-threatening issue at this time and must be addressed. 1. Incorrect: Uremic fetor is a gastrointestinal sign and symptom of end-stage kidney disease that should be reported but it is not the first priority. 2. Incorrect: Disorientation is a sign and symptom of end-stage kidney disease but the stem does not indicate the client is disoriented at this time so a room closest to the nurse's station is not the priority. 3. Incorrect: The client may need assistance with bathing and dressing but this is not the priority at this time.

A client admitted with a diagnosis of end stage kidney disease (ESKD) has been prescribed a diet containing no more than 1 gram of phosphate per day. Which food item, if found on the client's meal tray should be removed by the nurse? 1. Skinless chicken breast 2. Green beans 3. Asparagus 4. Ice cream

4. Correct: Ice cream, a milk product is high in phosphate. 1. Incorrect: Fresh or frozen red meats without breading, marinades or sauce are better choices for a kidney diet. On average, fresh meat contains 65 mg of phosphorus per ounce and 7 grams of protein per ounce. A 3 ounce serving would have 150 mg of phosphorus. 2. Incorrect: Green peas, green beans and wax beans are low in phosphate, whereas black-eyed peas, lima beans, kidney beans, pinto beans, and lentils are high in phosphate. 3. Incorrect: A serving of asparagus has approximately 20 mg of phosphorus.

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

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

A postpartum client who is 2 hours post vaginal delivery remains on a oxytocin infusion for bleeding. Upon examination, the nurse determines that the client's fundus is boggy and soft. What is the priority nursing intervention? 1. Ambulate in the room 2. Perform crede' exercises 3. Reassess the fundus in 30 minutes. 4. Massage the fundus.

4. Correct: If the fundus is boggy and soft, massaging the fundus until firm will increase uterine tone and decrease bleeding. This is the only option that will fix the problem. 1. Incorrect: Ambulation will not fix a boggy fundus and would not be safe. 2. Incorrect: Crede' exercises are for bladder tone. Although urinary retention will prevent uterine contraction, the appropriate nursing intervention in the case of a full bladder is to have the client empty her bladder or to catheterize her if she is unable to void. 3. Incorrect: Postponing care could make the bleeding worse. This is delaying care.

The edrophonium (Tensilon) test has been prescribed for a client. Which statement by the client would indicate to the nurse that the client understands this test? 1. "This medication will be given to me as an IM injection immediately after my muscles are tired." 2. "This test will determine if I have multiple sclerosis." 3. "The test is positive if my muscles do not get stronger after injection with this medication." 4. "I will be asked to perform a repetitive movement to test my muscles."

4. Correct: If the primary healthcare provider suspects myasthenia gravis (MG), the client will be asked to perform a repetitive movement to test a group of muscles. 1. Incorrect: The medication is given IVP after the muscle group has become fatigued. 2. Incorrect: The edrophonium (Tensilon) test is used to diagnose myasthenia gravis. 3. Incorrect: A person tests positive for MG if their muscles get stronger after being injected with edrophonium (Tensilon).

A client arrives at the emergency room with chest pain, dyspnea and diaphoresis, stating "I think I am going to die." What would be the most appropriate comment by the nurse? 1. "We will do everything we can for you." 2. "Would you like me to call your family?" 3. "What makes you think you are going to die?" 4. "Have you ever had these symptoms before?"

4. Correct: If you assume the worse here, then you must think the client could be having an MI. Remember Maslow: Fix physiologic problems before psychological problems. Determining whether the client has a history of cardiovascular disease, or even panic attacks, can help contribute to a positive outcome. 1. Incorrect: Even though this is a true statement, it does not address the client's expressed fear of dying. The nurse's comment is close-ended and can actually frighten the client more because of its possible implications. 2. Incorrect: The nursing focus has shifted to family rather than the client's present physical and emotional needs. The nurse should focus on the client at this point rather than presuming the client wants to have family present. This comment may even worry the client about the severity of the condition. 3. Incorrect: This question demands an explanation from the client about an emotional response in a frightening situation. Most clients cannot identify a reason for a specific emotional response; however, an answer would not contribute in any way to the ultimate outcome.

A client performed a home pregnancy test and received a positive result. She arrives at the clinic for her first prenatal visit. She reports to the nurse that her last menstrual cycle was December 26, 2019. Based on the Naegele's Rule, when is the estimated date of confinement (EDC)? 1. September 3, 2020 2. September 26, 2020 3. October 2, 2020 4. October 3, 2020

4. Correct: In order to determine the EDC, the nurse will perform the calculation by following three steps: First, determine the first day of the client's last menstrual period which was December 26, 2019. Next, count back 3 calendar months from that date, which would be September, 26, 2019. Lastly, add 1 year and 7 days to that date. Adding one year would make it September 26, 2020. Then add the 7 days, remembering that September has 30 days. The calculated EDC would be October 3, 2020. 1. Incorrect. Counting back 3 months from the first day of the last menstrual period would be September 26 2019, but you have to add one year (September 26, 2020) and then add 7 days. This would make the due date in October, not September. The due date would be October 3, 2020. 2. Incorrect. Counting back 3 months from the first day of the last menstrual period would be September 26, 2019. When you add one year, that would make it September 26, 2020. But you are not through yet. You still must add 7 days to that which carries it over to October 3, 2020. 3. Incorrect: Counting back 3 months from the first day of the last menstrual period would be September 26, 2019. When you add one year, that would make it September 26, 2020. You still must add 7 days to that. There are 30 days in September. Counting would be September 27, 28, 29, 30, Oct. 1, 2, and Oct 3 which is the 7th day and would make the due date October 3, 2020.

A child is admitted to the emergency department due to suspected ruptured appendicitis with perforation. What would be the priority nursing assessment for this client? 1. Monitor for the Rovsing sign. 2. Assess for an increase in temperature. 3. Check for rebound tenderness at McBurney's point. 4. Monitor for increasing pain and rigidity of the abdomen.

4. Correct: Increasing pain and rigid, board-like abdomen are signs that the appendix may have ruptured, with resulting peritonitis developing. 1. Incorrect: The Rovsing Sign results in RLQ pain that occurs with palpation of the LLQ. This suggests peritoneal irritation due to palpation of a remote location and would indicate appendicitis. 2. Incorrect: Although children with appendicitis may have an elevated temperature, the priority would be assessing for the signs of peritonitis which include increasing pain and rigidity of the abdomen. Children can have an increased temperature with many different types of inflammation and infections. 3. Incorrect: Although rebound tenderness at McBurney's point is indicative of appendicitis, the nurse should not check for this due to the possibility of rupturing the appendix.

The nurse is caring for a client with tuberculosis receiving isoniazid therapy. Because of the possible peripheral neuropathy that can occur, which supplementary nutritional agents would the nurse expect to administer? 1. Cyanocobalamin 2. Vitamin D 3. Ascorbic acid 4. Pyridoxine

4. Correct: Isoniazid interferes with vitamin B6 (pyridoxine) metabolism by inhibiting the formation of the active form of vitamin B6. This interference often results in peripheral neuropathy. 1. Incorrect: Vitamin B12 (Cyanocobalamin) is not given to prevent peripheral neuropathy caused from isoniazid therapy. It is used to treat vitamin B12 deficiency often caused by pernicious anemia. It may be given in client's with peripheral neuropathy, but is not beneficial in clients whose neuropathy is due to isoniazid therapy. 2. Incorrect: Vitamin D is not given to prevent peripheral neuropathy. It is used in the treatment of weak bones, bone pain and/or bone loss.3. Incorrect: Vitamin C is not given to prevent peripheral neuropathy cause from isoniazid therapy. It's use can be beneficial in clients with diabetic peripheral neuropathy.

During morning report, the nurse learns that a client's call bell is not working and maintenance cannot do repairs until tomorrow. The nurse is aware that the safest temporary method for the client to signal staff is what? 1. Provide a hand-held bell for client to ring. 2. Ask family to stay with client to alert staff. 3. Tell client to call out loudly to the staff. 4. Have staff visit client's room every 15 minutes.

4. Correct: It is vital for clients to be able to contact or alert staff for needs and concerns. The safest method is for the staff to check on the client at specified intervals. This will help alleviate client concerns about being able to signal the staff while ensuring that someone actually observes the client. 1. Incorrect: While a hand-held bell could be an option, it is not reliable. The client could easily push it onto the floor, or it could become tangled in the linens. Additionally, depending on the noise level of the unit, a hand bell could either disturb other clients or not be heard by staff. 2. Incorect: It is not the responsibility of the family to sit with the client 24/7 just because the hospital has non-working equipment. Not only would this be an imposition, it violates most visiting policies and places the burden on the family. 3. Incorrect: Having a client call out to staff is both inefficient and unsafe. Assuming the client's voice is even loud enough to be heard, it is unlikely that the verbalizations of one client could be distinguished from others that may call out because of dementia or normal nighttime utterances. This is not safe.

A nine year old child with attention deficit hyperactivity disorder (ADHD) is being admitted to the pediatric unit. Who should the charge nurse assign this client to room with? 1. Ten year old with Crohn's disease. 2. Eight year old with a history of seizures. 3. Six year old admitted with asthma. 4. Seven year old with a urinary tract infection.

4. Correct: It would be best to pair this child with the child with a urinary tract infection. They are close to the same age and this child's condition does not require a quiet environment that could be interrupted by a hyperactive child. 1. Incorrect: The ADHD clients behavior could be detrimental to the client's Crohn's disease. Crohn's disease is not caused by stress but it can make signs and symptoms worse and may trigger flare-ups. 2. Incorrect: You want to decrease stimulation when you have a client with seizures not increase it. Seizures can be precipitated by sensory stimuli. 3. Incorrect: Again, the client with asthma does not need any stimuli that could cause agitation and stress. Stress can trigger the release of chemicals like histamine and leukotriences which can trigger narrowing of the airways.

A term primipara is admitted in active labor and with rupture of membranes. Her last vaginal exam one hour ago revealed that she was dilated to 6 centimeters, 100% effaced, and at -1 station. The client calls out "My belly really hurts. I feel like I have to have a bowel movement!" Which action should the nurse perform first? 1. Offer her a bedpan. 2. Call the primary healthcare provider. 3. Prepare for epidural administration. 4. Perform a sterile vaginal exam.

4. Correct: Labor can progress rapidly even in a primipara. As the fetal presenting part descends, pressure is placed on the rectum and many women report that it feels as though they need to have a bowel movement. The symptoms described indicate that the client has fully dilated and is at +1 or better station, and delivery may be imminent. 1. Incorrect: The nurse should first determine labor progress with a vaginal exam since this complaint is a common symptom of labor progressing and the fetus descending through the birth canal. Often, the client has had an enema to cleanse the colon prior to delivery so there usually is no fecal material present. 2. Incorrect: First determine labor progress with a vaginal exam. This might be necessary later, but is not the first action to perform. 3. Incorrect: First determine labor progress with a vaginal exam prior to preparing the client for anesthesia.

The nurse enters a client's room and finds the client masturbating. Which action by the nurse would be most appropriate for the nurse to take? 1. Ask the client to stop 2. Remain in the room until client has finished. 3. Document the activity in the client's chart. 4. Quietly leave the room

4. Correct: Leaving the client's room, allows the client to have privacy. The client has the right to express self sexually in private. 1. Incorrect: The client has a right to express sexuality through masturbation, which is a normal way of finding sexual release.2. Incorrect: Ignoring the behavior and continuing presence in the room will embarrass the client. 3. Incorrect: The nurse can chart the client's sexual activity in the chart. However, when the nurse enters the client's room and finds the client masturbating, the nurse first needs to leave the client's room quietly.

A client asks the nurse, "What causes hypermagnesemia?" The nurse should explain 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 first generation Hispanic-American has been admitted to the psychiatric unit after being diagnosed with severe panic disorder. When developing the plan of care for this client, to which cultural background information should the nurse give priority? 1. Discuss treatment in terms of future plans for this client. 2. Do not use touch when communicating with this client. 3. Include the Protestant minister in the spiritual care of the client. 4. Allow family members to visit regularly.

4. Correct: Make allowances for individuals from other cultures to have family members around them and even participate in their care. Large numbers of extended family members are very important to African Americans, Native Americans, Asian Americans, and Hispanic-Americans. Denying access to these family support systems could interfere with the healing process. 1. Incorrect: Hispanic-Americans are more present oriented. They may be late to appointments and appear to be indifferent to some aspects of their therapy. Be accepting of these differences and refrain from allowing existing attitudes to interfere with delivery of care. 2. Incorrect: Hispanic-Americans have close personal space and use lots of touching and embracing.3. Incorrect: Hispanic-Americans are most often Roman Catholic. The nurse needs to ask about religious preferences first.

An expectant HIV positive client asks why zidovudine (ZDV) must be continued throughout the pregnancy. What is the best explanation by the nurse? 1. "The medication permits safe breastfeeding after delivery." 2. "It protects you against other infections during pregnancy." 3. "This drug prevents transmission of HIV to your partner." 4. "ZDV decreases the chance the baby will contract HIV."

4. Correct: New advances in the treatment of HIV have decreased the chances of transmitting the HIV virus from mother to fetus from 25% without treatment to less than 2 % with treatment. Several HIV medications have been shown to be safe for both the fetus and mother, including ZDV. The nurse is presenting the most complete, accurate information with this statement. 1. Incorrect: Even with treatment, most primary healthcare providers discourage breast-feeding after birth since the HIV virus has been shown to be transmitted through breast milk. The use of ZDV or other antiviral medications cannot completely eradicate the virus from breast milk, though some pediatricians allow breastfeeding under certain circumstances. 2. Incorrect: The use of antiviral medications, including ZDV, does not protect the client from contracting other acquired infections. The medication is strictly for the purpose of decreasing the chances of passing HIV to the fetus, and requires the mother to precisely follow the dosing regime and other healthy habits to increase its effectiveness. 3. Incorrect: While the use of antiviral medications during pregnancy can decrease the chances of the mother passing the virus to the fetus, the medication does not prevent transmission of the disease to the client's partner. This statement is incorrect.

A client has received 850 mL of an isotonic solution intravenously in less than 60 minutes. Which central venous pressure (CVP) reading noted by the nurse indicates a problem related to the amount of intravenous fluids infused? 1. 1 mm of Hg 2. 3 mm of Hg 3. 6 mm of Hg 4. 10 mm of Hg

4. Correct: Normal CVP is 2-6 mmHg. This client has received an isotonic solution amount of time. Remember that isotonic fluids stay "where I put them". The vascular space will increase in volume. More volume, more pressure! 1. Incorrect: This CVP reading indicates fluid volume deficit. There is no indication in the stem that the client is losing fluid. 2. Incorrect: This is a normal CVP reading. Normal CVP is 2 to 6 mm of Hg. 3. Incorrect: This is a normal CVP reading. Normal CVP is 2 to 6 mm of Hg.

A post-operative client has received morphine for pain. The nurse re-assesses the client 10 minutes later. Which assessment data warrants further action by the nurse? Exhibit B/P 110/76, Pulse 68, Respirations 8, Pain level of 5, dressing dry and intact. 1. Blood pressure 94/60 2. Pulse rate 72/min 3. Pain level 3/10 4. Respiratory rate at 8/min

4. Correct: Normal respiratory rate is 12-20 per minute. The respiratory rate indicates respiratory depression following administration of an opioid. Care should be taken to titrate the dose so that the patients pain is controlled without depressing the respiratory function. 1. Incorrect: Respiratory rate warrants immediate action. However, blood pressure will continue to be monitored. 2. Incorrect: Pulse rate warrants no further action. Pulse rate is normal.3. Incorrect: The pain level is expected following surgery. The client should continue to have a reduction on pain, as 10 minutes is not long enough to fully evaluate.

What action is most important for the nurse to take when a client receiving a cephalosporin develops abdominal cramping and diarrhea? 1. Administer antidiarrheal medication. 2. Increase fluid intake. 3. Provide food with the medication. 4. Notify the healthcare provider.

4. Correct: Notify the healthcare provider if diarrhea occurs as it can promote the development of Clostridium difficile infection. Cephalosporin difficile is a toxin producing bacteria that causes antibiotics-associated colitis, and can occur with antibiotic therapy. Cephalosporin is one of the most common antibiotics that cause clostridium difficile. 1. Incorrect: Taking a probiotic, stopping the antibiotic or switching to another antibiotic are standard treatments for antibiotic induced diarrhea. Administering an anti-diarrheal is not recommended for antibiotic induced diarrhea. 2. Incorrect: Increasing fluid intake will help with the associated dehydration seen with diarrhea, but will not correct the problem or decrease the risk of clostridium difficile. 3. Incorrect: If the client has GI upset, then cephalosporin may be given with food, however, the most important thing to worry about is the development of Clostridium difficile infection. So notifying the healthcare provider is the most important action.

The nurse is caring for a client and the family at a time of impending death for the client. What comment by the nurse would best assist the family to cope with their grief during this time? 1. "Don't cry. Your family member would not want it this way." 2. "Things will be fine. You just need to give yourself some time." 3. "Try not to be upset in front of your family member." 4. "I'm so sorry. This must be very difficult for you."

4. Correct: Nurses can best facilitate the family's expressions of grief by supporting and encouraging them to express themselves. This is the best option that best demonstrates that expressions of grief are acceptable and expected. Here, you are empathizing to provide emotional support during their grief and providing an open ended statement that would promote expression of the family members' grief. 1. Incorrect: Telling grieving family members not to cry is certainly not very therapeutic. They need to feel free to express their emotions of grief at the time of impending death of the loved one. This statement would be a barrier to demonstrating care and concern. 2. Incorrect: Telling the family that things will be fine and to give themselves time are trite assurances and clichés that should be avoided by the nurse. Instead, you should use therapeutic responses that promote the expressions of grief by the family. 3. Incorrect: Again, by telling them to try not being upset in front of the dying family member, this is not demonstrating care and compassion to the family members who are grieving. This would be a barrier to assisting them to communicate and express their feelings of grief.

An Orthodox Jewish client receives the following lunch tray. What is the nurse's priority action? Exhibit Lunch Menu: Spaghetti and meatballs in sauce Tossed salad with vinegrette dressing Hot rolls with butter Dessert: Fruit cocktail or cookie Milk - coffee available 1. Nothing, since this is a healthy and acceptable lunch. 2. Ask the client to eat the lunch so food is not wasted. 3. Remove the tossed salad so the client can eat the other foods provided. 4. Call dietary to immediately make a new tray for the client.

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

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

4. Correct: One potential risk during a thyroidectomy is the accidental removal of some or all of the parathyroid glands. The client would develop signs and symptoms of hypocalcemia from decreased blood levels of calcium. As muscles become rigid and twitch, the resulting tetany would cause the client to experience a tingling sensation in toes and fingers. The nurse needs to notify the primary healthcare provider so that a calcium level can be drawn and the client given supplemental calcium. 1. Incorrect: Following a transurethral resection of the prostate (TURP), it is normal for urine to be cherry red in color. Continuous bladder irrigation will keep clots from developing over several days and the deep red color of urine is an expected finding following this procedure. 2. Incorrect: Mastectomy clients return from surgery with one or more drains placed under skin flaps in the breast tissue. These drains are part of a collection system that allows serous drainage to be removed from the surgical site, thus enhancing the healing process. Because this client has just returned from surgery, 40 mL over 3 hours is not an excessive amount. This is an expected finding that does not need to be reported. 3. Incorrect: The sign of a healthy stoma immediately post-op is a beefy red appearance and slightly elevated above the level of the abdomen. It is expected that the stoma will have a mucoid discharge for a day or so until normal stool begins to form again. This client displays normal post-operative findings with nothing unexpected.

A military veteran with a history of post-traumatic stress disorder (PTSD) has arrived at the Crisis Center reporting an increase in nightmares, depression and anxiety. The nurse is aware the client would obtain the most immediate relief with what intervention? 1. Increase dose of antianxiety medications. 2. Greater family support interaction. 3. Referral to community support group. 4. Opportunity to verbalize memories.

4. Correct: PTSD is an emotional response to a traumatic event, usually beginning within several months of the event, although it can be delayed for years. When a client in severe distress arrives at the Crisis Center, the priority intervention must focus on relief of client's symptoms. The best non-invasive method to alleviate symptoms is encouraging the client to verbalize both memories and feelings. Though some individuals want to forget the incident, most clients experience a decrease in anxiety by discussing the event. 1. Incorrect: While it is true that a component of PTSD treatment involves either antianxiety or antidepressant medications, these drugs take several weeks to become effective. The nurse needs to provide an intervention that will give the client more immediate relief. 2. Incorrect: Clients with PTSD generally do benefit from family support and interaction, especially during periods of increased symptoms. However, the question requests a nursing action that would assist the client in crisis now. 3. Incorrect: Support groups are always beneficial for individuals experiencing long term problems, and are an invaluable resource to both client and family members. However, this question asks how the Crisis Center nurse could intervene to assist at this moment. This choice is a long term solution.

PSYCHOSOCIAL INTERGRITY A military veteran with a history of post-traumatic stress disorder (PTSD) has arrived at the Crisis Center reporting an increase in nightmares, depression and anxiety. The nurse is aware the client would obtain the most immediate relief with what intervention? 1. Increase dose of antianxiety medications. 2. Greater family support interaction. 3. Referral to community support group. 4. Opportunity to verbalize memories.

A client has been started on intravenous gentamicin for osteomyelitis. The nurse informs the client frequent blood work will be done to monitor the amount of medication in the body. The nurse knows what labs are a priority to check every three days for the client? 1. BUN and creatinine. 2. Liver function studies. 3. Hemoglobin and hematocrit. 4. Peak and trough levels.

4. Correct: Peak and trough levels help to determine the amount of medication in the body system at specific times. Gentamicin is a very potent antibiotic; therefore, it is crucial to keep track of blood levels of this medication. Too low a level of this drug would be ineffective against the bacteria while too high a level increases the potential for severe side effects or toxicity from this antibiotic. 1. Incorrect: Because aminoglycosides such as gentamicin can lead to nephrotoxicity, checking BUN and creatinine levels periodically is important. However, it would not be necessary to check those values every three days. 2. Incorrect: Aminoglycosides like gentamicin rarely affect the liver; therefore, liver function studies would not be needed frequently. 3. Incorrect: Hemoglobin and hematocrit levels are rarely impacted by aminoglycosides such as gentamicin. Although an initial level may be obtained prior to treatment, additional levels are not necessary.

The nurse instructs a client taking isoniazid for the treatment of tuberculosis (TB) regarding appropriate food choices. Which food choices indicate to the nurse that teaching has been successful? 1. Salad with bleu cheese dressing. 2. Smothered liver with onions. 3. Smoked salmon with crackers. 4. Pear salad with lettuce.

4. Correct: Pears are acceptable fruit. Foods high in tyramine can cause headaches, fast or irregular heartbeats, nausea and vomiting and sensitivity to light. Foods high in tyramine such as aged cheeses, certain meats, liver, moked fish, sour cream, raisins, bananas and avocados should not be eaten when taking isoniazid. 1. Incorrect: Avoid foods high in tyramine. Foods high in tyramine such as salad with bleu cheese dressing can result in severe reactions when client is taking isoniazid. 2. Incorrect: Avoid foods high in tyramine. Foods high in tyramine such as smothered liver with onions can result in severe reactions when client is taking isoniazid. 3. Incorrect: Avoid foods high in tyramine. Foods high in tyramine such as smoked salmon can result in severe reactions when client is taking isoniazid.

Which intervention should the nurse recommend to the adult child who is caring for an elderly parent diagnosed with Alzheimer's disease (AD)? 1. Give parent a small dog for company and comfort. 2. Reset the water heater to 125 degrees Fahrenheit (51.67 degree Celsius) to prevent burns. 3. Place mirrors in multiple locations so parent sees images of self. 4. Make floors and walls different colors.

4. Correct: People with Alzheimer's disease (AD) get more confused over time. They also may not see, smell, touch, hear and/or taste things they once did. By creating a contrast in color between the floors and walls makes it easier for the person with AD to see. 1. Incorrect: Be careful with small pets. The person with AD may not see the pet and trip over it. This is a safety issue. A fall could cause a major injury to the client. 2. Incorrect: The water heater should be set below 120 degrees Fahrenheit (48.8 degrees Celsius) to prevent burns. 3. Incorrect: Limit the size and number of mirrors in the home. Mirror images may confuse the person with AD. They may not recognize self and may see the person as a stranger.

A client taking phenelzine is admitted to the hospital. Which healthcare provider prescription should the nurse question? 1. Take blood pressure lying, sitting, and standing once per shift. 2. Order a complete blood count and liver profile studies. 3. Eliminate foods containing tyramine from diet. 4. Discontinue phenelzine. Begin fluoxetine 20 mg by mouth at bedtime.

4. Correct: Phenelzine is a non-selective monamine oxidase inhibitor (MAOI). Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). Both of these medications are antidepressants, but are in different drug classifications. They should not be taken in combination due to the risk of serotonin syndrome. Additionally 2 weeks should be allowed for phenelzine to be cleared from the body before starting a different classification of antidepressant. There should be at least two weeks between giving phenelzine and fluoxetine.1., 2., 3. Incorrect: These are correct prescriptions/interventions for this client. Clients taking antidepressants can have a sudden drop in blood pressure upon rising. Instruct them to rise slowly. The liver can be affected by these drugs so routine liver screening is acceptable. Foods containing tyramine can lead to hypertensive crisis when ingested while taking a monoamine oxidase inhibitor (MAOI).

A nurse enters a client's room to find the client on the floor having a seizure. Which nursing action is appropriate for this client? 1. Hold the client's arms and legs. 2. Insert a padded tongue blade in the client's mouth. 3. Assist the client back into the bed. 4. Place a rolled towel under the client's head.

4. Correct: Placing a rolled towel 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.

What room assignment would be best for the nurse to make for a primigravida with gestational diabetes who was admitted for glycemic control? 1. A private room near the nurses' station. 2. A room with a client admitted with a placenta previa. 3. A room with a client in preterm labor. 4. A room with a client admitted with pregestational diabetes.

4. Correct: Placing clients with similar diagnoses together can result in information sharing and emotional support. It is ok to put these two clients together. 1. Incorrect: A private room is not required since the client has no emotional or infection control issues. Also, it is not necessary to place them near the nursing station because they do not need monitoring on that close of a level. 2. Incorrect: A client with placenta previa is in an unstable state and can have emotional issues concerning this diagnosis. The client would be best in a private room. 3. Incorrect: The client in preterm labor needs a private room that is quiet with limited visitors, she is having issues herself and concerned about her unborn child.

The parents of a nine month old ask the nurse for toy recommendations. What recommendation should the nurse to make? 1. Mobile 2. Tricycle 3. Marbles 4. Pull toy

4. Correct: Push and pull toys. These come in handy at about 9 months, or when your baby attempts to walk by holding onto something. 1. Incorrect: Once a child can reach a mobile it should be taken down. It is then a safety hazard. 2. Incorrect: At this age the toddler is learning to walk. Tricycles are appropriate for the 4-5 year old. 3. Incorrect: Everything goes to the mouth at this age. Small toys such as marbles are a choking hazard.

