NCLEX-PN

The client is brought to the psychiatric emergency room by ambulance after being observed walking in the street and shouting at vehicles. The client states that aliens are trying to attack him and he is now on a mission to find and kill them. The mother says that last year he believed he was being watched by unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone number. The mother noticed he no longer cares about activities that used to interest him. He moved into the garden with the dog. He is malodorous and disheveled and laughing for no apparent reason. He shows little emotion. His answers are brief and asks if the interview is being secretly recorded. The clients speech is difficult to follow, and repeatedly says in a monotone voice , "I said I'll find them." He became angry and refuses to sit in a chair for the remainder for the interview.

-Aliens are trying to attack him, -watched by unidentified government agency, -asks if the interview is being secretly recorded, and "I said I'll find them." Acute psychiatric illness is bizarre thinking that is disconnected from reality. Including hallucination and delusions, could lead the client to be unsafe or aggressive.

Which of the following interventions should the nurse anticipate when caring for this newborn? Administer oral glucose water with each feed Allow skin-to-skin contact with the mother when possible Check the newborn's blood glucose levels Initiate newborn feeding within the first hour after birth. Monitor the newborn's respiratory rate frequently Wrap the newborn in warm blankets to alleviate tremors

-Allow skin-to-skin contact with the mother when possible, -Check the newborn's blood glucose levels, - initiate newborn feeding within the first hour after birth, -Monitor the newborn's respiratory rate frequently Hypoglycemia in a newborn is a increased risk if the mother has gestational diabetes. Close BG monitoring is crucial including skin-to-skin for warmth, initiating feeding to prevent depletion of glycogen stores, monitor for tachypnea and hypothermia as they increase glucose use.

Prior to feeding, the nurse prepares to obtain the newborn's vital signs and a capillary BG sample. The newborn is five hours old. Which of the following findings indicate that the newborn's condition has declined? Axillary temp 96.3 F and RR 84/min BG 32 mg/dL prior to feeding Newborn is jittery and has a high pitched cry Newborn is turning toward the breast while in skin-to-skin contact One wet diaper and no stools noted since birth

-Axillary temp 96.3 F and RR 84/min, -BG 32 mg/dL prior to feeding, newborn is jittery and has a high pitched cry A BG less than 40-45 is hypoglycemia for newborn. A temp less than 97.7 F is hypothermia, respirations should not exceed 60, newborn should have one wet diaper and one stool (meconium) in the first 24 hours.

Which client incident would be classified as an adverse event that requires incident event report? SATA

-Client receives one mg morphine instead of prescribed 0.5 mg. -Nursing did not report clients new hemoglobin result of 6.0 g/dL to oncoming nurse. -Provider was not notified of clients positive blood culture results. Adverse events are injuries caused by medical management. They include diagnostic, treatment, preventative, failure of communication, equipment, and other systems.

The nurse is caring for a 3 year old child. The child recently started attending a new preschool and hit a teacher during lunch. The parent says, "My child has never been aggressive before but he has always been particular about food." The client was born at full term without complication and has no significant medical history. The child started babbling at age 6 months, and the parent reports that the first words were spoken around age 12 months. The client then became quiet and "obsessed" with stacking blocks and organizing toys by color. The child can kick a ball, draw a circle, pedal a tricycle, and now says two-word phrases. Vital signs are normal, and the client's tracking adequately on growth curves. During the evaluation, the child sits in the corner of the room playing with blocks. The client does not follow the parent's gaze when the parent points to toys in the office. The child begins screaming a

-Quiet and "obsessed" with stacking blocks and organizing toys by color. -Now says two-word phrases. -Client does not follow the parent's gaze when pointing to toys in the office. -Child screams and rocks back and forth when the HCP comes near. Autism spectrum disorder is a neurodevelopmental condition characterized by impaired social skills and interpersonal communication, Manifestations include restricted activities and interest, delayed speech, poor eye contact, and repetitive patterns and behaviors.

The nurse in the emergency department is caring for a 66 year old client. GENERAL: The client comes to the ED with fatigue, SOB, dry cough, and exertional dyspnea for 1 week; the client is homeless; medical history includes chronic heart failure, uncontrolled hypertension, CAD, and type 2 DM PULMONARY: VS: RR 22, SpO2 88% on RA; the client is dyspneic but can speak in full sentences; lung auscultation reveals bilateral crackles; the client reports smoking 1 pack of cigarettes per day for 35 years; the client was hospitalized with pneumonia 6 months ago. CARDIOVASCULAR: VS: T 99 F (37.2 C), P 90, BP 170/100; continuous cardiac monitor shows sinus rhythm with occasional premature ventricular contractions; S1, S2, and S3 are heard on auscultation; bilateral lower extremity pitting edema is noted. Highlight below the 5 findings that are MOST concerning.

-SpO2 88% on RA (hypoxia), - lung auscultation reveals bilateral crackles (pulmonary edema), -BP 170/100 (HTN), -S3 are heard on auscultation (abnormal heart sounds), -bilateral lower extremity pitting edema (peripheral edema). Smoking and homelessness require follow-up to ensure the client receives appropriate resources and support, but they do not require immediate intervention. Decreased O2, crackles, extra heart tones, HTN, peripheral edema require further intervention due to concern of fluid overload and impaired gas exchange characteristics of HF.

A 39 year old, gravida 4 para 3, at 38 weeks gestation arrives at the L and D unit reporting contractions every 2-3 minutes. During this pregnancy, the client was diagnosed with gestational diabetes and prescribed insulin, but she reports not taking the insulin. The client reports cigarette smoking (3-5 a day) but denies alcohol or recreational drug use. The client received treatment for BV during the 2nd trimester. the client has gained 55 lb during the pregnancy. Group B Streptococcus result is negative. Highlight the 3 findings that should concern the nurse.

-The client was diagnosed with gestational diabetes and prescribed insulin, but she reports not taking the insulin, -The client reports cigarette smoking (3-5 a day) but denies alcohol or recreational drug use, -The client has gained 55 lb during the pregnancy. BV is not an STI and does not harm the newborn. A negative GBS test result indicates that the newborn is at low risk for infection. Antibiotics are recommended for a positive result. Recommended weight gain is 25-35 lb. if exceed this fetus is at risk for macrosomia, birth complications (shoulder dystocia and c-section)

The nurse is talking with the parent of an adolescent client who arrived in the emergency department after discovering that the client was involved in a motor vehicle collision. The parent ask about the clients condition. The client is unconscious, and is currently receiving CPR which of the following responses would be appropriate for the nurse?

-The healthcare team is currently attempting to revive your child after your child's heart stopped Veracity is a principle that refers to the duty to tell the truth and avoid dishonesty

The following abnormal laboratory results support the clients preeclampsia diagnosis _________ & ________ WBC count Hemoglobin 24 hour urine protein Serum creatinine

24 hour urine protein and serum creatinine

A newborn is being evaluated for possible esophageal atresia with tracheoesophageal fistula. Which finding is the nurse MOST likely to observe? A) Choking and cyanosis during feeding B) Concave (scaphoid) abdomen C) Diminished lung sounds D) Projectile vomiting after feeding

A) Choking and cyanosis during feeding Aspiration Is the greatest risk for client with esophageal atresia and tracheoesophageal fistula. Assessment will show frothy saliva, coughing, chicking, drooling, and distended abdomen s well as cyanosis and apnea with feeds.

The nurse is talking with the client who is entering the second trimester of pregnancy. Which of the following information should the nurse include? SATA A) "Anticipate experiencing light fetal movements around 16 to 20 weeks gestation." B) "Increase your consumption of iron-rich foods like meat and dried fruit." C) "Try to gain 3 lb (1.4 kg) each week if your pre pregnancy BMI was normal." D) "Expect to have an abdominal ultrasound scheduled to check fetal anatomy." E) "Plan to be screened for gestational diabetes around 24 to 28 weeks gestation."

A) "Anticipate experiencing light fetal movements around 16 to 20 weeks gestation." B) "Increase your consumption of iron-rich foods like meat and dried fruit." D) "Expect to have an abdominal ultrasound scheduled to check fetal anatomy." E) "Plan to be screened for gestational diabetes around 24 to 28 weeks gestation." The second trimester occurs at 14 weeks to 27 weeks and 6 days. Nurse should reinforce physical changes, potential complications, and routine screening/diagnostic test during this time period. Clients should expect quickening (Clients first perception of fetal movement) at 16-20 weeks, gain approximately 1 lb (0.5 kg) per week if prepregnancy BMI was normal, consume iron-rich foods, and anticipate screening/diagnostic tests (1-hour glucose challenge test, fetal anatomy ultrasounds.

The nurse is reviewing medical histories with several clients during a community health screening event. Which of the following client statements indicate a risk factor for cervical cancer? SATA A) "I have had four sexual partners during my lifetime." B) "I have smoked cigarettes for many years." C) "I never use birth control pills because my partners wore condoms." D) "I received treatment for chlamydia when I was younger." E) "I tested positive for human papillomavirus a few years ago."

A) "I have had four sexual partners during my lifetime." B) "I have smoked cigarettes for many years." D) "I received treatment for chlamydia when I was younger." E) "I tested positive for human papillomavirus a few years ago." the most important risk factor for cervical cancer is persistent human papillomavirus (HPV) infection. Other risks factors for cervical cancer include multiple sex partners (>1), smoking tobacco, being infected with other STIs (chlamydia). As these all increase the likelihood of HPV infection. Condoms help prevent HPV, and not taking oral birth control is associated with a decreased risk of cervical cancer.

The nurse has taught the parents of a 6 year old client with nephrotic syndrome. Which of the following statements by the parents would require follow up? A) "I will encourage my child to play with other children." B) "I will monitor my child's urine for protein everyday." C) "I will provide a healthy diet without added salt for my client." D) "I will report swelling or rapid weight gain to the HCP."

A) "I will encourage my child to play with other children." Nephrotic syndrome is characterized by a proteinuria, edema, and hypoalbuminemia. During relapse parent should minimize the risk by limiting sodium and limiting the client's physical contact with others (as they are more susceptible to infection).

The nurse is caring for a client who has been hospitalized for major depressive disorder. When the nurse reminds the client that breakfast will be served in the dining room in 20 minutes, the client says, "I'm not hungry and don't feel like doing anything." Which is the best response by the nurse? A) "I will help you get ready, then we can walk to the dining room together." B) "I will have breakfast brought to your room. I know you don't have much energy right now." C) "It is okay. You can join us when you are ready. Take your time." D) You will feel better when you get up and get dressed. You need to eat something."

A) "I will help you get ready, then we can walk to the dining room together." reduced appetite and low energy level are common in major depressive disorder. Hard to get out of bed and perform ADLs. Client needs direction and structure with their ADLs also assistance. The nurse should assist the client with completing ADLs and with initiating social interaction with others.

Client returns after 6 months after starting behavioral therapy. Which statement by the parent indicates a need for further therapy? A) "My child will eat but only if I cook the same meal everyday." B) "My child will make only brief periods of eye contact with the teacher." C) "My child will occasionally play with other children at the park." D) "My child will squeeze a soft toy instead of banging the head."

A) "My child will eat but only if I cook the same meal everyday." When evaluating the effectiveness of behavioral therapy the nurse should recognize that narrowed, restricted interest indicate a need for additional therapy.

A client is able to partially bear weight and follow the nurse's instructions. Which would be the MOST APPROPRIATE method for the nurse to safely transfer this client? A) 1-person standby assist and pivot with gait belt and walker B) 1-person standby assist with walker C) 2-person motorized stand-assist lift D) 2-person stand and pivot with gait belt and walker

A) 1-person standby assist and pivot with gait belt and walker Full weight bearing- Independent, 1 person standby or observation for fall risk Partial weight bearing- 1 person assist stand and pivot transfer with gait belt or motorized assist device if cooperative, 2 person assist with full body sling if uncooperative Non weight bearing- motorized assist is cooperative with upper body strength, 2 person assist with full body sling if uncooperative and had no upper body strength 1. Whether the client can bear weight 2. Is the client cooperative

The client is newly prescribed aripiprazole for ASD. The nurse is reinforcing teaching to the client's parents. Which statement by the nurse is appropriate? A) Abruptly stopping the medication can cause withdrawal symptoms." B) "Aripiprazole will cure your child's ASD." C) "Restlessness is an expected side effect and will eventually subside." D) This medication will eliminate your child's self-harm behaviors."