A nurse is providing education to a client regarding the use of an inhaler for acute asthma symptoms. Which statement made by the client would indicate the need for further teaching? 1. "I should shake the inhaler well before use." 2. "I should breathe out slowly and completely through my mouth before placing the mouthpiece of the inhaler in my mouth." 3. "I should hold my breath for approximately 8-10 seconds before exhaling slowly." 4. "I should administer the two puffs that are ordered in rapid sequence.

4. Correct: Rapid sequencing of the puffs is not a correct measure for using an inhaler. The client should wait 1 minute between puffs. This statement indicates the need for further teaching. 1. Incorrect: This is a correct measure that should be followed when using an inhaler. Clients are instructed to shake the inhaler well before use. 2. Incorrect: This is a correct measure that should be followed when using an inhaler. Clients are instructed to exhale slowly before bringing the inhaler to the mouth. 3. Incorrect: This is a correct measure that should be followed when using an inhaler. After removing the inhaler from the mouth, clients are instructed to hold their breath for 10 seconds, then breath out slowly.

A client comes into the clinic reporting muscle pain and tenderness but denies previous injury. Based on data gathered by the nurse, what client medication does the nurse suspect is causing this problem? Exhibit Lab Nursing Notes CPK: 300 U/L ALT: 38 U/L AST: 42 U/L 1. Captopril 2. Furosemide 3. Nadolol 4. Rosuvastatin

4. Correct: Rosuvastatin is a lipid-lowering agent. All lab work is abnormal and indicates muscle and liver damage. Lipid-lowering drugs can cause liver damage. The assessment of the lab values reveals muscle damage and could indicate rhabdomyolysis development. Creatine phosphokinase: males 55-170 u/L and females 30-135 u/L; Alanine aminotransferase (ALT): 4-36 u/L; Aspartate aminotransferase (AST): 0-35 u/L 1. Incorrect: Captopril does not affect the liver or muscle. Captopril is an angiotensin-converting enzyme (ACE) prescribed for treatment of hypertension. 2. Incorrect: Furosemide does not affect the liver or muscle. Furosemide is a loop diuretic which promotes diuresis. 3. Incorrect: Nadolol does not affect the liver or muscle. Nadolol is a non-selective beta blocker. The action of nadolol is to treat arterial fibrillation, hypertension, migraines and chest pain

What instruction would the nurse give a client about a newly prescribed salmeterol inhaler? 1. "Use the inhaler immediately if wheezing and shortness of breath occur during exercise." 2. "Use the inhaler when you experience a stuffy nose due to seasonal allergies." 3. "Carry the inhaler with you at all times and take 2 puffs anytime you experience an exacerbation." 4. "This inhaler should be used routinely as prescribed even when free of symptoms."

4. Correct: Salmeterol is a maintenance medication. It can prevent asthma attacks and exercise induced bronchospasm. Salmeterol acts as a bronchodilator. It works by relaxing muscles in the airways to improve breathing. 1. Incorrect: Salmeterol can be used to help prevent exercise induced bronchospasm, but it should be taken 30 to 60 minutes before exercise. 2. Incorrect: Salmeterol is indicated for asthma only and bronchospasm induced by obstructive pulmonary disease. It is not indicated for seasonal allergies. 3. Incorrect: Salmeterol is a maintenance medication. Albuterol is used as a "rescue inhaler" for bronchospasms.

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

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

Which finding should take priority when the nurse is assessing the skin of a client diagnosed with diabetes? 1. Vitiligo of the chest. 2. Scleroderma to scapula and posterior neck region. 3. Redness of face and upper chest. 4. Small abrasion on great toe.

4. Correct: Skin breakdown on the foot is priority. Healing is likely to be impaired and the abrasion can be an entry point for microorganisms. There maybe other risk factors observed in the assessment; however, this finding should receive priority.1. Incorrect: Vitiligo is a skin problem commonly associated with type I diabetes. The melanin containing cells are destroyed, resulting in patches of discolored skin. Vitiligo poses no harm to the client.2. Incorrect: Scleroderma affects people with type 2 diabetes causing thickening of the skin to the upper back and neck. Scleroderma poses no harm to the client. 3. Incorrect: Redness should be noted and reasons found; however, this is not the priority finding. Redness/flushing can be due to many conditions but poses no obvious harm to the client.

The nurse is caring for a client diagnosed with schizophrenia who is admitted to the hospital for possible bowel obstruction. The client has a nasogastric tube (NG) and reports pain 8/10. What is the priority nursing action? 1. Decrease the stimuli and observe frequently. 2. Administer the prn sedative. 3. Call the primary healthcare provider immediately. 4. Administer the prn pain medication.

4. Correct: Small bowel obstruction has a clinical manifestation of crampy pain that is wave like and colicky due to persistent peristalsis above and below the blockage. Nursing care of the patient includes pain management. 1. Incorrect: Decreasing the stimuli and observing are not appropriate. The pain needs to be assessed and treated.2. Incorrect: Not necessary, it will sedate them, but not help the pain. Sedation is not a necessary intervention for pain. A medication to relieve pain is needed. 3. Incorrect: The nurse can administer pain medication as ordered. There is no need to contact the healthcare provider.

A female client who identifies herself as a Muslim arrives at the outpatient clinic with abdominal pain. Which initial question should the nurse ask to obtain cultural information? 1. "Do you need a family member in the room with you?" 2. "What can you tell me about your culture?" 3. "Have I positioned you so that you are facing toward Mecca?" 4. "Are you comfortable being cared for by a male primary healthcare provider?"

4. Correct: Some Muslims will not feel comfortable with an RN or MD of the opposite gender. The nurse needs to find out prior to treatment. 1. Incorrect: Family is often important in this culture and the client may want a family member present. But initially, the nurse needs to find out who will need to care for the client. Is a male care giver acceptable? 2. Incorrect: The nurse needs to know about this culture, but most importantly, the nurse needs to know what, if any of their culture, is followed by the client. 3. Incorrect: A devout Muslim will prayer 5X a day. Bed-bound clients need to be positioned towards Mecca. It is not necessary for the client to continually face Mecca.

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

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

Four clients are admitted to the medical-surgical unit. The nurse is aware that what client will need standard precautions only? 1. The client with chicken pox. 2. The client with rubeola. 3. The client with impetigo. 4. The client with pancreatitis.

4. Correct: Standard precautions are observed with all clients admitted to the hospital, without the need for additional safeguards. The client with pancreatitis is not contagious and does not present any unique concerns other than the need for gloves and hand washing. 1. Incorrect: Chicken pox, also known as varicella zoster, requires airborne precautions. The virus can be spread through contact with the droplets, either touching or inhaling the droplet, while providing care for this client. 2. Incorrect: Measles, also called rubeola, is spread through droplet contact with the contaminated individual, including inhalation of the droplets. Airborne precautions are necessary when caring for a client diagnosed with rubeola. 3. Incorrect: Impetigo is a severe skin infection characterized by itchy, red, fluid-filled blisters caused by either staphylococcus or streptococcus bacteria. This skin infection is highly contagious, and requires contact precautions to protect staff and visitors.

A nurse is caring for a client who has been prescribed sucralfate. Which client education intervention would the nurse include for the client prescribed sucralfate? 1. Take medication 1 hour after meals. 2. Crush tablets prior to taking medication. 3. Consume 1000 mL of fluid every 24 hours. 4. Avoid antacids 1 hour before and after this medication.

4. Correct: Sucralfate is absorbed more effectively in an acidic state. Since an antacid medication will increase the alkaline state, the client should avoid taking antacids within 1 hour before or after taking sucralfate to increase the absorption rate of sucralfate. 1. Incorrect: Sucralfate should not be taken 1 hour after a meal. To increase the absorption of sucralfate the medication should be taken on an empty stomach when the stomach is more acidic. 2. Incorrect: Clients should not crush, or chew sucralfate tablets. The outer layer of the tablet has specific formulated pharmacokinetic properties that should not be crushed or chewed. 3. Incorrect: A potential side effect of sucralfate is constipation. An increase of fluids during the medication therapy is recommended to decrease the side effect of constipation. An intake of 1000 mL of fluid per 24 hours intervention is not enough fluid to reduce the possibility of constipation.

An elderly client comes to the clinic for a check-up. The client's daughter tells the nurse that her father's dementia symptoms become increasingly more difficult to handle in the evening. How would the nurse document this symptom? 1. Confabulation 2. Apraxia 3. Pseudodementia 4. Sundowning

4. Correct: Sundowning is a phenomenon where symptoms seem to worsen in the late afternoon and evening. Communication becomes more difficult, with increasing loss of language skills. Institutional care is usually required at this stage. 1. Incorrect: Confabulation is the term used for creating imaginary events to fill in memory gaps. This is sometimes associated with dementia, but more often with disorders like Korsakoff's syndrome, traumatic brain injuries or tumors. 2. Incorrect: Apraxia is the term used for the inability to carry out motor activities despite intact motor function. 3. Incorrect: Pseudodementia is depression. Depression is the most common mental illness in the elderly, but it is often misdiagnosed and treated inadequately. Cognitive symptoms of depression may mimic dementia.

A nurse is caring for a client that is lethargic and has the following ABGs: pH = 7.32, PaCO2 = 48, HCO3 = 28, O2 = 93%. What medication could contribute to these blood gases?

Select All 1. Fentanyl 2. Bumetanide 3. Prednisone 4. Promethazine 5. Lorazepam 6. Famotidine 1,4,5

The parents of a 1 month old report that their baby wakes up startled and stretches out the arms throughout the night. What suggestion should the nurse provide to the parents to decrease this reflex? 1. Rock to sleep. 2. Place in a baby swing. 3. Provide a pacifier. 4. Swaddle the baby.

4. Correct: Swaddling makes the baby feel more secure and decreases the baby's sense of falling. 1. Incorrect: The nurse wants to suggest something that will decrease the baby's sensation of falling. Rocking the baby will not accomplish this. 2. Incorrect: This startling occurs when the baby has a sense of falling. Placing in a baby swing will not decrease this response. 3. Incorrect: The nurse wants to suggest something that will decrease the baby's sensation of falling. A pacifier will not accomplish this.

A nurse is assessing a client with abdominal surgery 24 hours postop. Which assessment finding would require an immediate intervention? 1. The nasogastric (NG) tube contents are pale green. 2. An abdominal dressing with the tape on 3 sides of the dressing. 3. Abdominal pain of 5 on 10 point pain scale when client coughs. 4. A bulb-shaped Jackson-Pratt (JP) drain with 25 mL of sanguineous drainage.

4. Correct: The JP drain should be addressed first. The purpose of the JP drain is to remove fluids adjunct to the surgical site by suction. The JP bulb should be continually compressed to create suction in the tube which will remove fluid. The compression of the bulb is released when the fluid in the bulb is emptied and then recompressed. 1. Incorrect: The description of the contents in the NG tube are green. This is indicative of a normal finding of stomach contents. The gastric contents are usually cloudy and green. 2. Incorrect: The question does not indicate any drainage occurring along the side that is not taped. Taping the dressing on all four sides is not the immediate nursing intervention. 3. Incorrect: When the client coughs, the abdominal muscles contract. The resulting movement of the incision site will result in the client experiencing pain. The client's pain should be addressed, but this is not the immediate nursing intervention.

A client was admitted to the medical unit after an acute stroke. Which nursing activity can the registered nurse delegate to the LPN/VN? 1. Screen client for contraindications for tissue plasminogen activator (tPA) therapy. 2. Place seizure precaution equipment in client's room. 3. Perform passive range of motion (ROM) exercises. 4. Administer enoxaparin 1 mg/kg subcutaneously every 12 hours.

4. Correct: The LPN/VN can administer subcutaneously medications. 1. Incorrect: This is an RN only responsibility and cannot be delegated. 2. Incorrect: The unlicensed assistive personnel (UAP) can be assigned to place equipment in a client's room. 3. Incorrect: Passive ROM exercises can be done by the UAP.

The nurse is monitoring care provided to clients by a newly hired unlicensed assistive personnel (UAP). Which action by the UAP would require the nurse to intervene? 1. Uses a gait belt when ambulating a client with right sided weakness. 2. Repositions a client in bed using a lift sheet. 3. Disconnects nasogastric (NG) tube from suction to allow ambulation to toilet. 4. Massages a surgical client's calf after reports of leg cramping.

4. Correct: The UAP could dislodge a blood clot in the leg when massaging the calf. The nurse should intervene on behalf of the client. 1. Incorrect: Placing a gait belt prior to ambulating a client is an appropriate action for safety and would not require intervention by the nurse. 2. Incorrect: Using a lift sheet will help prevent injury to the client. The lift sheet decreases shearing that can occur when pulling a client up in the bed. It also allows for positioning without holding onto parts of the client's body, which could result in injury. 3. Incorrect: Disconnecting the NG tube from suction is an appropriate task for the UAP. Suction should be reconnected by the nurse, so that correct pressure is checked.

A nurse delegates an unlicensed assistive personnel (UAP) to transfer a client from the bed to a wheelchair with a mechanical lift. The UAP states "It has been a long time since I used the lift." To ensure that the UAP can properly operate the mechanical lift, which intervention would the nurse implement? 1. Assign the client to another UAP. 2. Verbally discuss the procedure for the lift. 3. Instruct the UAP to physically transfer the client. 4. Ask the UAP to demonstrate how to use the lift.

4. Correct: The UAP should demonstrate how to transfer a client with a mechanical lift. The demonstration will assess the UAP's knowledge and skill to safely transfer the client using the mechanical lift. 1. Incorrect: Assigning another UAP to use the mechanical lift is not the appropriate solution to determining the skill of the current UAP. The nurse is directly responsible for ensuring that delegated interventions are safely performed. 2. Incorrect: The psychomotor skill of demonstrating the proper use of the mechanical lift should be initated so the UAP can practice these skills safely. The verbal discussion related to the mechanical lift can be utilized in the evaluation phase. 3. Incorrect: Best practices reflect that the use of a mechanical lift for transfers is safer for both the client and the UAP than a physical transfer. Also the nurse has not identified that the UAP can safely transfer a client with a mechanical lift.

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

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

A young adult is brought into the ER after experiencing hallucinations at a beach party. The paramedics report a large quantity of beer cans and empty plastic baggies around the bonfire. During the nursing assessment, the client jumps up screaming, "Get those snakes away from me." What initial action by the nurse would most likely result in a positive outcome for client and staff? 1. Summon security to the ER to physically restrain the client. 2. Ask paramedics to restrain client to inject haloperidol. 3. Call nursing supervisor and request 4-point-leather restraints. 4. Close the door and quietly reorient client to current location.

4. Correct: The best initial reaction by the nurse with a hallucinating client is to decrease stimuli and try to re-orient the individual to location or surroundings. Arguing, shouting or attempting to restrain the individual could result in injury to client and staff. 1. Incorrect: Unless the client is holding a weapon and making terroristic threats, there is no need for security to restrain the client. The healthcare provider should be notified regarding client behavior for possible orders for sedation. 2. Incorrect: Restraining this client, even to inject haloperidol (Haldol) would escalate the situation to dangerous levels. Paramedic responsibilities do not include treating the client inside the emergency room. Client restraint inside the ER is not a medic protocol. 3. Incorrect: There is nothing wrong with notifying the supervisor about an out-of-control client in the emergency room. However, 4-point-leather restraints must be ordered by the healthcare provider and is done so only in dire cases in which the client is a danger to self or others.

A client has been on the nursing unit for two hours following a retropubic prostatectomy for the treatment of prostate cancer. The client is receiving a continuous bladder irrigation of normal saline infusing at 1000 mL/hr. The client's urine output for the past two hours is 410 mL. What is the nurse's first action? 1. Inspect the catheter tubing for obstruction. 2. Irrigate the catheter with a large piston syringe. 3. Notify the primary healthcare provider. 4. Stop the irrigation flow.

4. Correct: The catheter output should be at least the volume of irrigation input plus the client's actual urine. A severe decrease in output indicates obstruction in the drainage system. The first action is to stop the irrigation flow to prevent further bladder distention. Bladder distention is one of the main causes of hemorrhage in the fresh post op period. 1. Incorrect: The next action is to check the external system for kinks or obstruction to assess if this is the cause of the decreased urine output. Obstruction of the catheter tubing can also cause bladder distention. 2. Incorrect: After the external system is checked for kinks or obstruction, and the client's urine output doesn't change, then the catheter is irrigated with 30 to 50 mL of normal saline using a large piston syringe. However, irrigating a new post-op client is not the safest or first action for the nurse. 3. Incorrect: Of the options listed here, this is the last intervention. If the obstruction is not resolved after irrigating the system, the primary healthcare provider must be notified.

During evening rounds on a medical unit, a client is discovered in cardiac arrest. After activating the code button, the nurse initiates chest compressions. A second nurse enters the room to assist. What priority task could be delegated to the second nurse? 1. Retrieve the crash cart. 2. Document the code events. 3. Notify the primary healthcare provider 4. Begin oxygenating the client.

4. Correct: The chest compressions, airway, and breathing (CAB) sequence is always of primary concern. The first nurse correctly activated a code and then began chest compressions. The second nurse will assist by oxygenating the client, using a bag valve mask. 1. Incorrect: Although it will be necessary to bring the crash cart into the room, the initial priority should focus on the client's needs. In the case of a client in cardiac arrest, the first personnel to respond must focus on CPR protocols, including compressions and oxygenation. Other personnel can bring the crash cart into the room. 2. Incorrect: Documenting all the events that occur during a code is vital for both legal and quality assurance purposes; however, the initial priority must focus on stabilizing the client. 3. Incorrect: The Healthcare Provider does need to be notified, but it is not an immediate priority for either nurse. Ancillary personnel, such as the unit secretary, can complete this task. Professional personnel must focus on the client's immediate needs at this critical point.

Which prevention strategy should the nurse consider when developing a health promotion plan for new parents concerning sudden infant death syndrome (SIDS)? 1. Place the infant in the prone position when placing the infant in the bed. 2. The child should sleep in a separate room from the parents. 3. The child should not have a pacifier in place when sleeping. 4. The child should be placed in the supine position when sleeping.

4. Correct: The child should be placed in the supine position when being put to bed for naps or for the night. This position has helped to reduce the incidence of SIDS by as much as 50% since the 1990s. 1. Incorrect: The child should not be placed in the prone position when being put to bed for sleep. If the child is awake and supervised, the prone position encourages muscular development.2. Incorrect: The American Academy of Pediatrics recommends that the infant sleep in the same room with the parents, but not in the same bed.3. Incorrect: The American Academy of Pediatrics recommends that a pacifier be used for the first 6 months because of the benefit in regard to pain management and prevention of sudden infant death syndrome, but recommends the child be weaned from the pacifier during the second 6 months of life.

A client diagnosed with Alzheimer's disease tells the nurse, "I haven't eaten all day. When am I going to eat?" The nurse noted that the client ate 100% of the provided lunch 45 minutes ago. What would be the best way for the nurse to respond? 1. "I'll ask the kitchen if they can send you up another lunch." 2. "What makes you think you didn't eat lunch?" 3. "You ate lunch less than 1 hour ago." 4. "Would you like me to get you some crackers and milk?"

4. Correct: The client believes that he/she has not eaten. Do not argue with the client. Offer the client something to eat. Fix the problem that the client believes he/she has. 1. Incorrect: The client wants to eat but another lunch is not needed since the client ate 100% of the provided lunch, just 45 minutes ago. A snack can be given. 2. Incorrect: Do not argue with the client. This will cause agitation and possible aggression. 3. Incorrect: Again do not argue with the client. The client does not believe he/she has eaten.

The nurse is preparing to bathe a client who is confined to the bed. Which action by the nurse is important to preserve client's self-esteem as the task is completed? 1. Closes the door for privacy. 2. Introduces self and explains the procedure. 3. Bathes the client without the help of others. 4. Covers the client with a bath blanket.

4. Correct: The client does not have to be exposed during the bed change and should be covered with a bath blanket as the top sheet is removed. A bath blanket covers the client as once section at a time of the body is exposed and bathed. This allows for the most privacy and protects self-esteem.1. Incorrect: Closing the door is very important but the client's privacy should be maintained at all times even from the nurse administering the bath. A bath blanket promotes privacy and protects the self-esteem.2. Incorrect: Introducing yourself to the client and explain procedures shows respect. These two actions do not provide for privacy and preserve the self-esteem of the client.3. Incorrect: If help is needed during an occupied bed bath to protect the client and provide for safety, help should be obtained. The nurse should use measures to protect privacy and preserve the client's self-esteem.

A nurse has completed pre-operative instructions for an elderly client scheduled for a cholecystectomy. The following client's statement reflects a need for additional pre-operative instructions. 1. "I may have several small incisions." 2. "I may need to stay in the hospital overnight." 3. "I will ask my husband to bring my medications." 4. "My daughter had lots of problems after this surgery"

4. Correct: The client is expressing negative concerns about her surgery experience since her daughter had shared her problems after the same type of surgery. The nurse will need to provide additional pre-operative instruction. The nurse should use communication techniques that do not deny the client feelings, concerns, and needs. 1. Incorrect: This is a correct pre-operative instruction for a client scheduled for cholecystectomy. The client's statement of the possibility of several small incisions reflects an understanding of the pre-operative instructions. 2. Incorrect: Due to normal elderly physiological changes and the possibility of additional health risks, the elderly client presents with increase surgical risks. The scheduled time of day of the surgery also may result in the client staying overnight after the surgery. The client has identified an understanding of the possibility of staying in the hospital after the surgery. 3. Incorrect: The nurse should identify all the client's medications to prevent medication errors and to complete an accurate medication list. Medications that can interact with medications during surgery and perioperative period should be identified. The statement by the client for her husband to bring her medications does not reflect a need for further client teaching.

The nurse is caring for a client in the 8th week of pregnancy. The client is spotting, has a rigid abdomen and is on bedrest. What is the most important assessment at this time? 1. Protein in the urine 2. Fetal heart tones 3. Cervical dilation 4. Hemoglobin and hematocrit levels

4. Correct: The client may be bleeding, and that is an emergency! Common causes of hemorrhage during the first half of pregnancy include abortion and ectopic pregnancy. Ectopic pregnancy is a significant cause of maternal death from hemorrhage and the classic signs of ectopic pregnancy include positive pregnancy test, abdominal pain and vaginal "spotting". Remember that in the ruptured ectopic pregnancy, bleeding may be concealed and severe pain could be the only symptom. 1. Incorrect: Protein in the urine indicates preeclampsia, which is a condition in which hypertension develops during the last half of pregnancy. 2. Incorrect: We can't hear them yet because the client is just 8 weeks pregnant. It may be possible to detect heart beat with a Doppler transducer at 10 weeks, but this client is only in the eighth week of pregnancy. 3. Incorrect: A vaginal exam may stimulate heavier bleeding and will not provide information about concealed bleeding. A transvaginal ultrasound will be performed to determine whether a fetus is present and if so, whether it is alive.

Which type of comment should the nurse expect from a client exhibiting clang associations? 1. Concrete explanations for abstract ideas 2. Reporting very small details when explaining something 3. Comments that are illogically associated 4. Use of rhyming words when talking

4. Correct: The client may use rhyming words, such as dog, bog, cog, jog. It is the meaningless rhyming of words, often in a forceful manner. 1. Incorrect: This type of comment indicates concrete thought. Concrete thinking is characterized by immediate experience rather than abstraction. 2. Incorrect: This type of comment indicates circumstantiality. This is characterized by indirectness and delay before the person gets to the point or answers a question. The person gets caught up in countless details and explanations. 3. Incorrect: These indicate loose associations or derailment. It is a sequence of unrelated or only remotely related ideas.

The nurse has been working with a client who has a diagnosis of schizophrenia. The client has had three inpatient admissions in the past, but none in the past 6 months. Which statement by the client indicates adequate understanding of the medication treatment regimen? 1. I am feeling better so I hope that I don't have to take the medication for long. 2. I can stop the medication after I have been out of the hospital for a year. 3. The medicine is good for me now; however, I don't want to take it forever. 4. The medication keeps me out of the hospital, and I don't want to hear voices again.

4. Correct: The client must take the medicine long-term. If the client makes the connection between the medicine and feeling better, adherence is more likely. 1. Incorrect: This statement indicates lack of understanding of the disorder and required outcomes. Medication is likely to be required indefinitely. 2. Incorrect: The client does not understand the connection between adherence to medication and staying out of the hospital. 3. Incorrect: It is very likely that the client will be on the medication for a lifetime. This information should be a part of the plan of care and not withheld from the client's knowledge of the disorder and effective control.

A client who is in the manic phase of bipolar disorder was admitted to the psychiatric unit two days ago. Since admission, the client has been overly active, dressing bizarrely and sleeping very little. What type of activity should be planned for this client for the period following the evening meal? 1. Encourage the client to watch TV with the other clients on the unit. 2. Engage the client in a game of ping pong. 3. Suggest that the client play monopoly with other clients. 4. Provide soft lighting in the client's room for reading.

4. Correct: The client needs minimal stimulation to help reduce activity level and encourage sleep. A quiet environment that is calm and dimly lit is ideal for the manic client. 1. Incorrect: TV and other clients will increase stimulation for the client, which may cause this client to become more active. This client should be directed away from active environmental stimuli to minimize the escalation of mania.2. Incorrect: The less activity in the evening, the more likely the client will sleep. Ping pong is a constructive outlet for energy but should not be performed this close to bedtime. 3. Incorrect: The client would not be able to attend to a long monopoly game, and the other clients would provide too much stimulation. The board game is not the best choice for the manic client who needs sleep.

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.

During a disaster, four clients arrive at the emergency department (ED). Which client should the nurse assess first? 1. Confused client wondering around ED. 2. Client with a compound fracture. 3. Client having agonal respirations. 4. Client with sucking chest wound.

4. Correct: The client with a sucking chest can recover if given immediate attention. 1. Incorrect: This client may have a head injury, however, the client with a sucking chest wound is critical but can survive with immediate care. 2. Incorrect: The client with the compound fracture can be given temporary care, then fully treated later. The priority is the client with the sucking chest wound. 3. Incorrect: The client with agonal respirations will not likely survive and should not be among the first to be treated.

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

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

A client with nausea, vomiting, and diarrhea for the past three days has been prescribed one liter of normal saline with 40 mEq (40 mmol/L) of potassium chloride to infuse at 250 mL per hour. Which assessment would the nurse report to the primary healthcare provider prior to initiating the infusion? 1. Blood pressure of 106/54 2. Apical pulse of 112 per minute 3. Tenting of the skin over the sternum 4. Urinary output of 148 mL for the past 6 hours

4. Correct: The client's output is below normal. This could indicate a problem with renal perfusion. Potassium is excreted through the kidneys, so if the kidneys are not being perfused, the client would retain potassium. The healthcare provider would need to be aware of the client's low urine output. 1. Incorrect: A client in fluid volume deficit would have a low blood pressure. This is an expected assessment prior to fluid resuscitation. 2. Incorrect: A client in fluid volume deficit would have a fast pulse rate. This is an expected assessment prior to fluid resuscitation. 3. Incorrect: A client in fluid volume deficit would have tenting of skin. This is an expected assessment prior to fluid resuscitation.

Following amniotomy, what intervention should the nurse perform? 1. Administer oxygen to client. 2. Have client ambulate to promote labor. 3. Obtain temperature every 4 hours. 4. Monitor fetal heart rate.

4. Correct: The fetal heart rate is assessed for at least 1 minute after amniotomy. The umbilical cord could be displaced in a large fluid gush, resulting in compression and interruption of blood flow through it. 1. Incorrect: Oxygen is not indicated after amniotomy. 2. Incorrect: Ambulation is generally limited following amniotomy to prevent complications such as prolapsed cord if the fetal head is not fully engaged. 3. Incorrect: The client's temperature should be assessed every 2 hours after the membrane's rupture. Elevations above 100.4°F (38°C)should be reported.

A nurse has arrived late to work twice in the last week. What should be the nurse manager's first action? 1. Confront the nurse with the consequences of tardiness. 2. Ask the nurse to consent to a drug screening test. 3. Document the tardiness in the nurse's record. 4. Ask the nurse the reason for being tardy.

4. Correct: The first action should be discussing the tardiness with the nurse. There may be a situation that is impacting the nurse's ability to be on time. This will allow the nurse to explain the tardiness. The nurse manager may have to consider alternate scheduling for the nurse. 1. Incorrect: The first action should not be confrontational. The nurse manager needs to find out the reason for tardiness in a non-confrontational manner. This will demonstrate that the nurse manager is showing concern for the nurse. 2. Incorrect: The nurse is not exhibiting any impairment behaviors. Although drug use may be characterized by behaviors such as tardiness to work, this should not automatically be assumed. The nurse should have the opportunity to first provide an explanation for the tardiness. 3. Incorrect: Documentation should be done after the meeting with the nurse. The documentation would include the nurse's explanation for the tardiness.

Which medication should the nurse administer first after receiving the morning shift report? 1. Levothyroxine to the client with hypothyroidism and a thyroid stimulating hormone (TSH) level of 2.8 mU/L 2. Amlodipine to the client with hypertension and a blood pressure of 150/86 3. Regular insulin sliding scale dose to the client with diabetes and a 210 blood glucose level. 4. Cefotaxime intravenous piggyback to the newly admitted client with a diagnosis of pneumonia and a white blood cell count (WBC) of 12,000mm3

4. Correct: The first dose of intravenous antibiotic medication is the priority since the WBCs are elevated and the antibiotic should be administered first. 1. Incorrect: The TSH is normal so the thyroid medication is not the priority. 2. Incorrect: Amlodipine is for high blood pressure and is important but the antibiotic is the priority. 3. Incorrect: It is important to administer the regular insulin but it is not priority over initiating the intravenous antibiotic medication.

The nurse is talking with a parent regarding childhood immunizations. What vaccination is recommended for children at 12 months? 1. Pertussis 2. Rotovirus 3. Tuberculosis 4. Varicella

4. Correct: The first varicella vaccine is recommended at 12 - 18 months in the US and 12-15 months in Canada. 1. Incorrect: The 4th dose of pertussis is given at 15 months in the US and 18 months in Canada. 2. Incorrect: Rotovirus is recommended in the US at 2, 4, and 6 months and at 2 and 4 months in some areas of Canada. 3. Incorrect: Bacille Calmette-Guérin (BCG) is a vaccine for tuberculosis (TB) disease. This vaccine is not widely used in the United States or Canada, but it is often given to infants and small children in other countries where TB is common.

A nurse is conducting an initial admission history on a client who is reporting bone pain secondary to cancer with metastasis to the bone. What does the nurse determine is the most important information to gather during this initial screening? 1. The physical assessment of the client 2. The hemoglobin and hematocrit levels 3. The amount of pain medication the client is receiving 4. The client's description of the pain

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

While a nurse was in shift report, four clients called the nurses' station. Which client should the nurse see first? 1. Child whose colostomy bag is leaking. 2. Three day post op client requesting pain medication. 3. Child admitted with failure to thrive, whose mother requested formula. 4. Client who needs a peak blood level drawn because the antibiotic just finished infusing.

4. Correct: The most urgent task is the peak medication level that needs to be drawn. If the level is not drawn at the appropriate time, the results may not give an accurate report of whether the medication is at the appropriate dosage or not, and if the dosage is safe. 1. Incorrect: A leaking colostomy bag is uncomfortable and should be seen, but this is not time sensitive like the peak blood level. 2. Incorrect: Pain needs assessing and treated appropriately. The key here is three days post op so the administration of the pain medication does not take priority over the need to draw the blood levels at this time. 3. Incorrect: Nutrition for a baby that is admitted for failure to thrive is important, but can wait a few minutes until blood levels are drawn.

The nurse enters the med room to prepare the AM medication pass. A new nurse is drawing up morning insulin using a tuberculin syringe instead of an insulin syringe. What is the nurse's priority action? 1. Report the new nurse to the charge nurse. 2. Offer to pass the medications for the new nurse. 3. Prepare an incident report describing the issue. 4. Offer to help the new nurse re-draw up the insulin.

4. Correct: The new nurse obviously needs review or reinstruction on the proper equipment to use to draw up and administer insulin. The nurse has two responsibilities: to protect those clients ordered to receive insulin this morning, and to be certain the new nurse is aware of the appropriate syringe for insulin administration. By assisting the new nurse, the nurse has the opportunity to demonstrate both proper technique and verify the correct insulin will be administered. 1. Incorrect: Though the charge nurse should be made aware that the new nurse will need some additional instruction on preparing insulin, it is not the first priority for the nurse. 2. Incorrect: Completing the new nurse's assignment does not solve the problem of lack of knowledge regarding insulin preparation and administration. More importantly, the nurse may not be around to catch an error at another time, resulting in a serious injury to a client. 3. Incorrect: The new nurse did not actually administer insulin in the wrong syringe and without an injury, no incident occurred. Documentation may be requested but not on an incident report.

A client who is occasionally confused states that the medication is the wrong color when the nurse hands it to the client. What action should the nurse take? 1. Encourage the client to take the medication. 2. Tell the client that the medication is correct. 3. Explain that generic medications may be different colors. 4. Double check the medication before administering.

4. Correct: The nurse cannot assume that the client is confused. Assessing orientation, LOC and asking client to state his/her name would help identify if the client is confused. The nurse must double-check. An error may be prevented by doing this. Seeking clarification is the safest option. 1. Incorrect: The nurse may make a medication error if she/he encourages the client to take the medication without double checking. To prevent errors, the nurse must adhere to the five rights of medication administration: right drug, right dose, right time, right route and right patient. 2. Incorrect: The client may be identifying an error. The nurse should double check that this is the correct medication. Determine if the client understands the purpose of the medication. 3. Incorrect: This statement is true; however, to maintain safety of the client, the medication should be checked again. Seeking clarification is the safest option.

After a heart catheterization a client reports severe foot pain on the side of the femoral insertion site. The nurse notes pulselessness, pallor, and a cold extremity. What should be the nurse's first action? 1. Administer an anticoagulant. 2. Warm the room. 3. Increase intravenous fluids. 4. Notify the primary healthcare provider.

4. Correct: This is an emergency and the primary healthcare provider (PHCP) is the only one that can save this foot from ischemia. Don't delay. 1. Incorrect: The primary healthcare provider may treat with an embolectomy, bypass surgery or a thrombolytic. Giving an anticoagulant could alter treatment options. 2. Incorrect: The cold extremity is caused by decreased arterial perfusion, not room temperature. 3. Incorrect: In theory, increasing blood volume increases blood flow, but this client has an arterial obstruction. Blood cannot get passed the occlusion.

A client states, "I really do not want to go through open heart surgery. I have told my children this, but they still want me to go through with the surgery. I don't know what to do." What is the best response for the nurse as client advocate? 1. Your children are correct. The open heart surgery is the best thing for your health. 2. 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 open heart surgery. 4. You have some genuine concerns about the open heart surgery, and you feel as if your children are not addressing 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.

The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. The nurse received a client following surgery 8 hours ago. The first vital sign check was performed by the nurse. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. What was the rationale for this plan? You answered this question Incorrectly 1. The nurse did not trust the new UAP. 2. The nurse prefers to check all vital signs on all clients. 3. The nurse is responsible for the assessment of all vital signs of post-op clients. 4. The nurse does not know the skills of the new UAP.

4. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. When the licensed person cannot determine this, the task should not be delegated. This determination is needed to assure client safety is being considered. 1. Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. 2. Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. In this situation, it is not a matter of the nurse preferring to take all the vital signs, but the nurse needs to know the competency level of the UAP before delegating this task.3. Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. If the client is unstable, the nurse would retain the role of measuring the vital signs. Once the client is stable, the UAP could perform this task. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client.

A 3 year old child is being treated for asthma. The child weighs 31.5 lb (14.3 kg). The primary healthcare provider has prescribed Albuterol syrup 5 mg PO every 8 hours. What action should the nurse take? Exhibit Albuterol Classification: Beta 2 Agonist Dosing: 2-6 years: 0.1 mg (0.25 mL)/kg PO q8hr initially, not to exceed 2 mg (5 mL) q8hr; if necessary, may be increased to 0.2 mg/kg PO q8hr, not to exceed 4 mg (10 mL) q8hr 1. Administer the dose immediately to relieve respiratory efforts. 2. Split the dose in two equal parts and administer every 4 hours. 3. Notify the charge nurse that the child needs a different type medication. 4. Notify the primary healthcare provider.

4. Correct: The nurse is responsible for assuring that medications are administered safely. One aspect of safe medication administration is to assure that the prescribed dose is safe for administration. For this age child, the maximum dose that should be administered is 0.2 mg/kg PO every 8 hours. So, we need to determine how much albuterol this child, weighing 14.3 kg can safely have. To calculate this, we would first use the child's weight in this recommended dose formula: The maximum amount is 0.2 mg X 14.3 kg = 2.86 mg every 8 hours. The exhibit also says not to exceed 4 mg every 8 hours, which the prescribed amount exceeds. Remember, the maximum dose based on the individual child's weight is the safest guideline to use. The prescription for this child is to receive 5 mg PO every 8 hours. Is this a safe dose? No! Therefore, the nurse should not administer the medication and should promptly notify the primary healthcare provider. Administering the prescribed dosage could be dangerous to this child! 1. Incorrect: Although this option for administering the dose immediately to relieve respiratory efforts sounds good, could we cause more harm to the client by administering this dose of albuterol? Yes! Relieving respiratory efforts is a goal of therapy, but should be accomplished using safe dosages of the medication. This dose of medication should not be administered. 2. Incorrect: You may have realized that the single dose as prescribed was too much. But would splitting the dose in two equal parts and administering it every 4 hours be safe? No! First of all, the maximum safe dose would still be exceeded. And, as a nurse, it would be out of your scope of practice to alter an existing prescription. 3. Incorrect: What came to your mind when you looked at this? Did you consider if the medication is appropriate for use in a child with asthma? Albuterol acts as a bronchodilator, causing relaxation of the bronchial smooth muscles in the airways and is used to manage asthma and acute bronchospasm. The exhibit provides safe dosing information for a 3 year old child, so it is an appropriate agent for use in this child with asthma. Notifying the charge nurse that the child needs a different type medication would not be appropriate.

The nurse notices the primary healthcare provider removes gloves after performing an invasive procedure on a client. The healthcare provider then enters another client's room without washing hands. What is the initial action by the nurse? 1. Ignore it since the primary healthcare provider knows best. 2. Contact the nursing supervisor. 3. Notify the chief of medical staff. 4. Remind the primary healthcare provider of the importance of standard precautions.

4. Correct: The nurse is the client's advocate and can remind the primary healthcare provider of the importance of washing hands before entering a client's room. Hand washing should be performed when going from one room to another. 1. Incorrect: Nurses are to be client advocates and resolve a problem that they see. The primary healthcare provider should wash their hands prior to entering another client's room. 2. Incorrect: The nursing supervisor is not the first step, the nurse is. This incident may be reported to the charge nurse at a later time but the client's safety is priority. 3. Incorrect: This is not the first step. The nurse should address the problem when it is witnessed. The nurse should follow the chain of command when reporting a problem but speaking to the chief of medical staff is not the best action at this time.

An injured client brought to the emergency room by ambulance insists on leaving before being seen by the primary healthcare provider. What is the nurse's priority action? 1. Explain potential risks of leaving without proper care. 2. Insist the client sign "Against Medical Advice" form. 3. Calmly convince client to wait for needed treatment. 4. Notify primary healthcare provider immediately.

4. Correct: The nurse must notify the primary healthcare provider immediately about the client's desire to leave without care. The client cannot be physically prevented from leaving, or threatened with possible dire consequences by the nurse. The primary healthcare provider can explain potential risks of non-treatment and obtain a signature on the AMA form. 1. Incorrect: The client must be informed about the potential risks of leaving without medical treatment and that information is best explained by either the emergency room healthcare provider or primary healthcare provider based on knowledge of the client's potential injuries. 2. Incorrect: An "Against Medical Advise" (AMA) form is designed to protect staff and facility from potential litigation filed by clients leaving without treatment. However, a client cannot be forced to sign the form and this is not the nurse's priority action. 3. Incorrect: The nurse can use therapeutic techniques to discuss the situation and try to discover why the client wants to leave. However, there is another priority more important for the nurse.

The nurse is initiating the admission assessment on a client diagnosed with Parkinson Disease. The client is slow to answer questions and appears to be frustrated trying to find the right words. Which communication technique by the nurse is appropriate? 1. Share with the client that all will be OK. 2. Introduce another health issue to discuss with the client. 3. Identify other clients who have had communication issues. 4. Allow the client the opportunity to organize their response.

4. Correct: The nurse recognizes that the client needs additional time to communicate. By using silence, a therapeutic response, the nurse is providing the client the time to organize their thoughts. If the client is not rushed to respond, the client's anxiety may be reduced. 1. Incorrect: The nurse may be wanting to place the client at ease. By identifying the client's decreased communication ability the nurse may increase the client's anxiety. The nurse is using a reassuring cliché, a nontherapeutic technique, to reduce the nurse's anxiety when client's responses are delayed. 2. Incorrect: By abruptly changing topics with the client, the nurse is changing the direction of their communication. The nurse is leading the communication and not the client. This is a nontherapeutic communication technique of introducing an unrelated topic. 3. Incorrect: The nurse is utilizing the nontherapeutic communication technique of belittling feelings. The client is demonstrating their frustration after not being able to respond faster. The response by the nurse does not identify what the client is feeling, but what others feel. This action will not reduce the anxiety of the client.

The nurse is checking a two year old's developmental status. What finding would be of concern to the nurse? 1. Unable to use "me" and "you" correctly. 2. Has trouble focusing on one activity for more than 5 minutes. 3. Does not follow a 3-part command. 4. Does not know what to do with a spoon.

4. Correct: The nurse should be concerned if a 2 year old does not know what to do with common things such as a brush, phone, fork, or spoon. 1. Incorrect: The nurse should be concerned if the 4 year old doesn't use "me" and "you" correctly. 2. Incorrect: The nurse should be concerned if the 5 year old has trouble focusing on one activity for more than 5 minutes. 3. Incorrect: The nurse should be concerned if the 4 year old doesn't follow 3-part commands.

The nurse is bathing a confused client in the acute care unit. The nurse talks with the client and explains each procedure. During the bath, the client becomes very agitated. What should the nurse do? 1. Complete the bath as quickly as possible. 2. Reassure the client and request them to stop acting out. 3. Continue bathing with assistance from an unlicensed assistive personnel. 4. Stop the bath, dress and reassure the client.

4. Correct: The nurse should not continue bathing if the client is becoming so distressed. Perhaps the bath can be completed at a later time. Safety is the priority. 1. Incorrect: The client is obviously distressed. Continuing the bath could jeopardize the safety of the nurse and client. 2. Incorrect: Reassurance may not work with the confused client. It is difficult to know exactly why the client is becoming so distressed. The safety of the client is important. 3. Incorrect: Adding a second person will increase the feelings of powerlessness in the client. This could and will add to the client's distress. Stopping the procedure is the safest answer

The nurse is making rounds on the psychiatric unit at the beginning of the shift. Which client should be seen first? 1. Client with somatoform disorder. 2. Client with depression. 3. Client with panic attacks. 4. Client with hallucinations.

4. Correct: The nurse will need to assess the client with hallucinations first. The client who is actively hallucinating may be hearing voices, and the voices may order the client to do something harmful to self or others. 1. Incorrect: The client with Somatoform disorder has a physical symptom with a psychological cause and does not require immediate attention. Although the symptoms are real to the client and not under voluntary control as with fictitious disorders. They do not have a physical cause that would warrant immediate attention. Therefore, this client does not have a need to be seen before the client having hallucinations who may be at risk for harming self or others. 2. Incorrect: The client with depression should be seen second. There is no indication that the client is currently on suicide precautions. However, as the client receives medication and the energy level rises, the client may be at an increased risk of suicide. 3. Incorrect: The client with panic attacks is likely to summon the nurse if needed immediately. This client would not need immediate attention at this time. The client with panic attacks is not considered at risk of harm to self or others and would not have to be seen before the clients with hallucinations or depression.

A client has been prescribed a decongestant. The nurse identifies that the client has a diagnosis of glaucoma. Which nursing intervention would the nurse implement after identifying the client's diagnosis of glaucoma? 1. Administer the decongestant. 2. Reassess the client in 4 hours. 3. Identify when the client was diagnosed with glaucoma. 4. Notify the primary healthcare provider regarding the glaucoma diagnosis.

4. Correct: The primary healthcare provider should be notified of the client's diagnosis of glaucoma. Glaucoma is the result of elevated eye pressure due to a buildup of aqueous humor that flows throughout the inside of your eye. Decongestants can cause the pupil to dilate. This response can result in an acute glaucoma attack in a client diagnosed with narrow-angle glaucoma or angle-closure glaucoma. 1. Incorrect: The primary healthcare provider should be notified of the client's diagnosis of glaucoma and the prescription for a decongestant. The medication should not be administered until the primary healthcare provider is consulted. 2. Incorrect: Continual assessment of the client is recommended, but the nurse should not delay consulting with the primary healthcare provider. The primary healthcare provider should be notified of the client's diagnosis of glaucoma and the prescription for a decongestant. 3. Incorrect: The nurse needs to determine whether to administer the decongestant due to the client's diagnosis of glaucoma. The nurse does not need to identify when the client was diagnosed with glaucoma.

A child is brought into the school nurse's office after a fall on the playground which resulted in a nose bleed. What initial action by the nurse is most appropriate? 1. Hold cup under nose and allow fluid to drip. 2. Place an ice pack on the back of the neck. 3. Have child lie down and elevate the feet. 4. Pinch the bridge of the nose for 10 minutes.

4. Correct: The proper method to stop epistaxis is to place the client in the upright position, facing forward and pinch the bridge of the nose for approximately ten minutes. The head should not be tilted back, as that allows blood to run down the back of the throat. 1. Incorrect: Holding a cup under the nose to collect the blood does nothing to stop the bleeding. This action is only performed in the case of potential basilar skull fracture in which stopping the flow of spinal fluid would cause increased intracranial pressure (ICP). 2. Incorrect: If an ice pack is used for epistaxis, it should to be placed on the bridge of the nose. Placing an ice pack on the back of the neck will not stop a nose bleed, though it can be used to decrease fever. 3. Incorrect: Placing a client in the supine position, particularly with the feet elevated, is useful for those in shock. But with epistaxis, this action would allow blood to flow down to the stomach, resulting in vomiting.

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

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

The nurse is talking with several high school students after a classmate from their school died in a motor vehicular accident. Which statement by the nurse is therapeutic? 1. "Sometimes bad things happen to people we care about." 2. "I was so upset that the student who died had been drinking." 3. "Why are you angry? Tell me how you feel about losing your friend." 4. "What would you like to talk about concerning the loss of your classmate?"

4. Correct: The therapeutic communication technique of giving broad openings will allow the students to move the topic of the death of their classmate in the direction of their choice. The students will feel more freedom to communicate with the nurse and the other students. 1. Incorrect: The high school students are experiencing the grief process due the death of one of their classmates. The nurse is showing a lack of understanding about the feelings of the students. The students will not experience any relief from their grief by stating that others have lost persons they cared about. This statement is an example of the nontherapeutic technique of belittling feelings expressed. 2. Incorrect: The nurse is utilizing the nontherapeutic communication technique of expressing disapproval. The students may respond by being unsettled or resentful at the nurse. This will block the communication pathway, and the students will not be receptive to what the nurse as the group leader is communicating. 3. Incorrect: The nurse is stating that the students are angry without the students sharing their feelings. Beginning the statement with the word why implies that the nurse already has identified what emotion the students have. This presumption of anger may not be correct, and students may not express their feelings freely. This is the nontherapeutic communication of requesting explanation.

The nurse is caring for a client with a diagnosis of major depression. The client began taking a selective serotonin reuptake inhibitor (SSRI) three days ago. The client says, "I am just not feeling well. My medicine is not working." Which reply by the nurse indicates adequate understanding of treatment? 1. "I agree, your medication is not working." 2. "Your treatment may have to be changed." 3. "Most SSRIs take about 5 days to work." 4. "You should reach the desired effect in 1-3 weeks."

4. Correct: Therapeutic effect is usually reached in one to three weeks, or longer. Encourage the client to continue taking the medication as prescribed. Provide supportive care and reassurance during this time. 1. Incorrect: This response demonstrates that the nurse is not familiar with the time for therapeutic onset. This response would discourage the client. 2. Incorrect: It is too soon to determine if treatment should be changed. It may take several weeks to reach therapeutic effects. 3. Incorrect: While some clients may be more calm within a short period of time, therapeutic effect cannot be evaluated at this point. Initial effects may be seen in as little as 1-3 weeks, while full therapeutic effects may fake up to 4-6 weeks.

A client returns to the med-surg unit after having extracorporeal lithotripsy. Which would be the best indicator that the treatment has been effective? 1. The client is totally relieved of the pain. 2. The urine is straw colored and free of RBCs per dip stick test. 3. The urinary output has doubled since return to the unit. 4. There is sediment in the Foley catheter tubing and in the bedside drainage bag.

4. Correct: This answer provides visible proof that the renal calculi has been broken up by the shock waves. 1. Incorrect: Pain can occur because of spasm of smooth muscle when the stone is moving. 2. Incorrect: There will be blood in the urine for several days after treatment. 3. Incorrect: Blocked urine flow from stone fragments may cause decreased urine output.

A client is being cared for in the intensive care unit following a traumatic amputation of the left lower arm. As the nurse enters the room for a routine check, the client begins to cry and states "This is so overwhelming." What statement by the nurse would be most appropriate at this time? 1. "You have been through a lot, but look on the bright side; you are doing better now." 2. "Try to be optimistic. You are going to be fitted for a prosthesis once you are healed." 3. "I understand that you are upset, but crying is not going to help your situation." 4. "This must be very difficult for you. What seems to be the hardest part for you now?"

4. Correct: This client has experienced a very significant personal loss and can go through the grieving process, similar to those who experience the death of a loved one. The nurse should be very sensitive to the feelings of loss being felt by this client due to the loss of a body part. This client is reporting feeling overwhelmed. The best way for the nurse to respond to this client's feelings would be to first acknowledge that the situation must be very difficult for the client. The nurse can further explore this by asking what seems to be the hardest part for the client currently. This will guide the nurse with how to best assist the client at the current time and meet the most immediate emotional needs of this client. By addressing what is most overwhelming at the present time, the nurse can more effectively assist the client in gradually working through the grief process and dealing with the loss. 1. Incorrect: The nurse's comment starts out with an acceptable comment of acknowledging that the client has been through a lot but then immediately negates the client's feelings of being overwhelmed by telling the client to look on the bright side and that the client is doing better now. This statement discounts the client's feelings of loss and being overwhelmed with all that it entails. 2. Incorrect: This comment by the nurse that tells the client to be optimistic because a prosthesis will be fitted does not address the client's current feelings. This is a total disregard to the overwhelming feelings of loss that the client is experiencing. As the client works through the feelings of loss over time, the nurse can help provide a sense of hope and optimism about the use of a prosthesis, but the client's current feelings should be addressed first. 3. Incorrect: Again, the nurse's comment about recognizing that the client is upset could be appropriate, but the comment following this about crying not helping the situation could cause the client to feel belittled and may actually cause the client to become bitter or reluctant to share true feelings with the nurse. The nurse should support the client and explore how to best help the client work through these feelings of extreme loss.

Which client with a heat-related illness should the emergency room nurse provide attention to first? 1. Elderly person with reports of dizziness and syncope following working in the yard in the sun for several hours. 2. Football player who was at summer practice and developed severe leg cramps, nausea, tachycardia, and diaphoresis. 3. Low income individual who reports that the power has been turned off and has not had air conditioning for several days and who is experiencing increased respiratory rate, fatigue, extreme diaphoresis, and hypotension. 4. Person who had been lying in a roadside ditch for an undetermined length of time and was found with altered mental status, poor muscle coordination, and hot, dry skin.

4. Correct: This client is demonstrating signs of a heat stroke. This client would be a priority due to the severity of dehydration as evidenced by the altered mental status, poor muscle coordination, and absence of sweating. 1. Incorrect: This elderly client is probably dehydrated and may have experienced some postural hypotension while working in the yard which could play a role in the syncope. This client will need a workup to rule out other underlying issues. However, this client would not be a priority over the client with altered mental status. 2. Incorrect: It is not uncommon for athletes to experience heat related dehydration with muscle cramps, nausea, tachycardia, and diaphoresis. This should be managed with fluid and electrolyte replacement. This client still has diaphoresis, which makes the client less a priority than the client who no longer is producing sweat. 3. Incorrect: This client is showing signs of heat exhaustion with dehydration. However, this client continues to have diaphoresis, which makes this client less of a priority to see than the client who no longer has diaphoresis and has altered mental status.

A 68-year-old client with a history of angina presents to the emergency department (ED) reporting flu like symptoms progressively worsening over the past 24 hours.What action is most important for the nurse to initiate? Exhibit "I have the flu. I have been vomiting every couple of hours, running a fever and my chest hurts." Pulse-132 beats/minute Respirations-26 breaths/minute Blood pressure-94/60 mmHg Temperature-101.3° F (38.5°C) orally Capillary refill - 4 seconds 1. Administer acetamenophen. 2. Initiate IV of Normal Saline at 250 mL/hour. 3. Notify radiology and lab of diagnostic test prescriptions. 4. Discuss IV prescription with primary healthcare provider.

4. Correct: This client needs fluid because of dehydration, but did you notice that this client is elderly and has a history of cardiac problems? I hope so, because giving this client NS rapidly could throw our heart client into pulmonary edema, which would be a bad thing! Talk to the primary healthcare provider. 1. Incorrect: Acetaminophen needs to be administered but it is not the most important thing for the nurse to do. Clarification regarding the IV fluid prescription is necessary here to prevent a possible complication. 2. Incorrect: If this client receives an isotonic IV solution at this rapid rate, the client will be at increased risk of developing FVE and pulmonary edema. 3. Incorrect: Again, the radiology and lab departments can be notified of the test prescriptions to be completed. However, the nurse can assign this task to the unit secretary.

After making rounds on clients, a primary healthcare provider hands the nurse a client record and gives the following verbal order: Administer cisplatin 1 mg IV over 6 hours. What should be the first action by the nurse following this verbal prescription? 1. Call the pharmacy to prepare the drug. 2. Repeat the prescription back to the primary healthcare provider. 3. Ask the primary healthcare provider to spell the drug name for clarification. 4. Inform the healthcare provider that this medication requires a written prescription.