A) Abruptly stopping the medication can cause withdrawal symptoms." Antipsychotic to treat irritability in ASD. Should be weaned over time or client will withdraw ASD requires long term management with pharmacological measures.

A post operative client with obesity and DM has an abdominal wound and is at risk for poor wound healing. Which of the following intervention does the nurse anticipate to prevent wound dehiscence? SATA A) Administer docusate sodium PO every day B) Assist in applying a abdominal binder C) Implement cardiac restriction to promote weight loss D) Monitor blood glucose to maintain tight control E) Reinforce teaching to hug a pillow while coughing

A) Administer docusate sodium PO every day B) Assist in applying a abdominal binder D) Monitor blood glucose to maintain tight control E) Reinforce teaching to hug a pillow while coughing

The nurse is caring for a client who had an endoscopic procedure yesterday to stop upper gastrointestinal bleeding who started a clear liquid diet today. Which of the following foods would be appropriate to offer this client? SATA A) Apple juice B) Chicken broth C) Cranberry juice D) Cream of chicken soup E) Unsweetened tea F) Vanilla ice cream

A) Apple juice B) Chicken broth E) Unsweetened tea Post op diets start with ice chips and progress to clear liquids as tolerated and with the passing of flatus, Clear liquids that are contain red dye should be avoided in GI bleeding patients. Full liquid: Ice cream and cream of chicken soup because they turn into liquid when warmed to room temp and do not require chewing.

The nurse is reinforcing teaching to a client with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? SATA A) Avoid excess caffeine B) Immerse hands in cold water C) Practice yoga or tai chi D) Refrain from using tobacco products E) Wear gloves when handling cold objects

A) Avoid excess caffeine C) Practice yoga or tai chi D) Refrain from using tobacco products E) Wear gloves when handling cold objects Raynaud is a vasospastic disorder resulting in vascular response to cold temps or emotional stress. Women ages 15-40. Treat by immersing hands in warm water. CCBs may be prescribed to relax smooth muscle and prevent episodes

Which of the following findings indicate that the client is improving as expected? SATA A) BP 138/70 mm Hg B) Clear lung sounds C) Increased urinary output D) SpO2 95% on RA E) Unilateral lower extremity edema

A) BP 138/70 mm Hg B) Clear lung sounds C) Increased urinary output D) SpO2 95% on RA Improvement in a client with HF includes improvement of fluid volume status and gas exchange. Unilateral lower extremity edema is concerning for DVT and requires immediate follow-up, as it could lead to a life threatening PE.

General: Client is a G 2 P 1 at 36 weeks. reports a throbbing headache 7/10, blurred vision, and epigastric pain; client states she took 1000 mg tylenol with no relief. VS: prenatal visit 33 weeks: T 98.4, P 79, RR 17, BP, 122/75, 99% RA Admission: T 98.8, P 84, RR 18, BP 176/111, 97% RA What is priority for the nurse? A) Blood pressure B) Cervical exam C) Deep tendon reflexes D) Gestational age of fetus

A) Blood pressure

Which of the following complications is the newborn at risk for based on the maternal history? A) Brachial plexus injury B) Cephalohematoma C) Hypoglycemia D) Neonatal sepsis E) Polycythemia

A) Brachial plexus injury B) Cephalohematoma C) Hypoglycemia E) Polycythemia newborns to mothers with gestational diabetes are at risk for birth injuries (brachial plexus and cephalohematoma), hypoglycemia and polycythemia (a hct >65%) due to chronically impaired fetal oxygenation.

A client with HTN and type 2 DM has recently started taking chlorthalidone. Which report by the client is MOST concerning to the nurse? A) Dizziness on standing B) Fasting blood glucose of 160 mg/dL C) Presence of muscle cramps D) Sunburn on both arms

C) Presence of muscle cramps Thiazide diuretics are prescribed to treat HTN and edema, major side effects include F & E imbalances such as HYPOkalemia. This can lead to dangerous ventricular dysrhythmias.

A client is taking lithium for management of bipolar I disorder. The client's most recent serum lithium level is 0.8 mEq/L. Based on this result, what prescription does the nurse anticipate receiving from the HCP? A) Continue at the current dose B) Decrease the dose C) Discontinue the medication D) Increase the dose

A) Continue at the current dose Lithium is a mood stabilizer for bipolar disorder and decreasing suicidal thinking and behaviors. It has an increased risk for toxicity, but the therapeutic level is between 0.8- 1.4 mEq/L. Signs of toxicity include diarrhea, n/v, lethargy, weakness, and polyuria.

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which finding requires intervention by the nurse? A) Contraction duration of 95 seconds B) Contraction frequency of every 3 minutes C) Contraction intensity of 45 mm Hg D) Uterine resting tone of 10 mm Hg

A) Contraction duration of 95 seconds Uterine contractions in the first stage of labor: DURATION - 45-80 seconds, should not exceed 90 seconds (reduction of blood flow to the placenta) FREQUENCY: 2-5 contractions every 10 minutes, should not occur more frequently than every 2 minutes (fetal distress from uteroplacental insufficiency) INTENSITY: Strength at peak time (25-50 mmHg), should not exceed 80 mm Hg (sign of hypertonicity of the uterus) RESTING TONE: Tension in uterine muscle between contractions, allows fetal oxygenation between contractions, average 10 mm Hg, should not exceed 20 mm Hg

The nurse has reviewed the information from the Laboratory Results and Diagnostic Results, the nurse suspects the client is experiencing acute decompensated HF. Which of the following findings are consistent with this condition? SATA A) Crackles with auscultation B) Decreased capillary oxygen saturation C) Elevated b-type natriuretic peptide D) left ventricular ejection fraction 30% E) Lower extremity pitting edema

A) Crackles with auscultation B) Decreased capillary oxygen saturation C) Elevated b-type natriuretic peptide D) left ventricular ejection fraction 30% E) Lower extremity pitting edema Decompensated HF is characterized by pulmonary congestion (crackles, decreased O2, fluid overload [peripheral edema]). In addition clients will have an elevated b-type natriuretic peptide and low ejection fraction (<50%).

Which of the following symptoms are consistent with schizophrenia? SATA A) Disorganized speech B) Flat effect C) Laughing for no apparent reason D) Loss of interest in pleasurable activities E) Self care deficit

A) Disorganized speech B) Flat effect C) Laughing for no apparent reason D) Loss of interest in pleasurable activities E) Self care deficit

The nurse is caring for an 8 month old client with suspected acute otitis media. Which of the following findings would be consistent with the condition? SATA A) Frequent pulling on affected ear B) Purulent drainage from the affected ear C) Refusal to eat D) Restlessness and irritability E) Retracted tympanic membranes

A) Frequent pulling on affected ear B) Purulent drainage from the affected ear C) Refusal to eat D) Restlessness and irritability Otitis media is caused by a blocked eustachian tube leading to the buildup of purulent fluid and inflammation in the middle ear. In Otitis the tympanic membrane will appear red and bulging due to fluid build up.

The nurse is screening clients for those at risk of developing nephrolithiasis. Which of the following factors would increase a client's risk of developing nephrolithiasis. SATA A) Gout B) Dehydration C) Hypokalemia D) Thrombocytopenia E) Hyperparathyroidism

A) Gout B) Dehydration E) Hyperparathyroidism Nephrolithiasis (kidney stones) can obstruct the ureters leading to hematuria, flank abdominal pain and N/V. Risk factors for nephrolithiasis include GOUT, frequent UTIs, DEHYDRATION, HYPERPARATHYROID, and a family history. Gout increases uric acid in kidneys (uric acid stones). Dehydration increases concentration of solutes in kidneys. Hyperparathyroidism increases amounts of Ca in kidneys. Hypokalemia does not increase the risk for stones, but increases risk for cardiac dysrhythmias. Thrombocytopenia (low platelets) is not associated with kidney stones, but increases the risk for bleeding.

The LPN assigns the ambulation of a client to the UAP. The UAP placing the client's foley bag on the IV pole at the level of the client's chest during ambulation down the length of the hallway. What action should the LPN take initially? A) Immediately lower the bag and speak privately to the UAP B) Let UAP complete assigned tasks and speak to them at the end of the shift C) Praise UAP for encouraging the client to walk the entire hallway D) Speak with the nurse manager about the need for UAP inservice education

A) Immediately lower the bag and speak privately to the UAP The foley bag is too high and should be lowered below the level of the bladder. Correction of staff should be done privately not when the client is present. Attend to the error right away to stop potential harm to the client.

The client is diagnosed with autism (ASD autism spectrum disorder). The nurse recognizes that clients with ASD are at risk for which of the following complications? SATA A) Impaired interpersonal relationships B) Learning difficulties C) Malnutrition D) Self-harm behavior E) Sleep disturbances

A) Impaired interpersonal relationships B) Learning difficulties C) Malnutrition D) Self-harm behavior E) Sleep disturbances ASD begins in the developmental period, and symptoms tend to persist through life. More prone to psychiatric, medical, psychosocial impairments (impaired interpersonal relationships, learning difficulties, malnutrition, self-harm, and sleep disturbances).

The nurse is assisting with the admission of a client who had a nephrectomy 6 hours ago. The client should be assigned to a semiprivate room with a client who has. A) a PE, is receiving heparin therapy, and has a decreased platelet count B) cellulitis of the leg, is receiving antibiotic therapy, and is reporting loose stools. C) type 1 DM, a wound on the foot, and an elevated temp D) HIV infection, a decreased CD4+ cell count, and is reporting fatigue

A) a PE, is receiving heparin therapy, and has a decreased platelet count post op clients are at increased risk for infection therefore should not be placed in a room with a client who has an active or suspected infection.

The nurse is preparing to irrigate the wound of a seven year old client who sustained a laceration while on a playground. Which of the following action should the nurse take? SATA A) administer, he prescribed analgesic 30 minutes before irrigating the B) cleanse the wound from the most contaminated to the least contaminated area C) obtain a 10 mL syringe and a 27 gauge needle D) review the clients vaccination record E) use continuous pressure to flush the wound repeat until drainage is clear

A) administer, The prescribed analgesic 30 minutes before irrigating the wound D) review the clients vaccination record E) use continuous pressure to flush the wound repeat until drainage is clear Administer analgesic, 30 to 60 minutes before, fill 30 to 60 mL sterile irrigation syringe, attach 18 or 19 gauge needle to syringe, use continuous pressure, dry surrounding wound area to prevent skin breakdown, clean from the least to the most contaminated area

The client is two hours, postpartum, and the nurse is called to the clients bedside. Which action should the nurse perform immediately? The client is sleeping and not easily aroused, VS T 98 F, P 65, RR 11, BP 121/75, SpO2 93% RA A) alert the registered nurse B) collect a blood specimen for serum magnesium level C) perform fundal massage D) request a prescription for IV fluids

A) alert the registered nurse If symptoms of magnesium toxicity occur (somnolence, respiratory depression, diminished deep tendon reflexes) the nurse should stop the infusion, notify the RN, and anticipate giving the antidote calcium gluconate

The nurse cares for a confused client who continues to pull at the intravenous catheter on the left forearm, despite frequent instructions not to do so. What is the nurses next action? A) apply a gauze wrap and elastic stockinette around the IV site B) apply a mitt on the right hand C) apply a soft wrist restraint on the right wrist D) apply an arm board to the left arm

A) apply a gauze wrap and elastic stockinette around the IV site The least restrictive device or method should always be tried before applying restraints

The nurse prepares to administer a cleansing enema to a client with constipation. Which nursing interventions are appropriate? SATA A) apply water-based lubricant to the end of a tube B) assist the client into left lateral position C) encouraged client to retain the enema for as long as possible D) keep the animal solution refrigerated E) stop the infusion if the client reports abdominal cramping

A) apply water-based lubricant to the end of a tube B) assist the client into left lateral position C) encouraged client to retain the enema for as long as possible E) stop the infusion if the client reports abdominal cramping Place client and left lateral with right knee flexed, lubricate, and insert enema tube into rectum with the tip directed towards the umbilicus, slow rate of administration if cramping. Enemas should be administered at room, temp, or warm.