4. Correct: This drug is a high alert drug that should be given careful consideration. Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety. 1. Incorrect: The pharmacy should not be called to prepare this drug as it is unsafe to follow a verbal prescription for an antineoplastic. Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety. 2. Incorrect: The first action by the nurse should be to inform the primary healthcare provider that a verbal prescription is not adequate for this particular category of drug. Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety.3. Incorrect: Use the testing strategy of finding similar options to eliminate incorrect answers. Options 1, 2 and 3 insinuate the nurse is going to proceed with the prescription, which is an unsafe practice for antineoplastics. Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety.

A client is seen in the clinic expressing feelings of hopelessness and despair after losing his wife two months ago. He tells the nurse, "I think I am ready to go meet her. Please don't tell anyone." How should the nurse respond? 1. "I can see that you miss your wife very much." 2. "Tell me about your wife." 3. "I will keep your secret if you promise me you won't do anything until we talk again." 4. "I can't keep a secret like that. Are you planning to harm yourself?"

4. Correct: This elderly client is contemplating suicide. Elderly mean are at a high risk for succeeding at suicide because they tend to use lethal methods. The nurse has a responsibility to get the client help. 1. Incorrect: This ignores the problem. The issue is that the client is attempting suicide. 2. Incorrect: This question does not address the issues of suicide. Talking about his wife may make the client more depressed. 3. Incorrect: It is not appropriate to keep this information secret. The client may commit suicide in the meantime.

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 mg/dL 3. UOP 440 mL over previous 8 hour shift. 4. Heart rate 56/min

4. Correct: This is a beta blocker. 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. You can identify that nadolol is a beta blocker because it ends in "lol".1. Incorrect: Beta blocker are prescribed to lower BP. When the baseline BP is not known, worry about a BP of 90/60 or below. If the client's BP drops below 90/60, this beta blocker should be held and the primary healthcare provider notified. 2. Incorrect: This is a normal glucose level. If the client is a diabetic, beta blockers can mask the signs of hypoglycemia.3. Incorrect: Urinary output is adequate. Beta blockers do not alter renal function.

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

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

The nurse receives the morning lab results of four clients during the change of shift report. Which client should the nurse assess first? 1. Vomiting and diarrhea with a potassium 3.3 mEq/L (3.3 mmol/L). 2. One day post-operative hip replacement with a Hct 30% (0.30) / Hgb 10 g/dL (100 g/L). 3. Pneumonia with a White Blood Cell (WBC) count of 12,000/mm3 (12 x 10^9/L). 4. Diabetes with a Fasting Blood Sugar (FBS) of 40 mg/dL (2.2 mmol/L).

4. Correct: This is a critical value. 1. Incorrect: The potassium level is low but not critical. 2. Incorrect: The hematocrit and hemoglobin are low but not critical. 3. Incorrect: The WBC count is high but not critical.

A RN and a LPN are caring for a client who is post-op total right hip replacement. Which action by the LPN would necessitate intervention by the RN? 1. Reinforcing teaching about the use of the overhead trapeze bar. 2. Reminding client of the need for using the incentive spirometer. 3. Reinforcing the hip dressing as needed due to breakthrough bleeding. 4. Providing socks for the client to put on to help warm the feet.

4. Correct: This is a safety issue and the RN must intervene to prevent possible dislocation of the hip. If the hip becomes dislocated, it could result in neuro-vascular damage as well as result in the client having to go back to surgery. If the LPN gives the client socks to put on, it would require the client to have flexion at the hip to apply the socks. Hip flexion is a leading cause of hip dislocation following hip surgery and should be avoided. 1. Incorrect: Although LPNs cannot develop a teaching plan, the LPN can reinforce teaching to this client regarding the use of the overhead trapeze bar. 2. Incorrect: The LPN is not developing a teaching plan here, but is reminding the client of teaching that has been performed for the need of incentive spirometry following surgery. This is an appropriate action by the LPN and would not require intervention by the RN. 3. Incorrect: LPNs can reinforce dressings and can perform dressing changes. The healthcare provider may prescribe initially for the dressing to be reinforced, and will prescribe when the dressing should be changed. Performing the dressing reinforcement by the LPN would not warrant intervention by the RN.

A nurse is triaging a 2 year old child in the pediatric emergency department. The nurse notes that the child will not lie down and is consistently drooling. A croaking sound is heard on inspiration. What is the priority nursing intervention? 1. Examine the oral pharynx using a tongue depressor. 2. Administer a sedative so the child can be examined. 3. Have a second nurse hold the child down for the assessment. 4. Notify the primary healthcare provider immediately.

4. Correct: This is the safest answer. The child could suddenly obstruct the airway upon examination of throat. 1. Incorrect: If it looks like epiglottitis, do not examine as this could cause sudden airway obstruction which could be fatal. 2. Incorrect: The client is having trouble breathing, so do not sedate the client. Sedatives would depress the respirations more and potentially cause the client to go into respiratory arrest. Remember, the NCLEX® lady does not want you to be a killer nurse. 3. Incorrect: This will cause more respiratory and emotional distress to the child. This is an unsafe answer.

A post-operative client becomes anxious and reports acute onset of chest pain when taking a deep breath and shortness of breath. Initial vital signs obtained by the nurse reveals tachycardia, hemoptysis, and a pulse oximeter reading of 90%. What intervention should the nurse initiate first? 1. Administer oxygen. 2. Obtain a blood pressure reading. 3. Connect to cardiac monitor. 4. Raise head of bed to 90 degrees.

4. Correct: This is your priority. This position will facilitate maximum lung expansion. It will also decrease venous return to the right side of the heart so that pressure decreases in the pulmonary vascular system. 1. Incorrect: Oxygen is needed, but the first thing the nurse should do is raise the head of the bed, so the client can breathe easier. Then get the oxygen set up. 2. Incorrect: Obtaining a blood pressure reading at this point is delaying treatment. The problem is a breathing problem. Do something to fix the breathing problem first. Then, you can continue your assessment by checking circulation status. 3. Incorrect: Connecting the client to a cardiac monitor is an appropriate intervention, but facilitating breathing takes priority and should be done first.

How should the nurse assist a post-operative client in transferring from the bed to a chair? 1. Have the client look down and watch their feet as they move. 2. Tell the client to bend at the waist to lower the center of gravity. 3. Place a walker away from the bed so the client can lean forward while standing. 4. Ensure the client's feet are as wide apart as the hips.

4. Correct: This maintains the client's horizontal center of gravity. 1. Incorrect: Looking down shifts the client's center of gravity and moves the client out of alignment. 2. Incorrect: Bending at the waist will shift the client's center of gravity. This will not assist the client in tranferring. 3. Incorrect: Placing a walker away from the bed will shift the client's center of gravity. This could cause a fall.

A psychiatric client tells the day shift nurse, "The night nurses have been stealing from all of us while we are sleeping." What is the nurse's best response? 1. "Can you prove what the nurses are stealing?" 2. "No nurse working here would steal." 3. "You must have misunderstood what you were seeing." 4. "Tell me more about what you saw."

4. Correct: This open ended question allows for exploring the idea the client has. This statement does not accuse anyone or deny the possibility of stealing. This statement allows the nurse to remain nonthreatening and nonjudgmental. 1. Incorrect: This response shows disapproval. This statement could make the client feel uncomfortable and seem like the nurse is taking the side of the other nurses. 2. Incorrect: This response is disagreeing with the client. This is a closed-ended statement that does not allow the client to discuss this topic further. Since the nurse has said no nurse would steal then the client most likely will become defensive. 3. Incorrect: This response is defending. It also makes the client feel that the nurse does not believe them.

A client has just developed an abdominal wound evisceration post bowel resection. In what position should the nurse place the client? 1. Sims' position. 2. Dorsal recumbent. 3. Right side lying in the fetal position. 4. Supine, head of bed at 15 degrees with knees and hips bent.

4. Correct: This position will decrease pressure on the suture line and abdomen. 1. Incorrect: Sims' is a semi-prone position where the client assumes a posture halfway between the lateral and prone positions. If you place the client in this position the bowel contents can protrude out of the wound even more. 2. Incorrect: In this position the client's head and shoulders are slightly elevated on a small pillow. This does not ease the tension as much as supine with HOB elevated 15 degrees and knees and hips flexed. 3. Incorrect: Turning the client on their side will allow the abdominal contents to protrude out of the wound even more.

The nurse is providing care to an elderly widow recovering from surgical repair of a fractured hip. The client had been teaching school, but now fears the school district may use this injury to force retirement. The client indicates anxiety about not working and being bored. What statement by the nurse would be most therapeutic at this time? 1. "You should enjoy sleeping in and much quieter days." 2. "Don't you have friends or hobbies you would enjoy?" 3. "Maybe you could just look for another job to do." 4. "What part of being retired concerns you most?"

4. Correct: This question by the nurse is open-ended and indicates acceptance of the client's feelings. The client can elaborate on concerns, even though there is no concrete information that a retirement is pending. The nurse should initiate a therapeutic communication environment and encourage the client to verbalize concerns. 1. Incorrect: This nonchalant response by the nurse ignores the client's expressed concerns, thus belittling feelings. The statement is close-ended with no possibility for the client to share further thoughts about a possible forced retirement. 2. Incorrect: This question demands an explanation of the client in an almost accusatory manner without taking into consideration the remarks already made. Being alone is often used as a code for a loss of purpose, which may actually be what the client is experiencing as a widow. 3. Incorrect: Again, the nurse is belittling the client's desire to continue to teach, insinuating that any job will do in this situation. This is both close-ended and presumptive.

A client has returned to the medical surgical unit from surgery following an emergency appendectomy. The client's spiritual practice involves kneeling multiple times daily for prayer, and the client asks the nurse for assistance to get out of bed to kneel. What statement by the nurse is most appropriate at this time? 1. "You will have to remain in bed for the next 48 hours." 2. "The floor has too much bacteria for you to kneel down." 3. "Aren't there alternatives you can use till you heal more?" 4. "We can help you out of bed whenever you need to pray."

4. Correct: This response by the nurse indicates acknowledgement of the client's spiritual needs as well as specifying a plan to assist in that process. This non-judgmental reply could also provide a positive teaching opportunity regarding surgical recovery, splinting of any incision and appropriate methods for getting out of bed. 1. Incorrect: An appendectomy does not require a client to be bedfast for 48 hours. Remaining in bed would increase the potential for multiple, post-surgical complications, including blood clots or pneumonia. Most clients can be ambulated with assistance within hours of the procedure. 2. Incorrect: While this statement regarding bacteria may be true, it does not justify refusing to allow a client to follow spiritual practices. The nurse should discuss any specific precautions needed with the client. 3. Incorrect: This non-therapeutic communication by the nurse is demanding an explanation of the client. While the question may represent a valid nursing concern, it has not been presented in a positive manner to the client.

A renal transplant client has received discharge education. Which statement by the client indicates that further teaching is necessary? 1. "I will need to notify my primary healthcare provider if I develop a fever." 2. "I need to check my BP daily and report an increased B/P." 3. "I will tell my primary healthcare provider if I become easily fatigued." 4. "I will be on steroids for 3 months, then I will not have to take them."

4. Correct: This statement indicates a need for further teaching. Doses of immunosupressive agents are often adjusted, but the client will be required to take some form of immunosuppressive therapy for the entire time that the client has the transplanted kidney. 1. Incorrect: Yes, fever is a sign of post transplant rejection. Additional signs and symptoms include oliguria, edema, increasing blood pressure, weight gain and swelling or tenderness over the transplanted kidney, flu-like symptoms, shortness of breath and/or fatigue. 2. Incorrect: Yes, hypertension is a sign of post transplant rejection. Additional signs and symptoms include oliguria, edema, increasing blood pressure, weight gain and swelling or tenderness over the transplanted kidney, flu-like symptoms, shortness of breath and/or fatigue. 3. Incorrect: Yes, fatigue is a sign of post transplant rejection. Additional signs and symptoms include oliguria, edema, increasing blood pressure, weight gain and swelling or tenderness over the transplanted kidney, flu-like symptoms, shortness of breath.

The nurse instructs a client diagnosed with chronic obstructive pulmonary disease (COPD) about positions to use during times of dyspnea. Which statement by the client indicates that further teaching is needed? 1. "Lying on my side, propped up on three pillows is a good resting position." 2. "While sitting up, I will rest my elbows on my knees." 3. "If I become short of breath while walking, I will lean slightly forward and place my hands against the wall." 4. "I will open my lips and exhale quickly to decrease air trapping."

4. Correct: This statement made by the client indicates a lack of understanding. Clients with COPD should use slow pursed-lip breathing to increase the flow of expired air and delay the collapse of the small airways. This forced exhalation reduces air trapping. So, further teaching is necessary for this client. 1. Incorrect: High side lying will help improve gas exchange and decrease the work of breathing. 2. Incorrect: Sitting in the tripod position and sitting up while leaning over a table both allows for maximal chest expansion, which helps the client during periods of dyspnea. 3 Incorrect: Leaning against a wall allows the accessory muscles to work to facilitate breathing, thus relieving episodes of dyspnea.

A mother of a newborn is crying and tells the nurse, "I am worried about my baby. His Apgar score was 6 and the nurses had to help him breath for a while." What response should the nurse make to this mother? 1. "Don't worry about what score your baby received on the Apgar. The nurses know how to take care of him." 2. "Stop crying. Your baby is fine now and will continue to get stronger as the day progresses." 3. "Your baby's Apgar score was normal. The score was 6 at 1 minute which is typical." 4. "It is normal for you to feel this way. Let me explain what the Apgar score is used for."

4. Correct: This statement recognizes the mother's feelings and seeks to educate. Providing relevant information may decrease her anxiety and encourage further communication. 1. Incorrect: This statement belittles the mother's feelings and communicates that the nurse is not taking her concerns seriously. 2. Incorrect: This is nontheraputic and will discourage further expression of feelings. This response also gives false reassurance because the nurse does not know if the baby will continue to improve. 3. Incorrect: An Apgar score of 7 to 10 indicates a newborn in good condition. An Apgar score of 6 is not normal and indicates the need for interventions.

Which statement by a client would indicate to the nurse that education about gastroesophageal reflux disease (GERD) has been successful? 1. It would be better for me to eat 3 small meals a day. 2. I need to avoid eating foods high in purine. 3. When going to sleep, I should lie on my side. 4. My last daily meal should not be within 2 hours of bedtime.

4. Correct: To avoid reflux the client should not eat within 2 hours of bedtime. Late night meals may increase discomfort and should be avoided.1. Incorrect: The client should eat at least 6 smaller meals per day to help decrease reflux. Small, frequent meals help prevent over distention of the stomach. 2. Incorrect: The client with GERD should avoid high fat foods and increase high protein foods in an effort to lose weight. Eliminate foods high in purine with disorders such as gout. 3. Incorrect: The client should sleep with the HOB elevated on six inch blocks and several pillows under the upper body. Gravity fosters esophageal emptying.

A charge nurse receives a report of back discomfort after work every day from a surgical nurse. Which action by the surgical nurse should be addressed by the charge nurse? 1. Frequently shifting weight from one foot to the other. 2. Standing straight with knees slightly bent. 3. Raising work station to waist level. 4. Twisting at the waist to reach for an object during cleanup.

4. Correct: To reduce back injuries at work, it is important to find and avoid risk factors that increase the chance of injury. When any of the following occur in combination your risk of a back injury is increased: 1. Awkward posture 2. Overexertion 3. Repetition 4. Fatigue Your body posture determines which joints and muscles are used and the amount of force that is generated. Whether standing or sitting, there is a neutral position for the back. Postures that differ from the neutral position increase stress on the back, especially when combined with other risk factors. Avoid strenuous activity while the body is in a twisted or bent position, repeatedly bending, twisting and reaching, or bending forward while lifting. 1. Incorrect: The nurse should be alternating their weight frequently during surgery. Alternating weight from one foot to the other increases circulation and avoids strain on the back. Alternate tasks and postures that use different motions and muscles groups, such as sitting and standing. Take time to stretch during scheduled breaks. Break standing tasks with seated. 2. Incorrect: This action will decrease the possibility of back injury. The knees should never be locked. Locking your knees restricts blood flow and is a sure fire way to make yourself pass out.3. Incorrect: The nurse should change the work height so that items can be handled with the back in a neutral position. It will alleviate unnecessary bending.

A nurse is caring for a pediatric client who has been diagnosed with hypothyroidism. What is essential for the nurse to teach the parents of this child? 1. Administer the liquid medication with soy milk. 2. Notify primary healthcare provider of slow heart rate. 3. Monitor glucose before meals and at bedtime. 4. Wait 4 hours after giving medication before giving iron supplements.

4. Correct: Wait for 4 hours before giving child iron supplements, antacids that contain calcium or aluminum hydroxide, or calcium supplements as it interferes with medication. 1. Incorrect: Give the medication with a liquid, except soy milk, which interferes with the ability to absorb the thyroid hormone. 2. Incorrect: Bradycardia is seen with hypothyroidism. When taking thyroid medication, we want to watch for signs of hyperthyroidism such as tachycardia, rapid weight loss, sweating, restlessness. 3. Incorrect: Hypothyroidism does not affect glucose.

The nurse is caring for a client prescribed ondansetron due to postoperative nausea. Which side effect is the nurse most worried about the client experiencing with administration of this medication? 1. Respiratory depression 2. Hyperglycemia 3. Malignant hypertension 4. Torsades de pointes

4. Correct: Torsades de pointes is a life threatening dysrhythmia which can occur with administration of ondansetron. Clients who are at increased risk for Torsades de pointes are those with underlying heart conditions and those with hypomagnesemia or hypokalemia. 1. Incorrect: Respiratory depression is not a common side effect of ondansetron. Headache and drowsiness are more common. 2. Incorrect: Hyperglycemia is also not a side effect of ondansetron. Hyperglycemia is high blood sugar and may produce symptoms of urinary frequency, increased thirst and increased appetite. Hyperglycemia is not related to ondansetron. 3. Incorrect: Malignant hypertension is extremely high blood pressure that develops rapidly and causes some type of organ damage. Although it is a serious condition this is not a side effect of ondansetron.

What would be the best way for the nurse to evaluate the effectiveness of fluid resuscitation during the emergent phase of burn management? 1. Weight increases by 2 pounds in 24 hours 2. Urinary output is greater than fluid intake 3. Blood pressure is 90/60 mmHg 4. Urine output greater than 35mL/hour

4. Correct: Urine output of 30 to 50 mL/hour indicates adequate fluid replacement. 1. Incorrect: May indicate fluid retention. 2. Incorrect: Does not indicate fluid balance. 3. Incorrect: Blood pressure alone does not indicate adequate fluid balance.

The nurse has been talking with a depressed client at an outpatient clinic. When asked how the client feels to live alone, the client simply stares straight ahead. How should the nurse respond? 1. Ask, "Why won't you answer me?" 2. Leave the client alone for awhile. 3. Tell a joke to lighten the mood. 4. Use therapeutic silence.

4. Correct: Use of silence allows the client time to think over what he or she wants to say and gives the client a chance to collect thoughts. 1. Incorrect: This is not therapeutic and appears aggressive and confrontational. 2. Incorrect: This is not therapeutic. Depressed clients may need extra time to formulate their thoughts. 3. Incorrect: This is not therapeutic and demonstrates disregard for the client's feelings.

Which client in the emergency department should the nurse identify as being the highest priority? 1. Client with emphysema reporting shortness of breath. 2. Client with a cut on the left calf with moderate bleeding. 3. Client with onset of confusion 1 hour prior to arrival. 4. Client with facial swelling and rash after taking azithromycin.

4. Correct: Were you able to recognize this as a probable reaction to the antibiotic that was taken? Next, it is important to note that there is not only a rash, but facial swelling is also present. That should alert the nurse to the possibility that there could be a rapid onset of airway swelling that could cause airway occlusion. This makes this client the priority over the other clients. 1. Incorrect: It is not uncommon for clients with emphysema to experience shortness of breath. This is a concern, and the client needs additional measures to help relieve the shortness of breath, but is not as likely to result in a rapid airway occlusion as the allergic reaction could. 2. Incorrect: Again, this is a situation that will require intervention. It pertains to circulation because there is moderate bleeding from a cut. However, this does not take priority over the airway. 3. Incorrect: We are concerned about this client and neuro checks will need to be performed. This could be many various things including a stroke, effects of medications or drugs, or other neurological conditions. But, this does not take priority over the airway.

A client admitted to the mental health unit for a suicidal attempt has been progressing slowly in treatment. Suddenly, the client has voiced a much more positive outlook and tells the nurse "I am going to be fine now." What is significant about this situation? 1. The nurse should expect that the treatment has been effective. 2. The client is developing a more positive outlook. 3. The client sees hope for the future. 4. The client may have decided to kill himself.

4. Correct: When a depressed mood suddenly lifts, the client may have decided to kill himself. One would normally expect an incremental return to a positive mood with treatment. This client would need close monitoring to prevent another suicide attempt. 1. Incorrect: The effective treatment plan results in a gradual improvement in mood and energy level, unless the client is suicidal. 2. Incorrect: The client will demonstrate a positive outlook with treatment over the course of a few weeks, if he is not suicidal. 3. Incorrect: Hopeful comments should emerge more gradually, unless the client is suicidal.

The nurse is caring for a client who has been intubated and placed on a ventilator. The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a respiratory rate of 40/min, arterial BP 98/48, oxygen saturation 82%, cardiac monitor showing sinus tachycardia at 138 bpm. What action should the nurse take first? 1. Turn off alarm, then check ventilator settings. 2. Increase FiO2 settings to 100%. 3. Hyperventilate client. 4. Auscultate lung sounds.

4. Correct: When an alarm sounds, the first action by the nurse is to assess the client. In this situation, assessment of lung sounds, chest movement, and respiratory effort should indicate which respiratory complication the client may be experiencing. Depending on the assessment findings, the other actions may be necessary. 1. Incorrect: Depending on the assessment findings, the other actions may be necessary. Check the ventilator after checking the client. 2. Incorrect: Depending on the assessment findings, the other actions may be necessary. 3. Incorrect: Depending on the assessment findings, the other actions may be necessary.

A client asks the nurse, "How is relaxation therapy going to help reduce my stress?" What would be the nurse's best response? 1. Relaxation therapy leads to more awareness of potential stressors 2. Relaxation therapy reduces stress by releasing small doses of epinephrine into the body. 3. Stress can be eliminated from your life when you use this therapy. 4. Relaxation therapy can counteract the flight or fight response.

4. Correct: When stress overwhelms the nervous system, the body is flooded with chemicals that prepare for fight or flight. To counteract this stress response, relaxation techniques can be used. 1. Incorrect: Identifying stressors is part of the solution. The relaxation techniques themselves bring about the counter production of the stress response. 2. Incorrect: Epinephrine is released during stress and increases anxiety. Relaxation therapy counteracts symptoms of stress, such as increasing heart rate and respiratory rate, increased blood pressure, pupil dilation, and increased metabolism. 3. Incorrect: The goal of relaxation therapy is not to improve the stress response of fight or flight but to reduce or counteract the response. Relaxation therapy can help reduce the fight or flight response before it becomes severe.

An unlicensed assistive personnel (UAP) is asked to transfer a client with left hemiplegia from the bed to a wheelchair. The nurse tells the UAP the safest approach for this transfer is what method? 1. Lift client from edge of bed, supporting under arms and pivot to chair. 2. Utilize a slide board to transfer client from bed to the wheelchair. 3. Apply an ambulation belt around client's waist and pull into the chair. 4. Use a mechanical lift to move client from the bed into the wheelchair.

4. Correct: When transferring a large or physically impaired client out of bed to a wheelchair, safety for both staff and client is most important. The UAP should use a mechanical lift, first rolling the client onto the sling, attaching the lift loops, and allowing the machine to do the work of lifting the client. This provides a safe, gentle lift for the client and protects the UAP from injury. 1. Incorrect: This is not appropriate for a client with hemiplegia. Because the client has no sensation or control over the left side, managing that extra dead weight will be placed on the UAP. Trying to lift the client under the arms and pivot into the chair is extremely risky, putting both the client and UAP in danger of being injured. 2. Incorrect: A slide board is utilized when a client is lying flat and needs transferred between two flat surfaces, such as bed to stretcher. A slide board requires several people to utilize safely, and is not appropriate from bed to chair. 3. Incorrect: An ambulation belt is a wide, flexible belt of heavy cotton webbing that is placed around a client's waist to assist when moving from a standing position, whether walking or sitting in chair. In order to correctly utilize this belt, the client needs to be able to stand. This client has hemiplegia and would not be able to stand independently.

A newly admitted client informs the unit nurse the current identification band has the correct name but an incorrect birthdate. The best action by the nurse at this time is what? 1. Report the error to the HCP immediately. 2. Call family to verify the correct birthdate. 3. Tell client not to worry since name is correct. 4. Call Admissions office and request new band

4. Correct: Whether a client is treated in the ER or admitted directly, an identification armband is applied immediately before any treatment begins. Though some ID data differs between facilities, all ID bands contain the client's exact name and correct birthdate, plus sometimes the room number, date or doctor's name. If even one part of the armband is incorrect, a new ID band must be made and immediately placed on the client. 1. Incorrect: The primary healthcare provider rarely checks an armband when making rounds on a unit. The client is more likely to be addressed by name by the HCP at the beginning of an examination and dialogue. This error can be corrected without intervention by the HCP. 2. Incorrect: This scenario indicates the client personally informed the nurse about the error on the armband, which suggests the individual is alert and oriented. Therefore, there is no need to call the family to verify the client's birthdate unless mental confusion was noted. 3. Incorrect: A client's identification arm band must contain all correct, vital information and remain in place for the entire duration of the individual's hospital stay. If even one part of the data is incorrect, the entire armband must be replaced with an accurate replacement.

Which is an example of a sentinel event? 1. The terminally ill client is referred to hospice and dies 3 months later. 2. A client has a mammogram which reveals small cyst. 3. A client with a laceration to the knee falls when getting up unassisted after being instructed to remain in bed. 4. A client scheduled for knee replacement surgery has an above the knee amputation performed.

4. Correct: Yes! Unexpected occurrence causing death or serious injury.1. Incorrect: The terminally ill are expected to die.2. Incorrect: Sometimes cysts are found during mammogram- expected occurrence.3. Incorrect: Not enough injury for sentinel event.

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

4. Correct: Yes, airway is most important here. But don't pick it 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. 1. Incorrect: This is disturbing, and important, but AIRWAY is priority. 2. Incorrect: Renal calculi can cause problems and lead to pain and possibly renal failure but 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 the most important in this question.

The nurse is admitting an 8 month old infant to the pediatric unit. For what major developmental stressor in this infant should the nurse plan interventions? 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. Once your infant realizes the parent is gone, it may leave him unsettled. 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. Keep the good-bye short and sweet. 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.