The nurse is caring for a six month old client with a new tracheostomy. Which of the following findings would indicate that the clients airway require suctioning? SATA A) audible gurgling B) heart rate of 110/min C) increased irritability D) oxygen saturation of 88% E) respiratory rate of 30/min

A) audible gurgling C) increased irritability D) oxygen saturation of 88% A heart rate of 110 and a respiratory rate of 30 are within normal limits for a six month old client and do not indicate respiratory distress

A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should the nurse reinforce to reduce the risk of future episodes? SATA A) drink plenty of fluids B) exercise regularly C) follow a low-fiber diet D) include whole grains, fruits, and vegetables in the diet E) increase intake of red meat

A) drink plenty of fluids B) exercise regularly D) include whole grains, fruits, and vegetables in the diet Intracolonic pressure has been linked to constipation, methods to prevent this include a diet high in fiber (whole grains, fruits, vegetables), increasing daily fluid intake, and exercise, perhaps a fiber supplement. Red meat consumption or high fat/iron foods can lead to constipation and increase risks.

The nurse is caring for the assigned clients on a pediatric inpatient unit. Which client is the nurses priority? A) eight year old with sickle cell crisis, who is sudden onset, unilateral, arm weakness B) 11 year old with a viral meningitis requesting pain medication for headache C) male child scheduled for surgery for interception, who has reddish mucoid stool D) male child with hemophilia who has hemarthrosis and is receiving desmopressin

A) eight year old with sickle cell crisis, who is sudden onset, unilateral, arm weakness Children can have strokes, ischemic strokes are common in children with sickle cell. Desmopressin (DDAVP) is used to treat hemophilia

The nurse is caring for a 5 year old with sickle cell disease who is experiencing an episode of acute pain. The client has SOB, n/v, and severe generalized body and joint pain. Which of the findings require immediate intervention? A) enlarged spleen on palpation B) hemoglobin level of 9.0 g/dL C) bilateral swelling of the hands and feet D) pain rated as 8 on Wong Baker FACES scale

A) enlarged spleen on palpation Clients with sickle cell typically have small spleens unless there is crisis in which splenomegaly is caused by RBCs being trapped in the spleen. Blood pooling can lead to life threatening hypovolemia and shock.

The nurse suspects of the client has preeclampsia, which of the following findings are clinical manifestations of preeclampsia A) epigastric pain B) facial edema C) high blood pressure D) proteinuria E) throbbing headache F) visual disturbances

A) epigastric pain B) facial edema C) high blood pressure D) proteinuria E) throbbing headache F) visual disturbances

Which complication of schizophrenia should the nurse be MOST concerned about? A) Anxiety B) Insufficient nutritional intake C) Self-harm D) Substance use disorder

C) Self-harm Self harm and suicide is the most concerning complication as the rates are higher in patients with schizophrenia.

For each potential intervention, click to specify if the intervention is anticipated or not anticipated for the care of the client. Encourage the client to play with others in the playroom Follow a structured routine and schedule for providing care Consistently assign the same nursing staff to the client when possible Assign the client to a shared room with another child with ASD Use direct eye contact and therapeutic touch when talking to the client

ANTICIPATED: -Follow a structured routine and schedule for providing care -Consistently assign the same nursing staff to the client when possible. NOT ANTICIPATED: -Encourage the client to play with others in the playroom, assign the client to a shared room with another child with ASD, -Use direct eye contact and therapeutic touch when talking to the client

The nurse is reinforcing teaching for the client with active TB, is the statement by the nurse appropriate or not? A) "A nurse will need to watch you take your medications." B) "You should notify anyone that has frequently been in close contact with you." C) Weekly complete blood counts will track whether your antibiotics are effective." D) "Alcohol use while taking these medications can increase your risk for liver damage."

APPROPRIATE: A) "A nurse will need to watch you take your medications." B) "You should notify anyone that has frequently been in close contact with you." D) "Alcohol use while taking these medications can increase your risk for liver damage." NOT APPROPRIATE: C) Weekly complete blood counts will track whether your antibiotics are effective."

For each finding below, click to specify if the finding is consistent with the disease process of autism spectrum disorder, OCD, or separation anxiety. Each may support more than one disease process. Ritualized pattern of behavior Disinterest in social interaction Lack of spontaneous eye contact restricted, fixed thoughts or interests.

AUTISM: -Ritualized pattern of behavior. -Disinterest in social interaction. -Lack of spontaneous eye contact. -Restricted, fixed thought or interests. OCD: Ritualized pattern of behavior and restricted, fixed thoughts or interests. SEPARATION ANXIETY: Disinterest in social interaction

The nurse assists the RN with development of the POC. For each intervention, specify if the intervention is appropriate or not appropriate for the care of the client with schizophrenia. Allow the client to listen to music Use gentle touch to calm the client Open medication packages in front of the client Tell the client that you DO NOT believe that the voices are real Ask the client if he is hearing voices instructing him to self-harm

Appropriate: -Allow the client to listen to music, -Open medication packages in front of the client, -Ask the client if he is hearing voices instructing him to self-harm NOT Appropriate: -Use gentle touch to calm the client -Tell the client that you DO NOT believe that the voices are real Do not touch the client without warning. Do not discredit the client's beliefs as it can worsen paranoia.

The home health nurse is caring for a 45-year old client who is prescribed peritoneal dialysis for end-stage renal disease, which of the following actions are appropriate versus not appropriate when performing peritoneal dialysis? Microwave the dialysate bag before infusion. Sit at 20° angle during exchange wear clean gloves, when accessing catheter Place the drainage bag below the abdomen during drainage States, "I will notify my HCP if the dialysate outflow is cloudy" Change positions to facilitate drainage if the output volume is less than the input.

Appropriate: -Sit at 20° angle during exchange wear clean gloves, when accessing catheter -Place the drainage bag below the abdomen during drainage -States, "I will notify my HCP if the dialysate outflow is cloudy" -Change positions to facilitate drainage if the output volume is less than the input. Not appropriate: -Microwave the dialysate bag before infusion

Which of the following risks is the client receiving fosphenytoin at risk for?

Ataxia, Hirsutism, Nystagmus, Gingival hyperplasia, Stevens Johnsons Syndrome IV antiepileptic for Seizures When oral phenytoin is Contraindicated

The nurse is reinforcing information for a client with COPD. Which statements by the client indicate the understanding of the pursed lip breathing technique? SATA A) "I exhale for 2 seconds through pursed lips." B) "I exhale for 4 seconds through pursed lips." C) "I inhale for 2 seconds through my mouth." D) "I inhale for 2 second through my nose, keeping my mouth closed." E) "I inhale for 4 seconds through my nose, keeping my mouth closed."

B) "I exhale for 4 seconds through pursed lips." D) "I inhale for 2 second through my nose, keeping my mouth closed." Pursed lip-breathing helps decrease SOB by preventing airway collapse, promoting CO2 elimination. COPD patients should use this for 5-10 minutes 4 times daily. Step 1) Relax the neck and shoulders Step 2) Inhale deeply for 2 seconds through the nose with the mouth closed. Step 3) Exhale for 4 seconds through pursed lips, as if blowing through a straw. Or twice as long as inhalation.

Which action should the nurse perform FIRST for the schizophrenic patient? A) Administer lorazepam, haloperidol, and diphenhydramine B) Direct other clients away from the area C) Offer the client distraction activities D) Place the client in 4 point restraints E) Request additional staff presence

B) Direct other clients away from the area The nurse must recognize signs of escalating agitation (pacing, yelling, clenching fist) and intervene immediately to maintain a safe environment.

A nurse is collecting data on a 58 year old client with blurred vision and reduced visual fields. The nurse finds which clinical manifestation MOST concerning? A) Difficulty adjusting to dimmed lights B) Extreme eye pain C) Gradual loss of peripheral vision D) Opaque appearance of lens

B) Extreme eye pain glaucoma is characterized by increased intraocular pressure (IOP) resulting in compression of the optic nerve. When IOP increases rapidly sudden onset of severe eye pain can occur. Gradual loss of vision and difficulty adjusting to lights are not considered emergency situations. Opaque lenses are characteristics of cataracts which is not a medical emergency.

The nurse is caring for a patient with diabetes mellitus. The client is alert and oriented but appears shaky and pale. The client's capillary blood glucose is 50 mg/dL (2.8 mmol/L). Which of the following actions should the nurse take next? A) Administer 1 mg glucagon IM to the patient B) Give the patient 4 oz (120 mL of regular soda. C) Prepare 50 mL of dextrose 50% in water IV push. D) Repeat the capillary blood glucose level to verify accuracy.

B) Give the patient 4 oz (120 mL of regular soda. hypoglycemia occurs when blood glucose levels fall below 70 mg/dL. Conscious clients should be given 15 g of a simple carbohydrate (ex. 4 oz regular soda) to quickly increase the blood glucose level. IV dextrose and IM glucagon are given to patient who can not digest an oral simple carbohydrate. The blood glucose should be rechecked 15 minutes after administration of a simple carbohydrate to check effectiveness.

A client with seizure disorder is prescribed a moderately high dose of phenytoin. Which teaching topic should the nurse reinforce with this client? A) Diet high in iron B) Good oral care and dental follow-up C) Shaving with an electric razor D) Use of sunglasses for eye protection

B) Good oral care and dental follow-up Encourage good oral hygiene and go to dentist to prevent gingival hyperplasia (overgrowth of the gum tissues or red gums that bleed easily). The other major side effects are increased body hair, rash, folic acid depletion, and osteoporosis.

The graduate nurse (GN) is caring for a client with a fractured femur in balanced suspension skeletal traction. Which action by the GN will require precepting nurse to intervene? A) Encourages the client to drink plenty of water and choose high-fiber foods from the diet menu. B) Lifts the traction weights while the UAP provide a bed bath and linen change. C) Monitors the incision and pin insertion sites for erythema, drainage, and malodor. D) Performs doppler ultrasound pulse checks in the affected leg every hour for the first 24 hours after surgery.

B) Lifts the traction weights while the UAP provide a bed bath and linen change. to work effectively skeletal traction must be continuous, therefore weights should not be lifted or removed, even briefly unless prescribed by the HCP.

The nurse is monitoring a 12-month old diagnosed with intussusception. Which findings should the nurse expect? SATA A) Palpable olive shaped mass in epigastrium B) Palpable sausage shaped mass in URQ C) Projectile vomiting containing blood D) Screaming and drawing the knees up to the chest E) Stool mixed with blood and mucus

B) Palpable sausage shaped mass in URQ D) Screaming and drawing the knees up to the chest E) Stool mixed with blood and mucus the triad of intussusception is intermittent severe crampy abdominal pain; a palpable sausage shaped mass on the right side of the abdomen and jelly stools. Pyloric stenosis presents as frequent hunger, olive shaped mass right of the umbilicus, and projectile vomiting without blood.

Which of the following are correct nursing actions related to client positioning? SATA A) Position client in Fowler position after cardiac cath via femoral artery B) Position client in Trendelenburg position on left side if air embolism is suspected C) Position client on the left side following a liver biopsy D) Position client on the side with head, back, and knees flexed during lumbar puncture. E) Position client with the arm raised above the head for chest tube placement.

B) Position client in Trendelenburg position on left side if air embolism is suspected D) Position client on the side with head, back, and knees flexed during lumbar puncture. E) Position client with the arm raised above the head for chest tube placement. Fowler position is contraindicated for femoral cardiac cath because risk of hemorrhage, instead place supine. After a liver biopsy the client should lie on the right side for 2 hours to apply pressure and splint the site, then supine for 12-14.

The nurse observes a client self-administering nasal fluticasone. Which observation would require the LPN to intervene and reinforce the instruction provided by the RN? A) A sitting position is assume as the head is bowed slightly forward B) The client points the spray tip towards the nasal septum during instillation C) The nasal spray tip is inserted into the nostril as the other nostril is occluded D) While administering the medication, the client inhales deeply through the nose

B) The client points the spray tip towards the nasal septum during instillation The tip should be directed away from the septum, point towards the side (ear) and lean forward while occluding other side.