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

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

The client with obsessive-compulsive disorder (OCD) asks the nurse for help with a repetitive behavior. What is the most likely origin of this behavior? 1. Fear 2. Depression 3. Delusions 4. Anxiety

4. Correct: Yes, this is how they deal with anxiety. The obsession causes the anxiety such as a thought that can't be dismissed from the mind. The ritualistic behavior that the client is driven to perform is an attempt to reduce anxiety. The compulsive act temporarily reduces high levels of anxiety. 1. Incorrect: No, is phobia that deals with fears. A phobia is an excessive and irrational fear reaction. If you have a phobia you may experience a deep sense of dread or panic when you encounter the source of your fear. 2. Incorrect: OCD is not about depression. Depression is a mood disorder that causes persistent feelings of sadness and loss of interest. Not the origin of OCD. 3. Incorrect: Delusions are not associated with OCD. Delusions are most often defined as false fixed beliefs that cannot be corrected by reasoning.

What is the priority nursing intervention when caring for a client with an eating disorder? 1. Encourage the client to cook for others 2. Weigh the client daily and keep a journal 3. Restrict access to mirrors 4. Monitor food intake and behavior for one hour after meals

4. Correct: Yes, this is the primary problem and the most life-threatening. Provide a pleasant, calm atmosphere at mealtime and one hour after meals. Meal times become episodes of high anxiety and monitoring for one hour after prevents the client from vomiting up food. 1. Incorrect: No, remember the focus is on control and attention to food. These clients need to eat. They may enjoy preparing food for others but that does not mean they will partake. 2. Incorrect: No, we don't let them know their weight. If they gain one ounce, these clients will try anything to lose it. The nurse wants to know if the client is gaining weight. Knowledge of the weight increasing induces feelings of becoming out of control. 3. Incorrect: They still need to brush their hair and put on make-up. We focus on these clients' eating to keep them healthy and alive. The client should have limited time with mirrors but it is appropriate for them to have access when getting ready.

Which statement made by a client prescribed naproxen for rheumatoid arthritis would require further investigation by the nurse? 1. "I signed up for swimming classes at the local recreation center." 2. "I take acetaminophen when I have a headache." 3. "I have lost 2 pounds in the past 2 weeks." 4. "I am taking an antacid to help with indigestion."

4. Correct: Naproxen is a nonsteroidal anti-inflammatory drug (NSAID). It works by reducing hormones that cause inflammation and pain in the body. So what do we know is a concern about NSAIDs? They may cause GI bleeding and dyspepsia. This client might be experiencing these symptoms if they are taking an antacid for indigestion. Follow-up is required. 1. Incorrect: There is nothing wrong with the client taking swimming classes. This form of aerobic exercise can help decrease pain and improve strength. 2. Incorrect: Acetaminophen is not considered an NSAID. It can be taken for a headache while taking an NSAID. It is best to stagger the acetamenophen between naproxen doses if needed for headache. 3. Incorrect: There is nothing unusual or worrisome about a 1 to 2 pound (0.45 - 0.9 kg) weight loss a week. This weight loss would not be related to the medication.

The night nurse on a step down unit suspects another nurse may be intoxicated. What initial action should the nurse take? 1. Ask another nurse to confirm suspicions. 2. Call supervisor to report the intoxication. 3. Confront the nurse privately in person. 4. Discuss suspicions with unit nurse manager.

4. Correct:The greatest concern at this time is the safety of the clients to whom the intoxicated nurse is providing care. The nurses Code of Ethics dictates safe, effective care for the public with protection from incompetent or unethical practice. The chain of command for this floor nurse is to report directly to the unit nurse manager. 1. Incorrect: When dealing with ethical or legal issues, the chain of command starts with the nurse manager of the unit in question. Asking another staff nurse for a personal opinion would not provide any pertinent data and instead amounts to gossip. 2. Incorrect: In order to avoid undue conflict, the nurse needs to immediately alert the unit nurse manager and not the facility supervisor. The nurse manager must then manage any conflict that may result and bears the responsibility to control possible disruption resulting from re-assigning the impaired nurse's clients. 3. Incorrect: Direct confrontation of the allegedly impaired nurse would most likely result in denial or defensive behaviors which could place the clients at further risk. The chain of command for this staff nurse starts with the unit nurse manager who would be more qualified to deal with conflict resolution in this matter.

A client newly diagnosed with Celiac disease is being instructed on a gluten-free diet. What statement by the client would indicate to the nurse that further teaching 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 further explanation 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 causing symptoms to resurface. Eating in a restaurant may also be a challenge for those with Celiac disease. Because the client recognizes these possible symptoms, teaching was successful. However, the question asks for evidence the client needs further instruction. 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 teaching. 3. Incorrect: It is important for a Celiac client 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, dairyand 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 that teaching was successful.

A client with a history of syncope and transient arrhythmias has been ordered a Holter monitor for 48 hours. The nurse knows that teaching has been effective when the client makes what statement? 1. No follow up care will be needed after the monitor is removed. 2. It is okay to shower or bath while wearing this equipment. 3. I have to take it easy and not exercise for the next two days. 4. It's important to write down all my activities during this time.

4. Correct:The purpose of the Holter monitor is to detect cardiac irregularities over an extended period of time, in this case 48 hours. Although the monitor will record heart rate and rhythm for two days, it is vital for the client to keep a log or diary during that time, indicating the precise time and type of every activity. Additionally, this log needs to indicate any chest pain or palpitations the client experiences during that time, to assist the primary healthcare provider in diagnosing cardiac dysfunctions. 1. Incorrect: A Holter monitor is a mobile diagnostic test utilized by the cardiologist to help determine a cause for this client's syncopal episodes or arrhythmias. Once the client has the monitor and electrodes removed, the primary healthcare provider will analyze the data before meeting with the client to discuss the findings. Regardless of any suggested treatment options, the cardiologist needs a follow up visit with the client. 2. Incorrect: Showering or tub bathing is not permitted while wearing the Holter monitor as this may interfere with the functioning of the equipment. Only a careful sponge bath is permitted. Clients are also instructed to avoid heavy machinery, electric razors, microwave ovens and even hair dryers since can also affect accuracy and performance of the monitor. 3. Incorrect: The purpose of wearing Holter monitor for 24-48 hours is to diagnose cardiac arrhythmias during ADL's or exercise. The client cannot remove the monitor at any time during that period since that would cause inaccurate readings, or even the loss of valuable data. The client is instructed to complete all routine daily activities during that time, including work or exercise, to help identify actions that contribute to the symptoms or cardiac irregularities.

A 6 year old child is being cared for on the pediatric unit with a spiral fracture to the right humerus. Bruising and wounds in various stages of healing are noted, and physical abuse is suspected. What action would be appropriate for the nurse to include in the care of this child? Select all that apply 1. Obtain only the narrative of the history of the injury from the parent since the child is a minor. 2. Assure the parents that if they are honest, the information will only be used to care for the child and that it will not be shared with anyone else. 3. Focus on the abuse when identifying nursing care needs for the child. 4. Interact in a positive and constructive manner to the child in front of the parents. 5. Refer the parents to appropriate and available social service agencies. 6. Provide consistent caregivers during the period of hospitalization.

4., 5., & 6. Correct: Should the nurse try to become a substitute parent to the child? Of course not. However, the nurse should serve as a role model for the parents by demonstrating to them how to relate positively and constructively to their child. The nurse can also provide information to the parents regarding physical and emotional needs of children. The parents are often very sensitive to criticism or resistant to authority figures. Demonstration and example rather than through lecturing are best. We all know that not all of the needed care can be accomplished by the nurses and primary healthcare provider. Referral to appropriate social service agencies is also essential. What are some issues that have been found to be associated with child abuse that that social service could be helpful with? One of these is that many abusive parents live in poverty. They often feel overwhelmed by the daily stresses caused by their circumstances. Some of the resources that may need to be sought include financial aid, improved housing, and child care. In addition, parents may find self-help groups to be beneficial. Consistent caregivers help the child re-establish a sense of trust while in the hospital. The child needs an environment that is safe, secure, and where empathy is displayed in order for this trust to be developed. 1. Incorrect: Children who are verbal can often give a history of the injury. But the child may be reluctant to tell the events surrounding the abuse when the parent is present, especially if threats for more harm have been made if the child reports the abuse. So, separating the child from the caregiver may provide a more reliable history. However, the history of the injury should include a report of the injury from both the caregiver and child (if verbal). 2. Incorrect: You should never tell anyone that reports of abuse will be kept confidential. This would not be in the best interest of the child, as it could lead to lack of appropriate care and possible future harm. In addition, the nurse has a legal obligation to report abuse. Even though the laws can vary, all states and provinces in North America have laws for mandatory reporting of child maltreatment. 3. Incorrect: The nurse should recognize the need to promote self-esteem and minimize feelings of guilt by treating the child as having a physical problem, not focusing on the child as an "abused" victim. The child who has been abused still has the same needs as those of any other hospitalized child. The nurse should direct care at meeting the physical needs, promoting attainment of developmental tasks, and incorporating play to minimize the stress of hospitalization.

The nurse is caring for a client who is wheezing and struggling to breathe. Which inhaled medications might be indicated at this time? Select all that apply 1. Fluticasone 2. Salmeterol 3. Theophylline 4. Albuterol 5. Levalbuterol

4., & 5. Correct: Albuterol and levalbuterol are both rapid acting bronchodilators, that will quickly relieve shortness of breath, chest tightness and wheezing. This client is in distress now. Either medication would be indicated.1. Incorrect: Fluticasone is a corticosteroid that is used regularly to receive the most benefit. It does not work immediately but may take 12 hours to several days to get the full benefit. Steroid use is for control of symptoms. This client is having symptoms now.2. Incorrect: Long acting bronchodilators are not for use in an emergency. Salmeterol is an inhaled corticosteroid. It will not stop an asthma attack or breathing problem once it has begun. 3. Incorrect: Theophylline is inexpensive but it is often not utilized as a first line treatment. Takes a long time for this to work, and its purpose is to prevent frequency of attacks, not for emergency use.

What assessment finding would alert the nurse that a client's open pneumothorax has progressed to a tension pneumothorax? Select all that apply 1. Subcutaneous emphysema 2. Shortness of breath 3. Tachypnea 4. Distended neck veins 5. Hypotension

4., & 5. Correct: As pressure builds inside the chest cavity, a tension pneumothorax can develop. Symptoms that are commonly seen with a tension pneumothorax include distended neck veins, distant heart sounds, and hypotension. Now, why does the tension pneumothorax client experience distended neck veins? Because the pressure is building up in the chest causing pressure on the right side of the heart. This is a bad thing! There is decreased venous return and this can lead to cardiovascular collapse. Because of the compromised or obstructive blood flow, cardiac output decreases and hypotension develops. 1. Incorrect: You would expect to see subq emphysema with an open pneumothorax and can still be seen with a tension pneumothorax. 2. Incorrect: SOB is expected with open pneumothorax and tension pneumothorax. 3. Incorrect: Tachypnea would be seen with both.

The nurse is reviewing the plan of care for a client during the first day post-craniotomy. Which actions can the nurse delegate to an experienced LPN/LVN working in the ICU? Select all that apply 1. Determine Glasgow Coma Score. 2. Check endotracheal tube (ET) cuff pressure every shift. 3. Reposition client from side to side every 2 hours. 4. Administer acetaminophen via nasogastric tube for temperature greater than 101ºF (38.3ºC). 5. Monitor intake and output every hour.

4., & 5. Correct: Both of these actions are within the scope of practice for the LPN/LVN. 1. Incorrect: Assessing the Glasgow Coma Score should be done by the RN. 2. Incorrect: ET tube cuff assessment is accomplished by an experienced RN. 3. Incorrect: Usually, repositioning a client would be within the scope of practice for the LPN/LVN; however, this client is at risk for increased ICP during position changes. The RN must monitor.

The nurse is caring for a client who sustained a head injury with possible seizure activity. The primary healthcare provider prescribes an EEG. What client teaching should the nurse provide to the client prior to this test? 1. Instruct client to be NPO after midnight. 2. Tell client not to wash their hair the night before the test. 3. Assure client that they may take sleeping pill the night prior to the EEG. 4. Instruct client not to drink caffeinated beverages the morning of the test. 5. Take routine medications the morning of the EEG with a sip of water.

4., & 5. Correct: Caffeine is a stimulant and will speed up the electricity in the brain. We don't want to do anything that is going to alter a client's electrical activity in the brain before an EEG. The cliebts are encouraged to take their routine medications unless directed otherwise. 1. Incorrect: Fasting may cause hypoglycemia and could alter the EEG pattern. 2. Incorrect: The client should wash hair the night before the test. 3. Incorrect: No sedatives or hypnotics are given before the test. This could cause abnormal results on the EEG. In addition, the client may be directed to sleep less the night before the EEG if sleeping is desired during the EEG.

What discharge instructions should the nurse provide to the parents of a child diagnosed with sickle cell anemia? Select all that apply 1. Provide high-calorie, low protein diet. 2. Inheritance is by autosomal dominate genes. 3. Restrict all activities for 3 months. 4. Deferasirox helps prevent liver damage from iron deposits. 5. Avoid high altitudes.

4., & 5. Correct: Deferasirox is an orally administered iron chelation agent shown to reduce the liver iron concentration due to repeated RBC transfusions. It binds iron. Low oxygen environments such as airplanes and high altitudes should be avoided. 1. Incorrect: Provide a diet that is high-calorie and high-protein to promote growth and health. 2. Incorrect: Sickle cell anemia is an autosomal recessive disease. 3. Incorrect: Activities are not generally restricted. The client may not be able to tolerate vigorous exercise or exertion. Encourage children to participate in physical activities.

A client with a history of congestive heart failure (CHF) has been admitted with digoxin toxicity. After reviewing the initial laboratory results, the nurse knows what abnormal findings most likely contributed to the digoxin toxicity? 1. Sodium 2. Calcium 3. Albumin 4. Potassium 3.1 meq/l 5. Magnesium 1.2 mEq/l

4., & 5. Correct: Hypokalemia and hypomagnesemia both can increase the client's potential to develop digoxin toxicity. Digoxin and potassium both bind at the same location on the ATPase pump. When potassium levels are low, more digoxin will attach to the sites, leading to toxicity. Low magnesium levels sensitize the cardiovascular system to the toxic effects of digoxin. 1. Incorrect: The presence of digoxin in the body does slightly inhibit the activity of the NA/K+ pump. However, even though the sodium level is slightly elevated, there is no direct correlation between that increased sodium level and digoxin toxicity. 2. Incorrect: A calcium level of 9.9 is within the normal limits of 9.0 to 10.5 mg/dL (2.25-2.62 mmol/L). Calcium is controlled by the parathyroid glands, generally shifting between the bones and serum. A normal calcium level would not contribute to digoxin toxicity. 3. Incorrect: Albumin is a protein synthesized by the liver which helps to maintain fluid within the vascular spaces and transport soluble products throughout the body. This specific laboratory result is within normal limits. Nonetheless, albumin has no effect on digoxin levels in the body.

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? Exhibit pH - 7.49 (7.35- 7.45) PaCO2 - 29 (35.45) HCO3 - 24 (22-26) 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

4., & 5. Correct: The blood gases confirm respiratory alkalosis. Why? The pH is 7.49 (normal 7.35-7.45). This pH indicates alkalosis since it is high. Which other chemical says alkalosis? The PaCO2 of 29 (normal 35-45) is low which indicates alkalosis. The HCO3 is normal. This means that the client is in uncompensated respiratory alkalosis. 1. Incorrect: The blood gases confirm respiratory alkalosis. The Bicarb is normal, so the problem is not metabolic. 2. Incorrect: The blood gases confirm respiratory alkalosis. The PaCO2 of 29 (normal 35-45) is low which indicates alkalosis. For this client to bew in respiratory acidosis, the PaCO2 would be greater than 45. 3. Incorrect: The blood gases confirm respiratory alkalosis. The Bicarb is normal, so the problem is not metabolic. 6. Incorrect: Compensation has not begun because the bicarb is normal. To compensate the bicarb would need to decrease to bring the pH down to normal. 7. Incorrect: Fully compensated would occur if the pH is normal with abnormal CO2 and bicarb.

In which situation should the nurse consult the client's advanced directive? 1. Client scheduled for breast reconstruction after mastectomy. 2. Client with a T-5 spinal cord injury beginning rehabilitation therapy. 3. Client diagnosed with Guillain-Barre' who is receiving ventilator support. 4. Comatose client with end stage chronic obstructive pulmonary disease. 5. Client diagnosed with inoperative brain tumor who is confused.

4., & 5. Correct: The client must have lost decision-making capacity because of a condition that is not reversible or must be in a condition that is specified under state law, such as a terminal, persistent vegetative state, irreversible coma, or as specified in the Advanced Directive. Both of these clients are terminal. 1. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. The option does not say the client is terminal, in a vegetative state, or in a coma. 2. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions 3. Incorrect: A client diagnosed with Guillain-Barre' is mentally competent and being on a ventilator does not indicate that the client has lost decision-making capacity.

The nurse is preparing to teach a client about post percutaneous transluminal coronary angioplasty (PTCA) care. Which teaching points should the nurse include? Select all that apply 1. Restricting oral fluids until the gag reflex has returned. 2. Encouraging early ambulation and deep breathing exercises. 3. Discontinuing medicines following percutaneous intervention. 4. Reporting any chest discomfort following percutaneous intervention. 5. Avoid lifting more than 10 pounds until approved by healthcare provider.

4., & 5. Correct: The number one thing you are "worried" about post PTCA is re-occlusion or re-infarction, so report chest discomfort at once. Lifting more than 10 pounds can make the client bleed and would be contraindicated until cleared by the primary healthcare provider. 1. Incorrect: Fluids need to be increased to flush the dye used during the procedure from the kidneys. Oral fluids do not have to be restricted because the client does not have to be intubated for the procedure. 2. Incorrect: To ensure a stable clot is formed at the femoral access site, the client must remain on bed rest for a minimum of 4 hours. The client is at risk for hemorrhaging at the insertion site. DO NOT ambulate until it is certain that the clot is stable. 3. Incorrect: Medications are generally continued as before the procedure. Certain medications, like anticoagulants, may be held prior to the procedure, but typically all pre-procedure medications are resumed after PTCA.

What foods should the nurse inform the client to avoid for three days prior to a guaiac test? Select all that apply 1. Chicken 2. Carrots 3. Apple 4. Raw broccoli 5. Steak 6. Turnip greens

4., 5., & 6. Correct: Foods that affect this test include raw broccoli, red meats such as steak, turnip greens, cantaloupe, radish, and horseradish. All of these could cause a false positive reading for the guaiac test. 1. Incorrect: Red meats such as steak should be avoided, but chicken is okay. 2. Incorrect: Carrots are not prohibited and will not affect the results of the test. 3. Incorrect: The client can eat apples with no effect on the test results.

The primary healthcare provider prescribed diazepam 12.5 mg IM to a client. The pharmacy dispenses diazepam 5 mg/mL. How many mL will the nurse administer? Round answer using one decimal point.

5 mg : 1 mL = 12.5 mg : x mL 5 x = 12.5 x = 2.5

The nurse is caring for a client due for a dose of fluphenazine 10 mg. The drug is available as an elixir: 5 mg / 5 mL. How many mL will the nurse give to the client? ______mL. Round answer to the nearest whole number.

5 mg : 5 mL :: 10 mg : x mL 5 mg/x mL = 50 mg/mL 5 mg/x mL = 50 mg/mL 5 mg x = 10 mL

The nurse is planning care for a client admitted with Alzheimer's Disease. What interventions can the nurse delegate to the LPN/VN? Select all that apply 1. Teach caregivers memory enhancement aids. 2. Evaluate client's safety risk factors. 3. Make referrals to community services. 4. Determine caregiver's stress level and coping strategies. 5. Monitor for behavioral changes. 6. Check environment for potential safety hazards.

5. & 6. Correct: The LPN/VN can monitor for behavioral changes and can look for potential safety hazards. 1. Incorrect: The RN is responsible for teaching. This task cannot be delegated to the LPN/N. The LPN/VN can reinforce teaching. 2. Incorrect: The RN is responsible for assessment and evaluation of clients. The LPN/VN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. 3. Incorrect:The RN is responsible for developing the plan of care which would include necessary referrals. 4. Incorrect: This again is assessment which is the role of the RN only.

What signs/symptoms would the nurse expect to find in a client admitted to the unit with a diagnosis of Addison's disease? Select all that apply 1. Moon face 2. Buffalo hump 3. Hirsutism 4. Acne 5. Hyperpigmentation 6. Hypotension

5., & 6. Correct: Addison's disease results in a decrease in glucocorticoids, mineralocorticoids, and sex hormones resulting in a darkening in skin color and hypotension. 1. Incorrect: Moon face occurs when the body has too much cortisol, such as with Cushing's. 2. Incorrect: Buffalo hump occurs with Cushing's. 3. Incorrect: An increase in facial hair occurs with Cushing's. 4. Incorrect: Acne occurs with Cushing's.

The pathology report on a client diagnosed with urolithiasis reveals calcium oxalate stones. Which food selections by the client would indicate to the nurse that the client understands the prescribed low oxalate diet? Select all that apply 1. Spinach 2. Raspberries 3. Almonds 4. 100% bran cereal 5. Bananas 6. Raisins

5., & 6. Correct: Fruits provide valuable amounts of water, fiber, and antioxidants, all of which may help lower your risk for kidney stone symptoms. Many fruits are considered low-oxalate, meaning they contain less than 2 milligrams per serving. These include bananas, cherries, grapefruit, grapes, mangoes, melons, green and yellow plums and nectarines. Canned fruits, including peaches, pears, and dried fruits such as raisins, are also low in oxalate. 1. Incorrect: 1 cup of cooked spinach contains 1510 mg of oxalate. 2. Incorrect: Raspberries are the most significant fruit source of oxalate. One cup of raspberries contains 48 mg of oxalate. 3. Incorrect: 1 oz (28 g) of almonds contains 122 mg of oxalate. 4. Incorrect: One cup of 100% bran cereal contains 75 mg of oxalate.

The nurse, caring for a client post motor vehicle accident who sustained multiple crushing injuries, suspects that the client may be developing disseminated intravascular coagulation (DIC). Which assessment findings by the nurse suggest that the client is developing this complication? Select all that apply 1. Chest pain 2. Frothy sputum 3. Intermittent claudication 4. Subcutaneous emphysema 5. Petechiae 6. Blood oozing from chest tube insertion site

5., & 6. Correct: Petechiae are red dots on the surface of the skin seen because of minute hemorrhages within the dermal or submucosal layers of the skin. Oozing blood from invasive catheter sites is one sign of DIC. The client can have minor oozing of blood to bleeding from every orifice and into the tissues. 1. Incorrect: Chest pain may be a symptom of MI, or pulmonary embolus. It is not typical of DIC. 2. Incorrect: Think pulmonary edema and pulmonary embolus with frothy sputum. 3. Incorrect: Intermittent claudication is severe leg pain associated with decreased oxygenation to the leg muscles. 4. Incorrect: Subcutaneous emphysema is air under the skin, typically seen with chest tubes or tracheostomy insertion.

A roommate overhears the primary healthcare provider discussing a client's laboratory results, including a positive HIV test. The roommate requests to be moved immediately to another room. In what priority order should the nurse complete these tasks? 1. Notify nurse manager regarding breach in confidentiality. 2. Transfer roommate to another location as soon as available. 3. Encourage the client to verbalize feelings regarding situation. 4. Contact social services to address client's future needs. 5. Educate roommate about transmission of HIV and AIDS.

5.1,2,3,4 The first action by the nurse is to address the roommate's concerns and fears about contracting HIV by presenting information regarding disease transmission. Next, since this situation represents a definite breach of confidentiality, it must then be reported to the nurse manager. Third, despite educating the roommate on modes of transmission, the nurse should attempt to honor the request to be moved to another room. Fourth, address the roommate's needs, by encouraging the client to express feelings about the diagnosis and current situation. Additionally, the client will have other needs related to the diagnosis which can best be handled by the social services department.

A client is admitted to an ED after sustaining a head injury in a motor vehicle crash. The client opens eyes and moans as pressure is applied to the nail bed of fingers and then pulls hand away. Based on this information, what Glasgow Coma Scale score should a nurse document for this client? Category Score Response Eye Opening 4 Spontaneous 3 To speech 2 To pain 1 None Verbal Response 5 Oriented 4 Confused 3 Inappropriate words 2 Incomprehensible 1 None Best Motor Response 6 Obeys commands 5 Localizes to pain 4 Withdraws from pain 3 Abnormal flexion 2 Extension 1 None

The primary healthcare provider has prescribed KCL 20 mEq by mouth once a day. The pharmacy has dispensed KCL 8 mEq/5 mL. How many mL will the nurse administer? Round answer using one decimal point.

8 mEq : 5 mL = 20 mEq : x mL 8 x = 100 x = 12.5

The primary healthcare provider has prescribed KCL 40 mEq by mouth once a day. The pharmacy has dispensed KCL 8 mEq/5 mL. How many mL will the nurse administer? Round answer using one decimal point.

8 mEq : 5 mL = 40 mEq : x mL 8 x = 200 x = 25

The charge nurse is evaluating a newly hired LPN/VN graduate. Before assigning a client to be prepped for a colonoscopy, the nurse asks the LPN/VN to verbalize the correct steps for completing an enema. In what order should the LPN/VN verbalize the steps for an enema? The Correct Order Explain procedure to the client. Assist client to a side lying position. Add warm water to the enema bag. Raise enema bag 18" to 20". Insert lubricated tip into rectum.

All procedures should be explained to the client first, allowing time for the client to ask questions or express any concerns. Second, positioning the client comfortably with attention to privacy is important for both comfort and ease of completing procedure without complications. Positioning should be done so that the water remains warm during the procedure. Third, the water must be warm enough to prevent cramping and discomfort during the procedure; once the enema bag is filled, it should be hung next to the bed for use. Fourth, raising the enema bag allows gravity to assist with the flow of fluid from the bag into the client. Fifth, the tip of the nozzle must be completely lubricated to prevent friction or trauma to the rectal tissue. The tip is gently inserted into the rectum, aiming the tip of the nozzle towards the umbilicus when inserted. (If the client begins to experience cramping, the first action is to lower the bag and stop the flow.)

In what order should the nurse assess assigned clients following shift report? Place in priority order. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. Elderly client admitted 30 minutes ago with reports of constipation for four days. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour.

All these clients have a GI problem. So, now you must decide which of these high priority clients should be seen in what order. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. This is an elderly client who is a new admit. The client reports constipation for 4 days which may be an indication of worse problems. The client is considered unstable until assessed by the nurse. The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. Did you think dehydration and fluid volume deficit? The third client that should be assessed by the nurse is the client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. This is normal for clients with hemorrhoids. But the client does need to be assessed prior to the client with Crohn's disease who is improving. The fourth client the nurse should assess is the client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Semi-formed stools are great news! The client is getting better. During exacerbation, the client will have many diarrhea stools.