The nurse receives news of a local mass shooting. Stable Clients need to be discharged to make room for newly admitted client. Which client with the nurse identify as safe to recommend for discharge? A) client on chemotherapy, who started antibiotics today for cellulitis of the leg B) client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours C) client with diabetes, who has nausea, abdominal pain, and vomiting D) client with UC with fever/vomiting

B) client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours Asthma, patients can be safely discharged when respiratory status has stabilized

The nurse is assisting with community health screening. Which of the following client is the priority to refer for further evaluation. A) client with random blood glucose of 139 B) client with shiny, hairless legs that are cool to the touch C) client who is an athlete with a heart rate of 50/min D) client with a blood pressure of 129/79 mmHg

B) client with shiny, hairless legs that are cool to the touch PAD results in shiny cool pair, hairless skin, poor wound healing and ischemic pain. They have impaired perfusion, and are at risk for MI, stroke, death.

A client with methicillin resistant staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last three days. Which blood test is most important to review when preparing administration of the med? A) blood cultures B) creatinine levels C) magnesium levels D) white blood cell count

B) creatinine levels Creatinine levels should be closely monitored for signs of nephrotoxicity in the client. If increasing creatinine is identified, the nurse should hold the dose and contact the HCP.

A client on hospice home care is taking sips of water, but refusing food. Family members appear distressed and insists the personal care worker force feed the client. What is the priority nursing action? A) explain to the family that is the normal physiological response to dying B) explore the families, thoughts and concerns about the clients refusal food C) recommend a feeding tube D) tell the family that force feeding the client could cause the client to choke on the food

B) explore the families, thoughts and concerns about the clients refusal food It's common for family members to become distressed when a terminally ill loved one refuses food. The nurse should explore their fears and concerns and help them identify other ways to express how they care.

The nurse is preparing to administer eardrops to an adult client. It would require follow up if the nurse. A) instills the eardrops at room temp B) instills the ear drops by placing the dropper into the ear canal C) pulls the pinna of the clients ear up and back before installation D) place is a cotton ball loosely in the outer, most auditory canal after installation

B) instills the ear drops by placing the dropper into the ear canal The nurse should hold the dropper 1/2 inch or 1 cm above the ear canal to avoid damaging the ear with the dropper. Eardrops should be warm, a cotton ball should be placed, pin a should be pulled back

In addition to the maternal history of gestational diabetes, the newborns _________ and _________ place the newborn at risk for increased risk for hypoglycemia. Bruising, Temperature, APGAR scores, Birth weight, Gestational age

Birth weight and low body temperature.

The client is a 16 year old diabetic, highlight 4 clinical findings that require immediate follow up. Brought to ED due to n/v and abdominal pain began 24 hours ago. Client is lethargic Mucous membranes are dry Capillary refill time is 4 seconds Has missed one dose of levothyroxine

Brought to ED due to n/v and abdominal pain began 24 hours ago. Client is lethargic Mucous membranes are dry Capillary refill time is 4 seconds

The nurse is reinforcing home care instructions to a client newly diagnosed with osteomalacia. Which of the following statements indicate proper understanding of teaching. A) "I will avoid foods high in calcium and phosphorus" B) "I will avoid going outside on sunny days" C) " I will eat foods that are fortified with vitamin D" D) " I will engage in physical activity to increase bone strength" E) " I will use a cane to help me get around better"

C) " I will eat foods that are fortified with vitamin D" D) " I will engage in physical activity to increase bone strength" E) " I will use a cane to help me get around better" Osteomalacia occurs when the body is unable to use calcium and phosphorus for bone calcification, due to a vitamin D deficiency

The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the MOST concern? A) "I've felt the need for an afternoon nap most days this week." B) I've gained 3 lb since i began taking this med." C) "I've had the stomach flu for the past couple days." D) "My mouth seems to be drier than usual lately."

C) "I've had the stomach flu for the past couple days." Drowsiness, weight gain, and dry mouth are expected side effects of lithium. Dehydration and sodium loss from vomiting and diarrhea can lead to toxic lithium levels replicating flu like symptoms.

The nurse is assessing a 7-year old client recently admitted with nausea, vomiting, severe RLQ pain and an elevated WBC count. Which of the following statements by the client would be a priority to follow up? A) "I feel so tired." B) "I am hungry and I want to eat." C) "My stomach does not hurt anymore." D) "I do not like hospitals and I want to go home."

C) "My stomach does not hurt anymore." Likely acute appendicitis, requires immediate intervention before rupture. Once the appendix ruptures pain is temporarily relieved and may turn to peritonitis or sepsis.

A client with CAD is being seen in the clinic for a follow up. During the med reconciliation, the nurse identifies what med as requiring further investigation? A) 10 mg isosorbide dinitrate twice daily B) 20 mg atorvastatin once daily C) 500 mg naproxen twice daily D) 2,000 fish oil once daily

C) 500 mg naproxen twice daily CAD patients are cautioned to not take NSAIDS (naproxen) with an increased risk of heart attack or stroke.

The nurse is caring for assigned clients. Which of the following clients should the nurse check first? A) Client who had a cholecystectomy and is reporting incisional pan 5/10 B) Client who had an open reduction of the right femur and is reported nausea. C) Client with type 1 DM and a blood glucose of 55 mg/dL D) Client with type 2 DM and a blood glucose level of 250 mg/dL

C) Client with type 1 DM and a blood glucose of 55 mg/dL hypoglycemia is the most life threatening condition listed. Clients respond rapidly to nursing interventions (sugar tabs, OJ)

A nurse is preparing an educational presentation on herbal supplements for the local community center. The nurse anticipates discussion of saw palmetto to what type of clients? A) Clients diagnosed with dyslipidemia B) Clients experiencing major depression C) Clients with benign prostatic hyperplasia D) Perimenopausal clients experiencing hot flashes

C) Clients with benign prostatic hyperplasia Saw palmetto is a herbal supplement used to treat benign hyperplasia, should be taken cautiously with anticoagulants and antiplatelets because it may increase the risk for bleeding. Garlic is used to promote cardiovascular health and may reduce triglyceride levels and increase HDL cholesterol. St. John wort has been used for centuries to treat depression. It may cause HTN and serotonin syndrome with antidepressants. Black cohosh is use to treat perimenopausal clients experiencing hot flashes.

The nurse is caring for a client with type 2 DM who reports feeling lightheaded and shaky. Which of the following actions should the nurse take next? A) Administer glucagon by subQ injection as prescribed B) Administer rapid acting insulin per sliding scale as prescribed C) Give the client 4 oz of fruit juice or regular soda D) Give the client a snack of cheese or peanut butter with crackers.