A client is receiving morphine 12.4 mg/hour as a continuous rate via a patient controlled analgesia (PCA) pump. How many mL/hour would the nurse calculate that the client is receiving? Round to the second decimal place. Use numbers and decimals only. Exhibit

Answer: 1.24 Rationale: Prescription: Morphine 12.4 mg/hour at a continuous rate via PCA pump. According to the pump, there are 10 mg of morphine per mL. The client is to receive 12.4 mg/hour, so think: The client will be getting more than 1 mL but less than 1.5 mL. Remember the formula: D/H x Q = X 12.4 mg/10 mg x 1 mL = 1.24 mL

The nurse is monitoring the IV medications that a client is receiving by an IV infusion pump. How many micrograms per min of dopamine should the nurse determine that the client is receiving? Use numbers only to answer Mix Dopamine 400 mg in 250 mL of NS to yield 1600 mcg/mL

Answer: 376 Rationale: Prescription: Dopamine 5 mcg/kg/min IV per infusion pump Determine mcg /min. 5 mcg x 75.2 kg = 376 mcg / minute

In what order should the nurse assess assigned clients following shift report? Place in priority order. Client diagnosed with Addison's disease who is lethargic and has a BP of 86/48, P 120, and R 24. Client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. Client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22. Client two days post thyroidectomy who has a negative Trousseau's sign.

All these clients have an endocrine problem. So, now you must decide in what order to assess each of these clients. The first client the nurse needs to assess is the client diagnosed with Addison's disease who is lethargic and has a BP of 86/48, P 120, and R 24. Do you see shock (Addisonian Crisis)? You should. This BP is too low. You don't even have to know anything about Addison's disease to know this client is critical and could die if intervention is not rapid. The second client the nurse needs to see is the client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. The client's airway is stable since the client is intubated, however, the nurse needs to monitor this client frequently to ensure the airway remains patent. The third client that should be assessed by the nurse is the client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22. Look at these blood gases. Normal. What is iatrogenic? Caused by medical treatment: symptoms, ailments, or disorders induced by drugs or surgery. Most likely this client developed Cushing's due to steroid administration for the cancer. The fourth client the nurse should assess is the client two days post thyroidectomy who has a negative Trousseau's sign. A negative Trousseau's is a good thing. This client is stable two days postop.

Shortly after being admitted to the cardiac unit, a client reports shortness of breath. The nurse prepares to administer the prescribed morphine. How many mL should the nurse administer? Use numbers and decimals only to answer.

Answer: 0.4 Rationale: Prescription: Morphine 2 mg IV every 2 hours PRN shortness of breath. Available: Morphine 5 mg/mL Think, 5 mg is in one mL and you need to give 2 mg, which is less than ½. So you will want to give less than 0.5 mL. D/H x Q = X 2 mg/5 mg x 1 mL = 2/5 = 0.4 mL

A client has a prescription for nitroglycerin gr 1/400 SL prn for angina pain. How many tablets should the nurse give the client? Use numbers and decimals only. Exhibit

Answer: 0.5 Rationale: Prescribed: nitroglycerin gr 1/400 Step 1 is to convert grains to mg (gr 1 = 60 mg) 1/400 = 1/400 x 60/1 = 60/400 = 3/20 = 0.15 mg Step 2: Think - 0.15 is ½ of 0.30. You want to give the equivalent of ½ tablet as needed. Step 3: D/H x Q = X 0.15/0.3 x 1 tablet = 0.5 tablet nitroglycerin SL

The nurse is preparing to hang an IV bag of Heparin after receiving a prescription from a client's primary healthcare provider: Heparin IV to infuse at 1000 U/h. What flow rate should the nurse set the IV infusion pump rate at? Round to the nearest whole number. Exhibit

Answer: 10 Rationale: Prescription: Heparin IV to infuse at 1000 U/h. Available: Heparin 25,000 units in NS 250 mL Use ratio-porportion to calculate flow rate in mL/h which will administer 1000 units/hour. 25,000 units/250 mL = 1000 units/X mL 25,000X = 250,000 X = 10 mL/hr

A client was admitted with a diagnosis of Type II diabetes. The primary healthcare provider initiated the Insulin Sliding Scale Protocol for Type II Diabetic Clients. The prescription regimen was to begin at the high dose regimen with regular insulin AC & HS. How much insulin should the nurse administer at 2100 hours? Exhibit

Answer: 10 Rationale: Prescription: The prescription regimen was to begin at the high dose regimen with regular insulin AC & HS using the Insulin Sliding Scale Protocol for Type II Diabetic Clients. The protocol states to advance to the next higher dose regimen if glucose level is greater than 250 two (2) times in 24 hours and all readings are greater than 100. All glucose readings were greater than 100, and the readings were greater than 250 three times. So, the client should move to the next highest dose regimen which indicates that 10 units of regular insulin should be given at 2100 hours for a glucose of 248.

The nurse is preparing to administer 1000 mL D5W with 40 mEq KCL IV over 12 hours. How many gtts/min will the nurse need to set the IV rate at? Exhibit 10gtt/min

Answer: 14 Rationale: Prescription: 1000 mL D5W with 40 mEq KCL IV over 12 hours. Step 1: Determine what the drop factor is on the IV tubing. The one shown in the exhibit has a drop factor of 10 drops/mL. Step 2: Remember the formula for gtts/min = mL/hr x drop factor/time in minutes = gtts/min Step 3: 1000 ml/12 hours x 10 gtts/1 mL x 1 hour/60 min = 1000/12 x 10/1 x 1/60 = 10000/720 = 13.8 or 14 gtts/min

The nurse is preparing to initiate a dopamine infusion per protocol. The primary healthcare provider prescription: Dopamine 5 mcg/kg/min IV per infusion pump. At what rate should the nurse set the pump? Use numbers only. Exhibit

Answer: 15 Rationale: Prescription: Dopamine 5 mcg/kg/min IV per infusion pump using the Dopamine infusion protocol. The protocol states that a mixture of 400 mg Dopamine is put in 250 mL fluid to provide 1,600 mcg/mL. The table provides the mcg/kg/min infusion and weight in kg to yield the flow rate for the infusion pump. So, 5 mcg/kg/min for a client weight 80 kg is 15 mL/hour. BUT, always double check the chart to make sure it is correct. Step 1: Determine mcg /min. 5 mcg x 80 kg = 400 mcg / minutes is required. Step 2: Determine the mL/min. D/H X Q = 400 mcg/min/1600 mcg X 1 mL = 0.25 mL/min Step 3: Determine the flow rate (mL/h) 0.25 X 60 = 15 mL/h

The nurse is preparing to hang an IV bottle of fat emulsions 20% on a client. How many mL should be delivered in 12 hours? Answer in numbers only.

Answer: 204 Rationale: Prescription: Fat emulsions 20% IV at 17 mL/hour for 12 hours 17 mL/hour x 12 hours = 204 mL

The nurse is preparing to hang an IV bottle of fat emulsions 20% on a client. At what rate should the nurse set the IV infusion pump? Answer in numbers only. Exhibit Fat Emulsion 20% 200 mL fat emulsion 20% IV at 17 mL/ho

Answer: 17 Rationale: Prescription: 200 mL fat emulsions 20% IV at 17 mL/hour. Think, when an infusion pump is used, the flow rate is prescribed by the primary healthcare provider and programmed by the nurse by setting the device for milliliters per hour (mL/h). Rule - To regulate an IV by infusion pump, Total mL prescribed/Total hr prescribed = mL/hr If you forgot that, then work the formula for gtts/min - mL/hr x drop factor/time in minutes = gtts/min The drop factor for the infusion pump is 60. 17 mL x 60 / 60 minutes = 17 Therefore, the pump should be set at 17 mL per hour

The nurse is preparing to give a client's prescribed azithromycin dose. How many tablets will the nurse give to the client? Answer with numbers only. Exhibit Availability Azithromycin 1 gram by mouth times one dose now

Answer: 2 Rationale: Prescription: Azithromycin 1 gram by mouth times one dose now Available: Azithromycin 500 mg/tablet Step 1 is to convert grams to mg (1 gram = 1000 mg) Step 2: Think, 1 tablet is 500 mg and you need to give 1000 or twice the amount that is available. Step 3: D/H x Q = X 1000mg/500 mg x 1 tablet = 2/1 = 2 tablets

The nurse is preparing to give a client's prescribed levothyroxine dose. How many tablets will the nurse give to the client? Answer with numbers only. Exhibit Levothyroxine 0.05 mg by mouth every morning

Answer: 2 Rationale: Prescription: Levothyroxine 0.05 mg by mouth every morning. Available: Levothyroxine 0.025 mg per tablet Think, 1 tablet is 0.025 mg and you need to give 0.05 or twice the amount that is available. Remember the formula: D/H x Q = X 0.05mg/0.025 mg x 1 tablet = 0.05/0.025 = 2 tablets

The nurse is preparing to give a client's prescribed nafcillin dose. How many mL will the nurse give to the client? Answer as a whole number. Exhibit Nafcillin 500 mg IM every 6 hours 2gm per vital

Answer: 2 Rationale: Prescription: Nafcillin 500 mg IM every 6 hours Available: Nafcillin 2 grams in 8 mL Step 1: Convert grams to mg (1 gram = 1000 mg), so 2 grams = 2000 mg Step 2: Think, 500 mg is ¼ of 2000 mg. Look at the reconstitution instruction. Adding 6.6 mL diluent will provide 8 mL solution in the vial. So 2000 mg is in 8 mL. ¼ of 8 is 2. Step 3: D/H x Q = X 500mg/2000 mg x 8 mL

The nurse is preparing to give a client's prescribed furosemide dose. How many mL will the nurse give to the client? Answer to the first decimal place. Answer with numbers and decimal only. Exhibit Furosemide 25 mg by mouth daily Availabel 10mg/ml

Answer: 2.5 Rationale: Prescription: Furosemide 25 mg by mouth daily Available: Furosemide 10 mg/mL Step 1: The label states that 10 mg are in 1 mL Step 2: Think, 10 mg is in 1 mL, so 25 mg will in 2.5 mL Step 3: D/H x Q = X 25/10 x 1 mL = 5/2 x 1 = 5/2 or 2.5 mL

The nurse is preparing to administer cefazolin 0.5 grams in 100 mL D5W IVPB over 30 minutes. How many mL/hour will the nurse need to set the IV infusiton pump at? Round to the nearest whole number.

Answer: 200 Rationale: Prescription: Cefazolin 0.5 grams in 100 mL D5W IVPB over 30 minutes. Step 1: Determine what the drop factor is on the IV tubing. IV infusion pumps have a drop factor of 60 gtts/min. Step 2: Remember the formula to regulate an IV by infusion pump- Total mL prescribed/Total hr prescribed Step 3: 100 ml/30 x 60 gtts/1 mL = 100/30 x 60/1 = 200 mL/hr

A client who has been admitted to the intensive care unit with malignant hypertension has been prescribed nitroprusside IV. BP on admit is 210/112. Weight - 56 kg. Based on the prescription, what should the flow rate for a volumetric pump be set at initially? Round to the whole number. Titrate nitroprusside 50 mg in 250 mL D5W at 3 to 6 mcg/kg/min to maintain client's systolic blood pressure below 140 mm Hg.

Answer: 50 mL/hour Rationale: Convert to like units. Equivalent: 1,000 mcg = 1 mg Therefore 50 mg = 50,000 mcg Calculate the concentration of solution in mcg/mL. 50,000 mcg : 250 mL = x mcg : 1 mL 250x/250 = 50,000/250 X = 200 mcg/mL The concentration is 200 mcg/mL Always start with the lowest dosage when beginning nitropusside. 3 mcg/kg x 56 kg = 168 mcg/min Convert dosage range to mL/min 200 mcg : 1 mL = 168 mcg : x mL 200x/200 = 168/200 X = 0.84 mL/min Convert mL/min to mL/ hr. 0.84 mL x 60 min = 50.4 or 50 mL/hr.

A three year old weighing 13.6 kg is scheduled to receive a dose of digoxin elixir. The prescribed dose is 25 micrograms/kg How many mL will the nurse administer to the child? Round to 1 decimal place. Use numbers and decimals only. Exhibit: Lanoxin 0.05mg

Answer: 6.8 Rationale: Prescribed: Digoxin elixir 25 micrograms/kg Step 1: Determine how many micrograms per kg should be given. 25 mcg/kg x 13.6 kg = 340 mcg Step 2: Think: You will want to give less than 7 mL, since one mL is 50 mcg. Step 3: D/H x Q = 340 mcg/50 mcg x 1 mL = 34/5 = 6 4/5 = 6.8 mL

An elderly client was admitted with a diagnosis of Type II diabetes. The primary healthcare provider initiated the Insulin Sliding Scale Protocol for Type II Diabetic Clients. The prescription regimen was to begin at the low dose regimen with regular insulin every 6 hours. The 2400 hours glucose level is 252 mg/dL. How much regular insulin should the nurse give the client at this time? Answer using numbers only. Exhibit

Answer: 8 Rationale: Prescription: The prescription regimen was to begin at the low dose regimen with regular insulin every 6 hours using the Insulin Sliding Scale Protocol for Type II Diabetic Clients. The protocol states to advance to the next higher dose regimen if glucose level is greater than 250 two (2) times in 24 hours and all readings are greater than 100. All glucose readings were greater than 100 and greater than 250 at 1800 hours and 2400 hours, so the client should be moved to the medium dose regimen which indicates that 8 units of regular insulin should be given at 2400 hours.

The nurse is preparing to administer a unit of packed red blood cells (PRBCs) using a blood administration set. During the first 15 minutes of administration, the unit is to run at 25 mL / hour. How many gtts/min will the nurse need to set the IV rate at? Round to the nearest whole number. Use numbers only. Exhibit

Answer: 8 Rationale: Remember to calculate drops / minute you have to know what the drop factor is. The drop factor for the blood adminstration set shown in the exhibit is 20 drops/mL The formula for gtts/min = mL/hr x drop factor/time in minutes = gtts/min 25 mL x 20 / 60 minutes = 500/60 =

A 35 year old client, concerned about weight, asks a clinic nurse, "What is my BMI?" The client weighs 135 pounds and is 5 feet (60 inches) 2 inches tall. Determine the client's BMI to the nearest tenth?

BMI = 24.7 Formula: BMI = (703 x weight in pounds) ÷ (height in inches)2 BMI = (703 x 135) ÷ (62)2 BMI = (94,905) ÷ (3,844) BMI = 24.689 BMI = 24.7

During night time rounds, the nurse finds a client has cigarettes in bed and the room is filled with smoke. In what order should the nurse perform the following actions? Remove client from room. Pull the fire alarm handle. Notify hospital operator. Close the client's door. Get the fire extinguisher.

CORRECT. Anytime an internal disaster is suspected, client safety is always the first concern. National Fire Safety codes refer to the pneumonic "R-A-C-E" (rescue -alarm-contain-extinguish). If the area is safe for the nurse to enter, removing the client from that environment would be the first action. Secondly the nurse must activate the EMS alarm system so that emergency personnel are en route. Additionally, the hospital must be alerted by contacting the hospital operator to activate appropriate internal alarm systems. Closing the client's door will help contain any fire or smoke. Finally, the nurse should obtain the closest fire extinguisher appropriate for the type of fire.

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

A client is prescribed 1.5 grams of levodopa daily. Available forms of this drug include tablets of 250 milligrams. How many tablets should this client be given to receive the proper amount of medication? Round answer to the nearest whole number.

Changing 1.5 grams to milligrams equals 1500 milligrams as a daily dosage. Dividing 1500 milligrams by 250 milligrams equals 6.

A client is prescribed 2 grams of levodopa daily. Available forms of this drug include tablets of 500 milligrams. How many tablets should this client be given to receive the proper amount of medication? Round answer to the nearest whole number.

Changing 2 grams to milligrams equals 2000 milligrams as a daily dosage. Dividing 2000 milligrams by 500 milligrams equals 4 tablets.

The nurse is demonstrating ostomy care to a client with a new stoma in the sigmoid area of the colon. The nurse knows teaching is successful when the client completes care in what order? Cut center of new flange to fit stoma. Remove ostomy bag and old flange. Apply skin protectant and allow drying. Press flange into place and attach bag. Wash stoma with warm soapy water. Place stoma adhesive onto new flange.

Changing an ostomy appliance can be challenging for an individual without assistance from another individual. Successful completion of the procedure involves not only a willingness to learn, but also the client's physical capabilities to reach, view, and accomplish the task based on the type or location of stoma. The basic principles of stoma care are similar to any dressing change. The client must remove and dispose of the old, inspect and clean the area, then prepare and apply the new appliance. Though there are multiple steps, many clients can perform self-ostomy care with practice and minimal assistance. The ostomy flange is designed to remain in place for 3 to 5 days, while the bag can be changed, or cleaned, daily. There are many types of appliances, including some which are sealed and are simply thrown away at the end of each day. The steps have been simplified here, but are basic: First, remove both the ostomy bag and old flange. Second, thoroughly wash the entire abdomen with warm soapy water, being sure to wash stoma gently. (The client must be instructed to carefully inspect the skin for any signs of excoriation which should be reported to the primary healthcare provider). Third, a skin protectant is applied and allowed to dry. Fourth, the new flange is sized/cut to fit the stoma. Fifth, a thin "bead" of stoma paste is placed around the new flange opening. Lastly, Press flange into place and attach the bag. The bag is snapped over the center rim of the flange, and "burped" to allow any excess air to escape. This will create a strong seal. It is also vital to apply the clamp onto the bottom of the new bag to prevent leakage of stool.

The primary healthcare provider has prescribed ear irrigation for a client with earwax accumulation. In what order would the nurse perform the procedure? 1. Fill bulb syringe with luke warm water. 2. Tilt client's head to the opposite side. 3. Pull ear pinna upward and backward. 4. Aim syringe at back side of ear canal. 5. Squeeze syringe with moderate force. 6. Remove any debris in the outer canal.

Ear wax is a substance produced by the body to clean and protect the ear canal. Usually, the ear is able to remove wax that has dried up and become useless. However, in certain circumstances, a nurse may receive a prescription to irrigate ears for clients when the wax has become impacted. After gathering the needed equipment and explaining the process to the client, the nurse should first fill the bulb syringe with warm water. Next, positioning the client is always the nurse's responsibility. For irrigating ears, the client's head should be tilted slightly toward to opposite side, so the affected ear is easily accessible. Third, using one hand, the nurse pulls the ear pinna gently upward and back to straighten the ear canal. Fourth, aim the bulb syringe toward the back and side of the ear canal. Next, the nurse squeezes the syringe with moderate force to flush out loose debris or dried wax. Sixth, any debris visible in the outer canal can be carefully removed with tweezers.

In what order should the triage nurse send the following clients into the emergency department for treatment? Place in order from first to last.

Client who has a respiratory rate of 28/min and end-expiratory wheezes noted on auscultation. Client reporting continuing angina after taking three doses of nitroglycerin. Client who has soaked a towel with blood from a thigh laceration. Client with a BP of 92/52. Client with right sided hemiparesis and a BP of 150/88.

Which action by the nurse administering intravenous ciprofloxacin would require intervention by the charge nurse? 1. Sets IV pump to administer ciprofloxacin over a period of 30 minutes. 2. Educates client that medication may cause dizziness. 3. Instructs client to notify nurse for any tendon pain. 4. Administers ciprofloxacin through 20 gauge catheter into the cephalic vein.

Correct: Cipro IV should be administered to by intravenous infusion over a period of 60 minutes. Slow infusion of a dilute solution into a larger vein will minimize client discomfort and reduce the risk of venous irritation. Incorrect: This action does not require intervention by the charge nurse as dizziness is a side effect of this medication. Incorrect: This is a correct action. Fluoroquinolones, including Cipro IV, are associated with an increased risk of tendinitis and tendon rupture in all ages. This adverse reaction most frequently involves the Achilles tendon, and rupture of the Achilles tendon may require surgical repair. Tendinitis and tendon rupture in the rotator cuff (the shoulder), the hand, the biceps, the thumb, and other tendon sites have also been reported. Incorrect: Slow infusion of a dilute solution into a larger vein will minimize client discomfort and reduce the risk of venous irritation.

The nurse is caring for a client receiving an intravenous infusion of normal saline that is prescribed at 150 milliliters per hour. Using a tubing that has a drop factor of 15, how many drops per minute should the nurse deliver? Round answer to the nearest whole number.

Divide 150 by 60 minutes to equal 2.5. Multiplying 2.5 by the drip factor of 15 equals 37.5. Since partial drops cannot be counted, always round to nearest whole number, which is 38.

A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure?

Elevate head of bed to Fowler's position. Measure distal NG tube from nose tip to earlobe to xiphoid process. Lubricate 2-3 inches (5.08-7.62 cm) 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.

The charge nurse is evaluating a newly hired LPN/VN graduate. Before assigning a client to be prepped for a colonoscopy, the nurse asks the LPN/VN to verbalize the correct steps for completing an enema. In what order should the LPN/VN verbalize the steps for an enema? Explain procedure to the client. Assist client to a side lying position. Add warm water to the enema bag. Raise enema bag 18" to 20". Insert lubricated tip into rectum.

Explain procedure to the client. Assist client to a side lying position. Add warm water to the enema bag. Raise enema bag 18" to 20". Insert lubricated tip into rectum.

A hospitalized client is being prepared for transport to the dialysis unit when the nurse receives new orders for a stat unit of packed red blood cells to be infused. In what order should the nurse implement these actions? Allow client to proceed to the dialysis unit. Have dialysis nurse co-sign for the unit of blood. Verify client's blood identification arm band is in place. Proceed to blood bank and sign out the unit of blood. Advise dialysis nurse that blood is to be infused.

First - When clients have been typed and crossed for blood, a special arm band is applied and may not be removed as long as the client is hospitalized and needs blood. If the arm band has been removed, the nurse would have to request new blood work for re-type and cross. Second - When the floor nurse gives a short report to the dialysis nurse, it would be important to indicate the stat order for a unit of blood. The addition of this extra fluid may alter the dialysis process and the dialysis nurse must be prepared to make any necessary changes while monitoring vitals. Third - Dialysis is scheduled based on the degree of a kidney failure, and should not be altered or re-scheduled for non-urgent procedures. Sending the client for scheduled dialysis is a priority. However, renal clients are frequently anemic, and an order for stat blood is urgent. Therefore, the blood will be infused during the dialysis process. Fourth - The floor nurse has the responsibility to implement orders from the primary healthcare provider and will need to obtain the blood from the blood bank to deliver to the dialysis unit. The machine does not damage blood cells and the dialysis nurse will already be monitoring vitals as part of the dialysis protocols. Fifth - Infusion of blood requires two signatures. The first signature will be the nurse obtaining the blood from the blood bank. The second signature required is that of the nurse infusing the unit or another registered nurse: in this case, it is the dialysis nurse. Vital signs can be recorded during the dialysis on both the blood infusion form and dialysis forms.

The nurse is performing peritoneal dialysis on a client diagnosed with renal injury. In what order should the nurse perform this procedure?

First, the dialysate should be warmed to body temperature by allowing it to sit out for a short period of time. Second, the dialysate is infused through the peritoneal catheter into the peritoneal cavity. Third, the prescribed dwell time should be provided. In this case the dwell time is 30 minutes. Fourth, allow the dialysate to drain for 20-30 minutes. Fifth, turn the client from side to side if all the drainage does not come out of the peritoneum.

Place the steps in order that the nurse should take to administer a subcutaneous injection. Drag and Drop the items from one box to the other 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.

The nurse is caring for a client in the emergency department. In what order would a nurse correctly administer an intravenous push (IVP) medication through a continuous IV infusion of normal saline? Check medication label with healthcare provider's prescription Restart IV pump Draw up ordered dose of medication aseptically. Adminisiter medication while assessing IV site Stop IV pump Cleanse port closest to IV insertion site with an alcohol wipe.

First, check medication label with healthcare provider's prescription. Second, draw up ordered dose of medication aseptically. Third, stop the infusion pump. Fourth, cleanse the port closest to the IV insertion site with an alcohol wipe. Fifth, administer medication while assessing IV site. Sixth, restart IV pump.

A nurse is reviewing the lab values for a group of clients in a psychiatric emergency department. Rank each lab result from greatest to least concern to the nurse.

First, the client who has a potassium level of 7.0 mEq/L (7 mmol/L) should be of greatest concern to the nurse. The normal reference range for serum potassium is 3.5 mEq/L to 5.0 mEq/L (3.5-5 mmol/L) with a critical value of › 6.5mEq/L (6.5 mmol/L). This client is at high risk for cardiac death. Second,the client who has a WBC count of less than 3,000 mm³ (3 x 109/L) should then be of concern to the nurse. A serious adverse effect of clozapine is agranulocytosis and, if the total white cell and/or neutrophil counts indicate agranulocytosis, clozapine should be immediately discontinued. Third, a client who has a lithium level of 1.3 mEq/L should be documented by the nurse. Therapeutic lithium levels range from 0.8 to 1.2 mEq/L and, since this client's serum lithium level is high, the client is at risk for lithium toxicity. Serum lithium levels greater than 2.0 mEq/L is toxic. Fourth, the client who has a blood alcohol level of 0.08% (80 mg/dL) is intoxicated, but this is not at a dangerous level. A blood alcohol level of 0.30% (300 mg/dL) or greater may cause severe central nervous system depression, unconsciousness, and possible death. Normal is 0-50 mg/dL or 0-0.05%

A client on routine dialysis asks the nurse about the process of a family member donating a kidney. In what order should the nurse explain the steps for kidney organ donation? You answered this question Incorrectly The Correct Order The donor and recipient will undergo tissue typing and antibody screening. The donor will undergo a psychosocial examination and counseling. The recipient and donor will be assessed and treated for any dental caries. The recipient will undergo hemodialysis. The recipient will receive immunosuppressive agents.

First, the donor and recipient will undergo tissue typing and antibody screening; compatibility of tissues and cells of the donor and recipient have to be determined. Second, the donor will undergo psychosocial examination and counseling. Once it has been confirmed that the donor and recipient are compatible, the donor will undergo a psychosocial examination to assess the organ donor's motive for giving the organ and to ensure donor is making an informed decision. Pre-donation counseling for a nephrectomy is required. Third, the recipient and donor will be assessed and treated for any infection. Both must be free of infection at the time of kidney transplantation so they will be assessed for any infections, including gingival gum disease and dental caries. Fourth, the recipient will undergo hemodialysis. If a dialysis routine is established, then hemodialysis is performed the day before transplantation to optimize recipient's physical status. Fifth, the recipient will receive immunosuppressive agents. Lifelong immunosuppressive agents are prescribed to prevent rejection of the organ.

The nurse is caring for a client receiving peritoneal dialysis. Place the steps for peritoneal dialysis in the correct order. Drag and Drop the items from one box to the other Warm dialysate Access Tenckhoff catheter Begin dwell time Complete exchange Assess effluent

First, warm the dialysate. Would you put cold or even cool dialysate in your peritoneal cavity? NO, it would feel uncomfortable but more importantly, it would vasoconstrict the vessels of the peritoneal membrane. Would that affect the success of the dialysis? Yes, you want dilated blood vessels to promote osmosis and diffusion. Second, access the Tenckhoff catheter, assess it for patency and look at the site for infection. Just like you would do with any IV access. Third, begin the dwell time. Fourth, complete exchange by removing effluent by gravity drainage. Fifth, assess effluent. What would I assess the effluent for? Color, clarity, amount...just like urine? What am I worried about? Infection. How would my effluent look if I had an infection? Cloudy. If I have an infection in my peritoneal cavity, I need immediate antibiotic therapy to prevent peritonitis and damage to the membrane. The primary healthcare provider is going to want to culture the effluent and start a broad spectrum antibiotic.

In what order will the nurse provide instructions to a client on using a cane? Advance stronger leg forward toward cane. Advance weaker leg forward toward the cane. With cane on stronger side of body, support body weight with both legs. Move cane forward 6-10 inches (15 - 25 cm).

First, with cane on stronger side of body, support body weight with both legs. This will support the even distribution of weight away from the weaker side to promote a normal gait. Second, move cane forward 6-10 inches (15-25 cm). Moving the cane the approximate distance of a normal gait helps with stability. Third, advance weaker leg forward toward the cane. This allows the weight to be supported by the cane and the stronger leg. Fourth, advance stronger leg forward toward the cane. This allows the weight to be supported by the can and weaker leg.

The nurse initiates sterile wound care on a client's newly debrided foot ulcer. After removing the dressing and beginning a betadine cleanse, the client mentions an allergy to iodine not previously reported. Place the nursing actions in order of priority. Ask client about the type of "allergic response". Remove betadine solution from wound with normal saline. Cover wound with temporary sterile dressing. Notify primary healthcare provider of the allergy. Observe client for signs or symptoms of reaction.

First: Because many individuals confuse the term "allergy" with expected side effects, the nurse first needs to quickly determine the type of response this client may have previously experienced. Second: Whether or not the client is able to give a clear description of an allergic response, such as hives, swelling or reddened skin, the nurse must assume the worst and then immediately remove the betadine solution from the open wound/skin before any reaction occurs. Third: The previously unreported allergy may require a change in the plan of care; however, at this moment the nurse has a fresh wound exposed to air. The nurse should cover the wound with a dry sterile dressing. Fourth: Then observe the client for at least 10 minutes to determine the need for any emergency intervention in case of anaphylaxis. Fifth: Once it is determined the client is stable, the healthcare provider should be contacted regarding the new information, client's status and whether new wound care orders are needed.

The nurse initiates sterile wound care on a client's newly debrided foot ulcer. After removing the dressing and beginning a betadine cleanse, the client mentions an allergy to iodine not previously reported. Place the nursing actions in order of priority. Observe client for signs or symptoms of reaction. Remove betadine solution from wound with normal saline. Cover wound with temporary sterile dressing. Ask client about the type of "allergic response". Notify primary healthcare provider of the allergy.

A six month old infant has been admitted with a diagnosis of meningococcal meningitis. The primary healthcare provider has written multiple stat prescriptions. In what priority order should the nurse implement these prescriptions? Drag and Drop the items from one box to the other Place client on droplet precautions. Start IV of D 5 ¼ NS at 25 mL/hr. Draw blood cultures every 8 hours x 3. Prepare client for lumbar pucture. Administer ceftriaxone 250 mg IV TID.

First: This nurse's first priority must focus on safety for the greatest number of individuals, including staff and other clients. Because bacterial meningitis is highly contagious, the child should immediately be placed in isolation with droplet precautions. Second: Initiating the IV is urgent for several reasons. Third: Blood work can be drawn when the IV is started, thus decreasing the number of needle sticks. The IV site may also be used to administer a small amount of sedation prior to the prescribed lumbar puncture. Fourth: Prepare for lumbar puncture. Fifth: After that procedure, the first dose of ceftriaxone can be administered via the IV route.

A six month old infant has been admitted with a diagnosis of meningococcal meningitis. The primary healthcare provider has written multiple stat prescriptions. In what priority order should the nurse implement these prescriptions? Prepare client for lumbar pucture. Start IV of D 5 ¼ NS at 25 mL/hr. Administer ceftriaxone 250 mg IV TID. Place client on droplet precautions. Draw blood cultures every 8 hours x 3. Drag and Drop the items from one box to the other

The nurse is caring for a client receiving an intravenous infusion of normal saline that is prescribed at 150 milliliters per hour. Using a tubing that has a drop factor of 60, how many drops per minute should the nurse deliver? Round answer to the nearest whole number.

Multiply IV rate by drop factor, divided by time in minutes. 150 x 60 = 150 drops/min 60

A child receiving chemotherapy via a Port-a-cath needs blood cultures collected. In what order should the nurse complete this procedure? Access port with Huber needle. Withdraw 10 mL blood into vial. Flush port with normal saline. Wash hands and don gloves. Clean diaphragm with alcohol. Flush port with heparin solution.

Obtaining blood from a Port-a-cath decreases other needle sticks to an immunocompromised client. Drawing blood cultures is a slightly different process than obtaining blood for other lab work. First: Wash hands and don non-sterile gloves. As a nurse, you know that any procedure begins with hand washing! Since there is no option for sterile gloves, this option must be the first step. Second: If the nurse has donned gloves, prepping the client would be the next logical step. Cleaning the port, in this case with an alcohol wipe, is all that is necessary. However, if port access is completed as a sterile technique, you may observe a nurse cleaning the diaphragm with chlorhexidine. Again, this question does not provide you that choice. Third: Now that the diaphragm is clean, it is accessed with the Huber needle. The needle would already be primed and connected to the adapter (small tubing with a vacutainer) into which the blood vial is inserted to withdraw the sample. Fourth: The nurse will withdraw 10 mL of blood into the appropriate blood vial or tube for the blood cultures. For blood cultures, the first vial of blood is not discarded, as with other types of laboratory tests. Fifth: The port is flushed with normal saline to rinse the inner catheter and clear any remaining blood out of the diaphragm. In some situations, the process may end with the saline flush. But not in this example. Sixth: The final step is to flush the port and inner tubing with heparin to prevent blood clots or occlusion from occurring inside the port itself. Again, this step is dependent upon the type of port and the sample needed.

A client, scheduled for chemotherapy, has a prescription for Ondansetron 0.15 mg/kg IV over 15 minutes to be administered 30 minutes prior to chemotherapy. How many mL will the nurse give the client? Round to the whole number. Use numbers and decimals only. Height: 5'8" Weight: 68 kg

Prescribed: Ondansetron 0.15 mg/kg IV Available: 2 mg/mL Step 1: Determine how many mg per kg should be given. 0.15 mg/kg x 68 kg = 10.2 mg Step 2: Think - There are 2 mg/mL so you will want between 5-6 mL. Step 3: D/H x Q = 10.2 mg/2 mg x 1 mL = 5.1/1 = 5.1 The instructions say to round to the whole number, so 5.1 = 5 mL

Shortly after admitting a client to the unit, the nurse prepares to start an IV and hang 0.9% normal saline solution. At what rate should the nurse set the IV infusion pump? Answer using numbers only. Exhibit

Prescription: 0.9% normal saline solution IV at 150 mL/hour. Think, when an infusion pump is used, the flow rate is prescribed by the primary healthcare provider and programmed by the nurse by setting the device for milliliters per hour (mL/h). Rule - To regulate an IV by infusion pump, Total mL prescribed/Total hr prescribed = mL/hr If you forgot that, then work the formula for gtts/min - mL/hr x drop factor/time in minutes = gtts/min The drop factor for the infusion pump is 60. 150 mL x 60 / 60 minutes = 150 Therefore, the pump should be set at 150 mL per hour

The nurse is preparing to give 250 mL D5W IV over 2.5 hours. How many gtts/min will the nurse need to set the IV rate at?

Prescription: 250 mL D5W IV over 2.5 hours. Step 1: Determine what the drop factor is on the IV tubing. The one shown in the exhibit has a drop factor of 15 drops/mL. Step 2: Remember the formula for gtts/min - mL/hr x drop factor/time in minutes = gtts/min Step 3: 250 ml/2.5 hours x 15 gtts/1 mL x 1 hour/60 min = 250/2.5 x 15/1 x 1/60 = 3750/150 = 25 gtts/min

The nurse is preparing to administer 500 mL Normal Saline to a client over the next two hours per infusion pump. What number should the nurse set the pump at to deliver the prescribed amount per hour?

Prescription: 500 mL Normal Saline over 2 hours. Step 1: Determine how many mL will need to be delivered each hour. 500/2 = 250 mL per hour Step 2: Think, when an infusion pump is used, the flow rate is prescribed by the primary healthcare provider and programmed by the nurse by setting the device for milliliters per hour (mL/h). Step 3: Rule - To regulate an IV by infusion pump, Total mL prescribed/Total hr prescribed = mL/hr 500 mL/2 hr = 500/2 = 250/1 = 250 Therefore, the pump should be set at 250 mL per hour

The nurse is preparing to give a client's prescribed ampicillin dose. How many mL will the nurse give to the client? Answer to the first decimal place. Answer with numbers and decimal only. Exhibit

Prescription: Ampicillin 200 mg IM every 8 hours Available: Ampicillin 1 gm/ vial Step 1: Convert grams to mg (1 gram = 1000 mg). The vial also says that there are 250 mg/mL The instructions say to add 3.4 mL sterile water for injection to the vial. Volume yields 4 mL (250 mg/mL) Step 2: Think, 250 mg is in 1 mL, so 200 mg will in less than 1 mL but more than ½ mL. Step 3: D/H x Q = X 200/250 x 1 mL = 4/5 x 1 = 4/5 or 0.8 mL NOTE: This insert tells you that 200 mg is in 0.8 mL in the bottom left corner but it is always good to do your own math to double check the dose!

Ceftazidime 1 gm IM every 6 hours

Prescription: Ceftazidime 1 gm IM every 6 hours Available: Ceftazidime 1 gm in 3.6 mL Step 1: The instructions say to add 3.0 mL sterile water for injection to the vial. Volume yields 3.6 mL. Step 2: Think, 1 gram is in 3.6 mL. We want to administer 1 gram, so you need 3.6 mL Step 3: D/H x Q = X 1 gm/1 gm x 3.6 mL = 1 x 3.6 = 3.6 mL

The nurse, preparing to begin Heparin therapy on a client admitted to the hospital, is calculating the hourly unit dose from the prescription received to ensure that it is within the safe and effective range. What hourly unit dose should the nurse obtain? Use numbers only.

Prescription: D5W 1 liter IV with heparin 40,000 units to infuse at 30 mL/h Use ratio-porportion to calculate hourly heparin dose in units delivered by 30 mL/hour. Remember that 1 Liter = 1000 mL 40,000 units/1000 mL = X units/30 mL 1,200,000 = 1000 X 1200 Units/hour = X

The nurse is preparing to administer 0800 medications to a client. How many mg of Citalopram should the nurse administer?

Rationale: Prescription: Look at the medical record for medications. There are two doses of citalopram written: Citalopram 10 mg 1 tablet daily with a 20 mg tab totalling 30 mg. Citalopram 20 mg 1 tablet daily with a 10 mg tab totaling 30 mg. So, the nurse will administer 30 mg of citalopram.

The nurse is reviewing the Patient Care Analgesia (PCA) pump settings delivering hydromorphone to a client. Based on the available information, what is the maximum mg amount of hydromorphone the client can receive via PCA dosing? Answer using numbers and decimals only. Exhibit

Rationale: The client is receiving a continuous infusion of hydromorphone at 0.2 mg/hour. PCA dosing is 0.1 mg every 15 minutes, which would mean that the client could get 4 doses of 0.1 mg (0.4 mg total) if the 1-hour limit allowed this. However, the 1-hour limit is 0.5 mg. Since the client is getting 0.2 mg / hr over a continuous infusion, there is only 0.3 mg available for the client to receive by PCA dosing.

A client is being treated for fluid volume deficit with D5W, oral hydration, and management of viral symptoms. Which client data would indicate to the nurse that treatment has been successful?

Select All 1. BP 104/70 lying; 94/68 standing. 2. Moist mucous membranes. 3. Skin turgor recoil below clavicle is 3 seconds. 4. Urine specific gravity of 1.032 5. Serum sodium 152 mEq (152 mmol/L) 1,2

Select All 1. "Lying on my side, propped up on three pillows is a good resting position." 2. "While sitting up, I will rest my elbows on my knees." 3. "If I become short of breath while walking, I will lean slightly forward and place my hands against the wall." 4. "I will sit up and lean over a table." 5. "Lying on my stomach will help drain secretions." 1,2,3,4

Following vaginal birth, a neonate has a large area of diffuse swelling over the left occiput that crosses the sagittal suture line. When discussing this finding with the neonate's parents, which statements by a nurse are accurate?

Select All 1. "No treatment will be required to resolve swelling." 2. "Due to the swelling, hyperbilirubinemia may occur." 3. "The swelling lies above the periosteum that covers the skull bone." 4. "Pressure on the fetal head before delivery caused the swelling." 5. "Your infant has a collection of blood under the skull bone." 1,3,4

What assessment findings would the nurse expect when evaluating whether treatment has been effective for a client hospitalized with systolic heart failure?

Select All 1. 3+ pedal edema 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 4. Purse-lip breathing 5. Pale conjunctiva 6. Urine output at 50 mL/hr 2,3,6

Which clients would the nurse monitor for the development of hypovolemic shock?

Select All 1. 50 year old having an allergic reaction form multiple wasp stings 2. Elderly client post-operative hip replacement with spinal anesthesia 3. 40 year old in Addisonian crisis 4. 10 year old with 40% total body surface area (TBSA) burns 5. Adult with type 2 diabetes and a urinary tract infection (UTI) 3,4,5

A nurse is performing eye care for a comatose client. Which interventions should the nurse include?

Select All 1. Administer moist compresses to cover eyes every 2 hours. 2. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 3. Use a new cotton ball for each cleansing wipe. 4. Instill artificial ears into the lower eye lids as prescribed. 5. Protect the eyes with a protective shield. 6. Monitor eyes for redness, and exudate. 1,3,4,5,6

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 1. Assess client's ability to perform activities of daily living. 2. Educate nursing staff to facilitate client's independence in activities. 3. Place a clock and calendar in client's room. 4. Limit family visits to once a week. 5. Have nursing staff spend time talking and listening to client. 1,2,3,5

An occupational health nurse is planning to teach a group of manufacturing workers how to prevent back injuries. What teaching points should the nurse plan to include?

Select All 1. Assistive devices should be used when lifting greater than 50 pounds (22.72 kg). 2. When sitting, keep knees slightly lower than the hips. 3. Avoid movements that require spinal flexion with straight legs. 4. Squarely face the direction of anticipated movement. 5. Pivot to turn while holding an object. 6. Wear comfortable, low-heeled shoes. 3,4,5,6

What should the nurse emphasize when teaching clients with chronic obstructive pulmonary disease?

Select All 1. Avoid exposure to individuals with respiratory infections. 2. Increase intake of Vitamin C. 3. Eliminate exposure to second hand smoke. 4. Maintain a healthy weight. 5. Get a yearly pneumonia vaccination. 1,2,3,4

A client with a severe cough is suspected of having lung cancer. When preparing the client for testing to confirm a diagnosis of cancer, which tests should a nurse anticipate?

Select All 1. Chest x-ray 2. Arterial blood gas 3. Bronchoscopy 4. Pulmonary arteriogram 5. Pulmonary function test 1,3

Which clients would be appropriate for the charge nurse to assign to the LPN/VN?Select All 1. Client admitted with exacerbation of asthma. 2. Client needing oral antibiotics for a diagnosis of gastroenteritis. 3. Client 4 hours post lobectomy. 4. Client with terminal cancer refusing pain medication. 5. Client with arthritis who needs scheduled pain medication around the clock. 6. Client

Select All 1. Client admitted with exacerbation of asthma. 2. Client needing oral antibiotics for a diagnosis of gastroenteritis. 3. Client 4 hours post lobectomy. 4. Client with terminal cancer refusing pain medication. 5. Client with arthritis who needs scheduled pain medication around the clock. 6. Client who has a chronic graft versus host disease. 2,5,6

In which client should the nurse question a prescription for an oxytocin challenge test?

Select All 1. Client at 26 weeks gestation. 2. Client at 38 weeks with 4 Cesarean section deliveries. 3. Client at 38 weeks with a history of gestational diabetes. 4. Client at 37 weeks gestation. 5. Client that is 35 weeks gestation and has preeclampsia. 6. Client with a current history of placenta previa. 1,2,6

During the admission examination of a client diagnosed with acute pyelonephritis, what signs or symptoms would the nurse expect to find?

Select All 1. Dysuria 2. Costovertebral angle tenderness 3. Pale conjunctiva 4. Chills 5. Urinary frequency 1,2,4,5

A client has been admitted with advanced Cirrhosis. The nurse's assessment of the abdominal girth verifies an increase in 5 inches (12.7 cm) and an increase in 6 lbs. (2.72 kg) since yesterday's measurements. Which interventions would the nurse expect to see in this client's plan of care?

Select All 1. Elevate HOB to a semi-fowlers position. 2. Provide oral hygeine before meals. 3. Turn every 2 hours. 4. Instruct about a 1200 calorie diet. 5. Monitor creatinine levels daily. 1,2,3,5

A client is admitted with arterial disease of the lower extremities. Which client teachings should the nurse initiate?

Select All 1. Elevate extremities above the level of the heart. 2. Discourage use of tobacco. 3. Protect extremities from cold exposure. 4. Assess need for stress management. 5. Avoid isometric exercise. 2,3,4

Which client instruction is important when the client is scheduled for a vanillylmandelic (VMA) test?

Select All 1. Eliminate sweets and pastries 2 to 3 days before and throughout the test. 2. A 24 hour urine specimen requires starting with an empty bladder. 3. Limit physical exercise throughout the test. 4. Avoid all commercially prepared foods for 24 hours prior to testing. 5. Add HCL acid to specimen as preservative. 1,2,3,5

The nurse is planning care for a client with bipolar disorder in the manic phase. Which interventions are appropriate for this client?

Select All 1. Engage in a knitting class 2. Sign up for large group activities 3. Provide frequent snacks 4. Sit with client for long periods of time 5. Provide a structured schedule 6. Decrease stimulation 3,5,6

Which information should the community health nurse include when explaining to a group of college students living in a dormitory about receiving an immune globulin (IG) injection for hepatitis A virus (HAV)?

Select All 1. Immune globulin contains antibodies that destroy the hepatitis A virus (HAV), preventing infection. 2. Immune globulin protection is permanent, so no other injection is required. 3. Common side effects of the injection include soreness and swelling around the injection site. 4. The sooner you get a shot of IG after being exposed to HAV, the greater the likelihood that infection will be prevented. 5. Crowded living environments such as dormitories place people at risk for HAV. 1,3,4,5

The client's EEG revealed epileptiform abnormalities predictive of seizure activity and was started on valproic acid 500 mg PO twice a day. What nursing interventions should the nurse include in this client's plan of care?

Select All 1. Instruct client to report insomnia 2. Assess for abdominal pain and Grey Turner's sign 3. Monitor ALT and AST 4. Teach client not to discontinue medication abruptly 5. Administer acetaminophen 650 mg PO for mild pain 6. Obtain daily weights 2,3,4,6

What information about cast care should the nurse provide to the client?

Select All 1. Keep the cast uncovered until it is completely dried. 2. Use the palms of your hands to position the cast for the first 24 hours. 3. Place an ice pack on top of the cast to keep the limb from swelling. 4. Elevate the extremity on a pillow, but make sure it is not plastic. 5. Be careful not to do anything that would indent the cast. 1,2,4,5

A nurse is planning discharge education for a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which instructions should the nurse include when teaching this client?

Select All 1. Limit fluid intake. 2. Report muscle twitching. 3. Measure intake and output. 4. Perform mouth care once a day. 5. Report weight gain of 2 pound (0.9 kg) over 24 hours. 1,2,3,5

What nursing interventions should a nurse initiate for a client diagnosed with pyelonephritis?

Select All 1. Monitor for dark, cloudy, foul smelling urine. 2. Monitor intake and output. 3. Decrease fluid intake to 1 liter/day. 4. Advise that urine may turn blue with administration of nitrofurantoin. 5. Monitor for hypotension, tachycardia, and chills. 1,2,5

A nurse is assigned to care for a client diagnosed with obsessive compulsive disorder. Which interventions should be part of the treatment plan?

Select All 1. Provide a structured schedule 2. Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants should be considered 3. Discuss why the ritual is harmful for the client 4. Allow as much time as necessary for the ritual 5. Encourage relaxation techniques 1,2,5

The client reports intense headaches with increasing pain for the past month. A magnetic resonance imaging (MRI) is ordered. In reviewing the client's history, which information is of concern to the nurse?

Select All 1. Shellfish allergy 2. Has a cardiac pacemaker 3. Prescribed glimepiride every morning 4. Client is pregnant 5. History of working with metal fragments 1,2,4,5

A client is preparing to be discharged after a total hip replacement. Which client statements would indicate teaching has been successful regarding prevention of hip prosthesis dislocation?

Select All 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 client has sublingual nitroglycerin added to his medication regimen. Which statements made by this client indicates teaching has been effective?

Select All 1. "I will take this medication if I have an episode of chest pain." 2. "I will wait at least 1 hour after I take my erection agent before using Nitroglycerin." 3. "I can take up to 3 tablets every 5 minutes if my angina occurs." 4. "I know that I must put this tablet under my tongue for it to work." 5. "I will keep my medication handy, in my pants pocket." 1,4

A client who has been diagnosed with chronic venous insufficiency has received teaching regarding how to prevent venous stasis ulcerations. Which statements by the client indicate to the nurse that teaching has been effective?

Select All 1. "Stationary standing should be kept to a minimum." 2. "It is important to avoid wearing constricting clothes longer than 2 hours." 3. "Elevation of my legs should be done for 15 minutes every 4-6 hours." 4. "Protecting my legs from trauma is very important." 5. "I will wear compression stockings every day." 6. "I will elevate the foot of my bed 6 inches (15.24 cm) when I sleep." 1,4,5,6

Which statements made by a client diagnosed with Addison's disease indicates to the nurse that the client understands fludrocortisone therapy?

Select All 1. "Taking my medicine at night will help me sleep." 2. "It is important to wear a medical alert bracelet all of the time." 3. "I will limit my sodium intake to 200 mg per day." 4. "My medication dose will change based on my daily weight." 5. "I may need more medication if I feel weak or dizzy." 2,4,5

A client who has been receiving care for cirrhosis arrives to the clinic for follow-up care. Which signs and symptoms noted by the nurse would indicate that the client's condition is worsening?

Select All 1. A musty breath odor 2. Poor concentration 3. Fatigue 4. Slow movements 5. Asterixis 6. Anorexia 1,2,4,5

A confused client falls out of bed. When the nurse arrives, the side rails are up, the client has urinated on the floor, and an abrasion is noted on the client's forehead. Which information should be included in the incident report?

Select All 1. Abrasion on the client's forehead. 2. Nurse's perspective as to how the client fell. 3. Client's confused state. 4. Presence of urine on the floor. 5. Side rails were up. 1,3,4,5

Standard orders on the nurse's unit include an intravenous infusion of 1000 mL normal saline with 20 mEq (20 mmol) potassium chloride to run at 100 mL per hour. These IV fluids would be appropriate for which client diagnosis?

Select All 1. Addison's disease 2. Psychogenic polydipsia 3. Abdominal cramping 4. Graves' disease 5. Hypokalemia 3,4,5

A nurse, planning an educational seminar on chronic kidney disease, should invite the client with which medical conditions?

Select All 1. Atherosclerosis 2. Diabetes 3. Hypertension 4. Glomerulonephritis 5. Acute urinary tract infections 1,2,3,4

What interventions can an occupational health nurse discuss with a client in an effort to improve lateral epicondylitis (tennis elbow) pain?

Select All 1. Avoid activities that make the pain worse. 2. The primary healthcare provider may prescribe an oral nonsteroidal anti-inflammatory drug. 3. Apply an epicondylitis strap 2 to 3 centimeters above the elbow. 4. Stretching and strengthening the muscle and tendon should be started immediately. 5. If pain persists, a cortisone injection into the inflamed area may be recommended by the healthcare provider. 6. Apply ice for 45 minutes six times a day. 1,2,5

Which signs and symptoms would concern the nurse if assessed in a client post radical neck surgery?

Select All 1. Bradypnea 2. Flaccid muscle tone 3. Flushed, warm skin 4. Positive trousseau's sign 5. Dysphagia 6. Decreased deep tendon reflexes 4,5

Which client would the nurse monitor for the development of hypovolemic shock?

Select All 1. Client admitted with acute myocardial infarction. 2. Elderly client post-operative hip replacement with spinal anesthesia. 3. Client diagnosed with Addisonian crisis. 4. A 10 year old client with 40% Total body surface area (BSA) burns. 5. Client with Type 2 diabetes, who has a current blood sugar of 425 mg/dL (2.359 mmol/L) 3,4,5

Standard orders on the nurse's unit include an intravenous infusion of D5 1/4 NS 1000 mL with 20 mEq (20 mmol/L) potassium chloride to run at 100 mL per hour. This IV solution would be appropriate for which clients?

Select All 1. Client diagnosed with Addison's disease. 2. Client diagnosed with hypertension. 3. Client diagnosed with chronic renal failure. 4. Client diagnosed with Cushing's disease. 5. Client diagnosed with hypokalemia. 4,5

What teaching points should the nurse include when educating a client how to prevent a venous stasis ulcer?

Select All 1. Dangle legs for 30 minutes, three times a day. 2. Perform leg exercises regularly. 3. Wear graduated compression stockings. 4. Treat itching with prescribed topical corticosteroids. 5. Minimize stationary standing. 2,3,4,5

As a member of the emergency preparedness planning team at the hospital, which action should the nurse encourage the team to implement?

Select All 1. Developing a response plan for each potential disaster. 2. Providing education to employees on the response plan. 3. Practicing the response plan on a regular basis. 4. Evaluating the hospital's level of preparedness. 5. Preparing every hospital for all the same emergencies. 2,3,4

What teaching should the nurse provide the client regarding prevention of deep vein thrombosis when traveling by plane for a long period of time?

Select All 1. Do not cross legs longer than 15 minutes at a time. 2. Get up and move around the plane every 4 hours. 3. Wear compression stockings while traveling. 4. Move legs frequently while sitting. 5. Avoid alcohol and coffee while traveling. 3,4,5

After a cholecystectomy, a client experiences palpitations, weakness and diarrhea following meals. Which teachings would be appropriate for the nurse to provide the client?

Select All 1. Drink minimum fluids with meals. 2. Follow a high carbohydrate, high protein meal plan. 3. Avoid electrolyte replacement sports drinks. 4. Lie down on right side after meals. 5. Eat at least six small meals per day. 1,3,5

Which signs or symptoms would a nurse expect to find in a client admitted to the hospital in the oliguric phase of acute kidney injury (AKI)?

Select All 1. Edema 2. Hypotension 3. Hyperkalemia 4. Decreased blood urea nitrogen 5. Metabolic acidosis 1,3,5

Which signs and symptoms experienced by the client correlate with chronic renal failure diagnosis?

Select All 1. Fatigue 2. Anorexia 3. Dark skin pigmentation 4. Swollen extremities 5. Hypocalcemia 1,2,4,5

A client was admitted two days ago in the oliguric phase of acute kidney injury (AKI). What evaluation by the nurse would indicate that treatment has been effective?

Select All 1. Fixed urine specific gravity 2. Serum K+ 4.9 mEq (4.9 mmol/L) 3. Serum Na+ 143 mEq (143 mmol/L) 4. Minimal crackles auscultated in bases of left lung 5. Urine output = 1250 mL/24 hours 2,3,5

The charge nurse recognizes that a new nurse can properly perform a linear wound dressing change on a surgical client when the new nurse performs which interventions correctly?

Select All 1. Hand hygiene is done prior to the dressing change. 2. Dressing tape is removed in the direction opposite of the hair growth. 3. The soiled dressing is discarded in a biomedical waste bag. 4. Clean gloves are donned in order to clean the wound. 5. The center of the wound is cleaned first, then the wound area farthest from the nurse, then the area closest to the nurse. 6. New sterile dressing is applied to the wound. 1,3,5,6

A client with acute pancreatitis is prescribed total parenteral nutrition (TPN), methylprednisolone, and sliding scale insulin. What is the rationale for the insulin prescribed?

Select All 1. Impaired endocrine function of the pancreas 2. Inability of the liver to convert glucose 3. Steroid therapy side effects 4. Dextrose concentration of TPN 5. Re-establish potassium concentration 1,3,4 Really what we are saying here is why would the client be on insulin? Well, the pancreas is damaged and so the endocrine function of the pancreas is impaired. We know that hyperglycemia or pseudo diabetes is a side effect of steroid therapy and TPN is high in glucose and may require additional insulin. These are the three rationales for why they might need insulin.

What should a nurse include when planning an educational program for a group of women on how to prevent a urinary tract infection (UTI)?

Select All 1. Increase daily intake to at least 9 cups (2160 mL) of water. 2. Urinate within one hour after sexual intercourse. 3. Help soothe the peritoneum using bubble baths. 4. Wipe from the anal area to the vaginal area after a bowel movement. 5. Void when the urge occurs. 1,5

A nurse is planning care for a client admitted to the unit after application of a halo apparatus to immobilize the cervical spine. What interventions should the nurse include?

Select All 1. Insert the index finger between the vest and client's skin to make sure it is not too loose. 2. Turn the client in bed every 2 hours using the log roll technique. 3. Provide a soft diet to prevent pain from chewing. 4. Assess tolerance to upright position. 5. Teach client to use eye, rather than head and neck movements, for visual scans. 6. Inspect skin under halo vest. 2,3,4,5,6

The nurse cares for a client after a gastroscopy examination. Which nursing interventions are appropriate post-procedure?

Select All 1. Maintain NPO status until the gag reflex returns. 2. Observe for hematemesis. 3. Monitor intake and output. 4. Assess bowel elimination. 5. Monitor respirations. 6. Connect to oxygen saturation monitor. 1., 2., 5, & 6. Correct: A gastroscopy examination uses a flexible fiber-optic tube to visualize the esophagus and/or stomach. The throat is numbed before the procedure to inhibit the gag reflex and to allow the scope to pass freely. Therefore, it is important to maintain NPO status until the gag reflex returns. The nurse should monitor for hematemesis, respirations, and oxygen saturation to ensure the scope did not damage any structures like the esophagus or lungs.

A client at 28 weeks gestation reports swollen hands and feet during her prenatal visit. Which additional signs/symptoms would be of concern to the nurse?

Select All 1. Nasal congestion 2. Hiccoughs 3. Capillary blood glucose of 150mg/dL (8.32 mmol/L) 4. Muscle spasms 5. Headache and blurred vision 2,4,5

Which statements should the nurse include when teaching a client about osteomyelitis?

Select All 1. Osteomyelitis is a risk factor for people who have chronic illnesses. 2. Activity restriction is necessary to avoid stress on the affected bone. 3. Oral antibiotics must be taken for at least 3 to 6 weeks. 4. High calcium levels may occur so report muscle weakness, anorexia, nausea and vomiting. 5. Osteomyelitis requires subcutaneous administration of calcitonin to reverse the course of the disease. 1,2

What medications should the nurse anticipate the primary healthcare provider may prescribe for the client with advanced cirrhosis and bleeding esophageal varices?

Select All 1. Oxygen 2. Clopidogrel 3. Pantoprazole 4. Octreotide 5. Lactulose 1,4,5

A client's arterial blood gas report has arrived at the nurses' station. Based on the results what interventions are required by the nurse? pH - 7.47 PaCO2 - 29 HCO3 -23 PO2 95%.

Select All 1. Oxygen at 4 liters/min 2. Instruct slow deep breaths 3. Re-breath into a paper bag 4. Calm the client 5. Administer anxiolytic 2,3,4,5

A nurse is assigned a client who is one day post thyroidectomy. While taking the blood pressure, the client's hand starts to tremble. On auscultation of the heart, the nurse notes an arrhythmia. What actions should the nurse take?

Select All 1. Pad the side rails 2. Monitor potassium level 3. Take blood pressure in opposite arm 4. Place trach set at bedside 5. Check for airway patency 1,4,5

A client's absolute neutrophil count (ANC) is 750/mm3. Which measure should the nurse take to protect the client?

Select All 1. Prohibit the client from shaving. 2. Instruct the client to wear a mask when leaving the hospital room. 3. Remove fresh flowers and plants from the client's room. 4. Ask visitors to perform hand hygiene before entering the client's room. 5. Instruct client to avoid vigorous flossing of teeth. 2,3,4

Which interventions should the nurse initiate to lessen acid reflux in a client diagnosed with gastric esophageal reflux disease (GERD)?

Select All 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 is attempting to help a client who has self-care difficulty due to left-sided paresthesia. Which interventions should the nurse plan to include?

Select All 1. Provide the client with a button hook for dressing. 2. Encourage client to complete eating within 30 minutes. 3. Have client comb own hair. 4. Offer to take the client to the toilet every four hours. 5. Identify preferences for personal care items and food. 1,3,5

The nurse is monitoring the client's heart rhythm. The monitor shows sinus tachycardia. What is expected with this assessment finding?

Select All 1. Regular rhythm 2. Rate of 101-200 3. P-wave normal 4. P-R interval not measurable 5. QRS complex normal 1,2,3,5

A client with a long standing history of diabetes presents to the emergency department (ED) with a serum blood sugar of 400 mg/dL (22.19 mmol/L). What lab values for this client are consistent with diabetic ketoacidosis (DKA)?

Select All 1. Serum sodium 140 mEq/L 2. Decreased urine specific gravity 3. Serum potassium 5.3 mEq/L 4. PaCO2 48 5. pH 7.33 2,3,5

Which assessment findings would the nurse expect in a client diagnosed with Paget's disease?

Select All 1. Severe back pain 2. Walking with a limp 3. Upper extremity grip weakness 4. A shuffled gait 5. Difficulty hearing 1,2,5

A construction worker comes into the occupational health nurse's clinic reporting chest heaviness. What additional signs and symptoms should the nurse assess for?

Select All 1. Severe headache 2. Dry, flushed skin 3. Lightheadedness 4. Dyspnea 5. Irregular pulse 3,4,5

The nurse recognizes that Rho(D)immune globulin would be indicated for which Rh negative clients?

Select All 1. Sixteen weeks gestation and has an elective abortion 2. Involved in a major car accident 3. Requires amniocentesis 4. Diagnosed with an ectopic pregnancy 5. Forty-eight hours post delivery of a term Rh positive baby 6. Twenty weeks gestatation 1,2,3,4,5

Select All 1. Small frequent feedings 2. NG tube to low suction 3. Cimetidine 300 mg IV four times a day 4. Hydromorphone by PCA pump 5. IV isotonic solutions 2,3,4

What should the nurse include in the teaching plan for a client receiving external beam radiation?

Select All 1. Small marks will be placed on the skin to mark the treatment area. 2. Lotion may be used around the treatment area to decrease dryness. 3. The radiation therapist can see, hear, and talk with you at all times during treatment. 4. Stay away from babies for 24 hours. 5. You will have to hold your breath during radiation treatment. 1,3

A petite female client presents to the clinic with symptoms of back pain and states, "I think I am getting shorter." Which teachings would be appropriate for the nurse to provide?

Select All 1. Spend time in the sunlight twice a week for 5 to 30 minutes. 2. Wear rubber sole shoes for traction. 3. Walk at least 30 minutes most days. 4. Include yogurt and hard cheese in diet. 5. Take regularly scheduled prescribed corticosteroids. 1,2,3,4

A nurse is assigned to care for a client with bi-polar disorder in the manic phase. Which behavior by the client would be a concern for the nurse?

Select All 1. Tearful with poor concentration 2. Easily distracted 3. Excessive physical exercise 4. Irritable mood 5. Decreased intake of meals 3,5

A client has been prescribed levothyroxine sodium. What should the nurse teach the client about this medication?

Select All 1. Therapy will last six month to one year. 2. Notify the primary healthcare provider for heart rate less than 60/minute. 3. Take medication ½ hour before breakfast. 4. Do not take medication with calcium supplements. 5. Improvement of symptoms will occur within days. 3,4

The client asks the nurse what the primary healthcare provider means when he says that she has right sided heart failure. What should the nurse include in the teaching plan?

Select All 1. There is a backup of blood in the right upper chamber of the heart. 2. There is swelling of lower extremities. 3. The heart rate decreases. 4. You may experience fatigue and depression. 5. You may experience nausea and loss of appetite. 1,2,4,5

What signs and symptoms of ovarian cancer should a nurse include when educating women?

Select All 1. Urinary frequency. 2. Menorrhagia with breast tenderness. 3. Watery vaginal discharge. 4. Increasing abdominal girth. 5. Fullness after a heavy meal. 1,2,4

A nurse is caring for a client who was admitted with severe dehydration due to excessive vomiting. Which data noted by the nurse validates this diagnosis?

Select All 1. Urine specific gravity - 1.036 2. Hematocrit - 53% (0.53 volume fraction) 3. Bradycardia 4. Tachypnea 5. Postural hypotension 6. Distended neck veins 1,2,4,5

The nurse is monitoring the IV medications that a client is receiving by an IV infusion pump. How many milligrams per hour of epinephrine should the nurse determine that the client is receiving? Round to the second decimal place. Use numbers only to answer.

Step 1: Determine how many micrograms there are in 1 hour. 1.0 mcg/ min x 60 minutes = 60 mcg/hour. Step 2: Convert micrograms to milligrams. There are 1000 mcg in 1 mg. Step 3: Calculate micrograms There are 1000 mcg in 1 mg. How many mg are in 60 mcg? 1000 mcg/1 mg = 60 mcg/x mg 1000x = 60 1000x/1000 = 60/1000 x = 0.06 mg/hour

A client who is scheduled for a total hip replacement surgery in the morning begins to verbalize anxiety related to the surgery. Arrange the client's comments in order as the client's anxiety advances beginning with mild to panic anxiety. You answered this question Correctly The Correct Order "Can I wear my wedding ring during the surgery?" "I know those hip exercises after the surgery are painful." "Having trouble thinking about anything, but the surgeon cutting on my hip." "My Dad died on the operating table, and I keep thinking I will die too."

The client is experiencing mild anxiety when asking a question about whether their wedding ring needs to be removed during surgery. The client is concerned about the ring, and is able to ask a direct specific question. Mild anxiety includes feelings of worrying and apprehension. Expressing a negative concern about their ability to complete the hip exercises after surgery is an example of moderate anxiety. The client is worrying about the hip exercises which is causing an increase in the anxiety level. The client is worried about the surgeon cutting on their hip. The physical action of cutting the hip is very troubling for the client. The client's continuous worrying is causing the client to have decreased ability to concentrate. This action indicates an increase in their anxiety level to severe. The client is expressing panic anxiety with the statement of feelings of impending doom. If the client's father had died on the "operating table", then there is a possibility that the client will also die during the surgery.

A nurse is reviewing the lab values for a group of clients in a psychiatric emergency department. Which findings should be of greatest concern to the nurse? Rank each lab result from most to least important.

The client with schizoaffective disorder and a potassium level of 7.0 mEq/L (7 mmol/L The client taking clozapine and a WBC count of < 3000 mm³ (3 x 10^9/L) The client with bipolar disorder and a lithium level of 1.3 mEq/L. The client with a blood alcohol level of 0.08% (80 mg/dL)

A nurse is caring for a group of clients and is considering the risk of infection for each. Place the client conditions in rank order from the highest to least potential for infection. Thermal burns covering 30% of body surface area (BSA) 2 days ago Total hip prosthetic device placement 3 days ago Laparoscopic exploration of right knee 2 days ago Indwelling foley catheter inserted the previous day

The client with the greatest risk of infection would be the client with thermal burns covering 30% of the BSA. Burns are considered contaminated wounds. Normally, skin provides a natural barrier against invasive microorganisms. However, with this major burn injury, the client is predisposed to infection as a result of the loss of skin integrity. Additional factors that will place this client at higher risk for infection include the development of eschar, which bacteria loves to live in, and the fact that thermal injuries alter the body's natural immunity. So, are the clients with the other conditions at risk for infection? Well, they could be, but the risk is not as great. Let's consider why the risk is less. The client with the total hip arthroplasty (replacement of the damaged hip with a prosthetic device implanted) would be the next highest in ranking for risk of infection. This client has a relatively large surgical incision and a prosthetic device that infection, when present, tends to migrate to the area. But, this type surgery is performed using sterile technique in sterile environments to minimize the risk of infection. In addition, any dressing changes should be performed using sterile technique. The next client at risk of infection would be the client with the laparoscopic exploration of the right knee. Again, there is surgical perforation of the skin. However, these are smaller puncture sites that are created under sterile conditions, and when cared for appropriately, do not carry a high risk for infection. Finally, the client who has the indwelling foley catheter is the least at risk for infection. The catheter is a portal of entry into the body, but if inserted using sterile technique and proper catheter care is provided, the risk of infection can be kept to a minimum. The longer the foley catheter remains in place, the risk of infection will increase.

In what order should the nurse address these client events that occur at the same time? Place in order of highest to lowest priority.

The client with the highest need is the client who has a tracheostomy that needs to be suctioned. This client has an airway problem. Maintaining a patent airway is vital to life and is always the first priority. The next client to be seen is the client whose water seal chamber is empty which prevents the CDU from being a closed system. This can create a breathing problem. The purpose of the water seal chamber is to allow air to escape from the pleural space and yet prevent air from re-entering the pleural space. It is a one-way system. The water should be at the prescribed level (2 cm) to maintain this one-way water seal. If air is allowed to re-enter the pleural space, the lung can collapse again (pneumothorax). Once the other client's airway is suctioned, this would be the next priority. The third client to be seen is the client with a heart rate of 40/min which may be affecting cardiac output. This is a circulatory problem. Circulation follows airway and breathing in priority setting. The fourth client to be seen is the client on bedrest for a DVT. If the client gets up and ambulates, the clot can break lose and form an embolus. Although this could potentially be dangerous, it does not take priority over airway or circulatory issues that exist. The fifth client would be the one reporting frequency and dysuria. This client does not have a life-threatening problem. Therefore, this would be the lowest in priority from the events presented.

The triage nurse in the emergency department is prioritizing the client care for new clients. What is the correct order in which the clients should be evaluated? Infant having a tonic-clonic seizure. Elderly client rating intermittent substernal chest pain a 4 on a 10-point pain scale. Adult reporting right lower quadrant abdominal pain. Child who has a laceration to the hand with bleeding controlled by pressure. Teenager with a blood glucose of 108 mg/dL (6 mmol/L).

The correct order is: First the nurse needs to evaluate the infant having a seizure. This client is in acute distress. The infant should be treated first to assess the infant's airway and neurological status. Second would be the elderly client presenting with chest pain who has a pain intensity of 4 on a scale of 10. Chest pain is possible symptom of a lethal cardiac event. At the time of the triage the infant's seizure activity and potential airway obstruction should be attended to first. Third would be the adult client with abdominal pain. The abdomen is painful, but clients with potential life-threatening complications should be evaluated first. Next, the child presenting with a laceration to the hand, should be seen. The bleeding is under control with pressure so can be seen after the other three clients. The teenage client's blood glucose level is with normal limits. The other clients should be attended to first, so this client would be last.

A newly hired nurse has been instructed by the preceptor nurse on burn dressing techniques. The nurse knows teaching has been effective when the new nurse performs wound care in what order? Medicate client with pain medication. Wash hands and apply clean gloves. Set up sterile field and open packages. Remove the old dressing and discard. Wash hands and apply sterile gloves. Clean burn and place sterile dressing

The correct protocol for changing burn dressings consistently follows a specific pattern. The client must first be medicated for this painful procedure, and at least 30 minutes in advance so the drug has time to work. The nurse must then wash hands thoroughly and apply the clean (non-sterile) gloves. Depending on the type and extent of burns, the nurse may also need a gown to prevent contaminating the client. Although not mentioned here, the nurse would most certainly explain the procedure to the client, which could actually be accomplished while the nurse sets up the sterile field, opens sterile packages and pours the ordered cleansing fluids. Once properly set up, the nurse will gently remove the old dressing and discard along with the non-sterile gloves, per facility protocols. After washing hands a second time, the nurse will apply the sterile gloves to complete care. The burned area is cleaned, prescribed antibiotic cream is applied, and a new sterile dressing placed over the burn.

A newly hired nurse has been instructed by the preceptor nurse on burn dressing techniques. The nurse knows teaching has been effective when the new nurse performs wound care in what order? Medicate client with pain medication. Wash hands and apply sterile gloves. Wash hands and apply clean gloves. Remove the old dressing and discard. Clean burn and place sterile dressing. Set up sterile field and open packages

A roommate overhears the primary healthcare provider discussing a client's laboratory results, including a positive HIV test. The roommate requests to be moved immediately to another room. In what priority order should the nurse complete these tasks? Educate roommate about transmission of HIV and AIDS. Notify nurse manager regarding breach in confidentiality. Transfer roommate to another location as soon as available. Encourage the client to verbalize feelings regarding situation. Contact social services to address client's future needs.

The first action by the nurse is to address the roommate's concerns and fears about contracting HIV by presenting information regarding disease transmission. Next, since this situation represents a definite breach of confidentiality, it must then be reported to the nurse manager. Third, despite educating the roommate on modes of transmission, the nurse should attempt to honor the request to be moved to another room. Fourth, address the roommate's needs, by encouraging the client to express feelings about the diagnosis and current situation. Additionally, the client will have other needs related to the diagnosis which can best be handled by the social services department.

Four clients arrive for their appointment at a diabetic clinic. In what order should the nurse see the clients? Client reporting a headache and has a fruity breath. Client eating a simple-carb snack due to weakness. Client scheduled for a dressing change to foot ulcer. Client to receive dietary education.

The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. Remember, pick the killer answer first! This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). What was the hint? Fruity breath. The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. This is a diabetic clinic. This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. The third client would be the one needing a dressing change. Nothing life threatening, but an assessment needs to be made regarding the ulcer. The last client would be the one needing dietary education. Nothing life threatening. This client can wait until the others are treated.

A nurse has been assigned to care for five clients. In what order should the nurse assess these clients after shift report? Place in priority order from highest to lowest priority. 1. Client hospitalized to r/o adbdominal aortic aneurysm who is reporting deep, aching pain in the flank area 2. bp 200/102 3. arterial ucer to the right leg who reports pain of 8/10 4. Burerger disease reporting numbness, tingling and cold in toes. 5. smoking cessation

The first client the nurse should assess is the client reporting deep, aching flank pain with suspected abdominal aortic aneurysm. This is a sign of ruptured aortic aneurysm. This client is at greatest risk of death if the nurse does not do something. Clients who experience a ruptured aortic aneurysm may develop shock rapidly because the aorta is a large vessel and blood loss occurs quickly. Death can occur within minutes to hours. The second client who needs to be seen by the nurse is the one whose BP is high. This is the second most life threatening problem. The client is experiencing a hypertensive crisis which is a systolic pressure greater than or equal to 180 mmHg or diastolic greater than or equal to 120 mmHg. Uncontrolled blood pressure at this level can lead to progressive or impending end-organ dysfunction, including a possible cerebral vascular accident (CVA). This is an emergency situation and should be treated immediately. Third, the nurse should see the client experiencing leg pain due to arterial ulceration. The nurse needs to perform vascular checks to note if there is adequate arterial circulation. Although the symptoms listed are characteristic of arterial ulcers, the client may be experiencing further arterial occlusion. The goal for this client would be rapid surgical or medical approaches to help improve circulation to the areas. If circulation cannot be restored, amputation may be required. The fourth client to assess is the one diagnosed with Buerger's disease. These signs/symptoms are typical of this disorder. The disease is characterized by inflammation in the arteries that results in a vaso-occlusion type phenomena. The claudication, with symptoms described here, can quickly progress to a critical degree of limb ischemia. As it progresses, revascularization may not be possible, and amputation may be the only viable option. This is seen almost exclusively in heavy smokers or those who use other forms of tobacco. Medications are not generally helpful, so stopping tobacco use is basically the only way to stop the progression of this disease. The last client to assess is the client requesting information on smoking cessation. This is the most stable client. Although smoking is considered hazardous to the overall health status and can worsen this client's condition, cessation is not something that must be done as an emergency measure in this case. The other clients have more serious or life threatening issues than this client.

In what order should the emergency department triage nurse send these clients to a room for treatment? Place in priority order. The Correct Order Client who has multiple injuries from a motor vehicle accident. Elderly client who fell and fractured the left femoral neck. Female client stating she has been raped. Client reporting epigastric pain and nausea after eating.

The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. Injuries from a motor-vehicle accident can be life threatening. The client should be assessed first to rule out respiratory difficulty and hemorrhage. The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. Elderly clients have special fluid and electrolyte issues after a fall. The cause of the fall may be cardiac, but the question does not indicate this. The third client that should be sent back for treatment is the female client stating she has been raped. We do not know the extent of her injuries based on what the option tells us. There will likely be both physical and emotional injury that needs attention, which places this client third. The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. This is likely cholelithiasis, which will need to be checked out. This is the most stable of the four clients which places this client last to be seen.

The nurse inadvertently administered the wrong medication to a client. Place the tasks to be completed in order of priority. The Correct Order Obtain the client's vitals. Report what happened to the health care provider. Alert the Unit Manager. Complete an incident report.

The first priority in such a situation is to check the client for any immediate problems secondary to receiving the incorrect medication and obtain a set of vitals. The client status is always your priority. Second, the nurse should notify the Health Care Provider of what happened, and implement any counter measures that may be ordered. Third, the Unit manager must be informed of this occurrence, allowing for a review of medication administration protocols and policies. This person is contacted after the client is stable. Take care of the client first. Fourth, the nurse will complete an incident report, per the facility's protocol, to assist in the identification and correction of any safety issues regarding the administration of medications.

A healthy newborn has just been delivered and placed in the care of the nursery nurse. What nursing actions should the nursery nurse initiate? 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.

The first priority is to assess newborn's airway and breathing. This is done immediately to determine the need for resuscitation or other airway interventions. The infant is positioned in a modified Trendelenburg position in order to facilitate drainage of mucus from the upper airway. Second, bulb suction excessive mucus. This is performed to clear the airway and facilitate the ease of respirations. Third, assess newborn's heart rate. In the absence of respiratory distress, the assessment continues with the vital signs. Heart rate is part of the Apgar scoring of the newborn in which the physical status of the newborn is evaluated at 1 and 5 minutes after birth. The heart rate is the most important aspect of the Apgar scoring. A newborn heart rate that is less than 100 beats/minute is indicative of the need for stimulation and/or resuscitation. Fourth, place identification bands on newborn and mom. The ID bands with identical codes are placed on the mom and the newborn before leaving the delivery room. The band should be applied snugly enough on the newborn to prevent the accidental loss of the band. These must remain on the mom and newborn throughout the hospital stay and discharge. This ensures correct identification and placement of infant with the mom. Fifth, administer sterile ophthalmic ointment containing 0.5% erythromycin. The administration of this eye treatment for Neisseria gonorrhoeae is required by law. However, instilling this medication can be delayed up to 1 hour after birth to facilitate bonding through eye contact between the parent and infant. The other interventions would all precede this.

The nurse walks into a client's room and discovers the radioactive uterine implant lying on the bed. In what order should the nurse properly dispose of the implant? Put on gloves Pick up implant with tongs Place implant in lead lined container Call radiation department to take the implant out of the room

The first thing the nurse should do is put on gloves. Second, pick up the implant with tongs. Third, place the implant in a lead lined container. Fourth, call the radiology department to take the implant out of the room.

The nurse should document a Glasgow Coma Scale score of 8 for this client indicating that this client has a severe head injury. The nurse should receive a score of 2 for eye opening in response to pain a score of 2 for an incomprehensible verbal response, and a score of 4 for withdrawing from pain. Generally, head injury is classified as: Severe head injury: GCS score of 8 or less Moderate head injury: GCS score of 9 to 12 Mild head injury: GCS score of 13 to 15

A client receiving treatment for hypertension is scheduled to receive hydrochlorothiazide 25 mg orally. Based on the label on the bottle, how many tablets should the nurse administer? 50mg

The prescription is for 25 mg. Strength available is 50 mg/tab. 50 mg /1 tab = 25 mg/x tab 50 mg x = 25 mg tab 50 mg x/ 50 mg = 25 mg tab/50 mg X = 0.5 tablets.

In what order should the triage nurse send the following clients into the emergency department for treatment? Place in order from first to last. Client reporting severe left lower leg pain and swelling after driving a car for 12 hours. Client reporting right lower quadrant abdominal pain with nausea since early morning. Client reporting sore throat and fever. Client who ran out of blood pressure medication yesterday; BP 150/92. Client who has poison ivy, reporting intense itching.

Those with the most critical injuries or symptoms, such as clients with multiple traumas or those unconscious or not breathing, are first priority. Clients with urgent symptoms that could deteriorate quickly into an emergency are typically seen in 15 minutes to one hour, while clients with semi-urgent symptoms are generally seen within in one to two hours. Non-urgent clients are given the lowest priority, and could wait as long as two hours or more in a crowded ED. The first client to be seen should be the client reporting severe left lower leg pain and swelling, which is a circulatory problem, making the client the highest priority. The second client to be sent to the ED should be the client with possible appendicitis (right lower quadrant abdominal pain). This client will need an exam, lab studies, IV fluid, abdominal CT, and perhaps surgical consult. The third client should be the client who has a fever and sore throat. A throat culture is needed to r/o strep throat, and possible antibiotics. The fourth client would be the client needs an assessment and a prescription. The last client to be sent to the ED would be the client who has poison ivy. This is the most stable client and can be seen in a clinic.

The nurse is removing the client's peripheral IV line prior to discharge. The nurse completes the appropriate steps in what order? Apply gauze and tape tightly. Loosen tape and tegaderm cover. Stabilize cannula with one hand. Clamp IV line closed securely. Wash hands and apply gloves.

When preparing to remove a peripheral IV line, the nurse begins by washing hands and applying non-sterile gloves. Next, the clamp is closed on the IV line or saline lock extension to prevent fluid or blood from leaking during process. Third, the nurse needs to stabilize the cannula with one hand to prevent trauma at the insertion site. Fourth, carefully begin to loosen all the tape on the site. The bottom dressing or tegaderm, is loosened last. Lastly, the nurse will place large, folded gauze square over the insertion site and gently pull the cannula out of the skin, while placing pressure on that gauze. After holding the gauze in place for a few moments, and checking for excess bleeding, the nurse will tightly tape that gauze square in place, providing pressure over the site. The client should be instructed to keep that dressing in place for at least one hour.

The primary healthcare provider's prescription for a client instructs the nurse to give digoxin 0.125 mg intravenously as a one-time dose. The available medication is in a concentration of 0.5 mg/2 mL. How many milliliters should the nurse give? Round answer using one decimal point.

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