C) Give the client 4 oz of fruit juice or regular soda

A) also takes ibuprofen for pain B) Frequency of urination has increased C) Mild red rash has developed over torso D) Nausea occurs after each dose

C) Mild red rash has developed over torso Immediately discontinue drug is a rash occurs as these rashes could develop into severe fatal hypersensitivity, such as Stevens Johnson syndrome. Similar instruction are for anticonvulsants (carbamazepine, phenytoin, lamotrigine) and sulfa antibiotics

The nurse is performing rounding on clients in restraints. Which situation would require immediate intervention by the nurse? A) client in a belt restraint in the semi Fowler position B) client in mitten restraints in the side lying position C) client in soft wrist restraints in the supine position D) client in vest restraint in the high Fowlers position

C) client in soft wrist restraints in the supine position Restrained clients are at risk for aspiration when supine. They cannot safely swallow expel, secretions or emesis. They should be placed in side lying, semi Fowler, or high fowler position.

The LPN is working with a RN to care for a client who has just returned to the cardiac unit after having a percutaneous coronary intervention. Which actions by the RN should the LPN question as outside of their scope? A) administering oral pain meds B) checking for bleeding at catheter site C) performing post procedure, vital signs D) reinforcing instructions to keep involved extremity straight E) reviewing ECG for dysrhythmias

C) performing post procedure, vital signs E) reviewing ECG for dysrhythmias The RN should perform initial assessments like vital signs and review the ECG for dysrhythmias. If the client is stable, the RN may delegate it to the LPN. LPNs can monitor the RNs findings, reinforce education, routine, procedure, most medication's, ostomy care, tube patency and feedings

The nurse has attended a staff education program about interdisciplinary communication. The nurse should recognize that the most important outcome is effective interdisciplinary communication is. A) increase client satisfaction B) improved education of clients C) reduce number of medical errors D) decreased length of hospital stay

C) reduce number of medical errors

For the findings below, click to specify if the finding is consistent with the expected action of the medication carvedilol, enalapril, or furosemide. May support more than one medication. Decreases HR Increased urinary output Decreases BP Increases O2 saturation

Carvedilol: Decreases HR and Decreases BP Enalapril: Decreases BP Furosemide: Increased urinary output, Decreases BP and Increases O2 saturation Beta blockers (carvedilol) reduce cardiac workload and decrease myocardial oxygen demand by DECREASING BP and DECREASING HR Angiotensin-converting enzyme (ACE) inhibitors (enalapril) reduces circulating aldosterone, promoting vasodilation resulting in DECREASED BP. Aldosterone retains Na and water promoting vasoconstriction, we want to use ACE inhibitors to prevent the release of aldosterone. Loop diuretics (furosemide) prevent the reabsorption of Na and Cl in the kidneys, INCREASING URINE OUTPUT and fluid excretion. Decreases in fluid volume will DECREASE BP and reduce pulmonary edema (INCREASE O2 SATURATION) Management of HF focuses on reducing cardiac workload and improving cardiac output.

The client is diagnosed with acute post infectious glomerulonephritis. The client is most at risk for __________ and ____________. Lab values include elevated BUN, serum creatinine, positive urine protein and RBC casts Hemorrhagic cysts Cerebral edema Pyelonephritis Pulmonary edema

Cerebral edema, and Pulmonary edema Results in decreased glomerular filtration resulting in systemic sodium and fluid retention.

The nurse is preparing to administer scheduled medication's to assigned clients. Which of the following medication should the nurse hold for classification prior to administration?

Clopidogrel for a client with a platelet count of 70,000 mm3 (70 x 10/L) It is a platelet inhibitor used to prevent clots. It can cause thrombocytopenia and increase a clients risk for bleeding. A cause for concern and clients with low platelets.

A nurse has received a new medication prescription for a client admitted with HTN of COPD. Which prescription should the nurse question? A) amlodipine B) codeine C) ipratropium D) methylprednisone

Codeine A narcotic medication that can cause accumulation of secretions in COPD AND LEAD TO RESPIRATORY DISTRESS. CCBs- treat HTN do not worsen bronchoconstriction Ipratropium- bronchodilator to reduce bronchospasm Prednisone- improves respiratory symptoms in COPD exacerbations

The nurse is talking with the parent of a 1-day-old newborn who had a circumcision using the plastic ring method. Which of the following statements by the parent would require follow-up? A) I will contact the HCP if bleeding does not stop with gentle pressure B) I should avoid using alcohol based cleansing wipes during diaper changes C) I need to leave the device in place and allow it to fall off on its own D) I understand that yellow exudate on the area is a sign of infection

D Yellow exudate on the glans penis after circumcision indicates normal healing, unusual swelling, increasing redness, odor, abnormal discharge, or excessive bleeding should be reported

The nurse is talking with the parents of a 7-year old client with newly diagnosed type 1 DM. Which statement by the parents would indicate effective coping? A) "Our child may not be able to participate in any sporting activities." B) "Our whole family is willing to make sacrifices for our child's health." C) "We will make separate meals for our child to accomodate any dietary needs." D) "We are working to manage this condition so that our child can have an independent life."

D) "We are working to manage this condition so that our child can have an independent life." DM can impact the entire family, when parents say that the client can be in control of the condition it is increasingly likely for it to be well managed and the child may live and independent life.

A client with multiple sclerosis is voicing concerns to the nurse about incoordination when walking. Which instruction by the nurse would be most appropriate at this time? A) "Avoid excess stretching of your lower extremities." B) "Build strength by increasing the duration of daily exercise." C) "Let me speak to your HCP about getting a wheelchair." D) "You should keep your feet apart and use a cane when walking."

D) "You should keep your feet apart and use a cane when walking." Gait training and assistive devices can help prevent falls ad injury while providing independence for as long as possible.

A nurse in the gynecology clinic is reviewing client histories. Which report would be MOST concerning to the nurse? A) 25 year old who reports a fish-like vaginal odor for the past month B) 30 year old client with an IUD who report heavy bleeding with menses C) 40 year old client with endometriosis who reports pain during intercourse D) 60 year old client who reports bloating and pelvic pressure for the past two months.

D) 60 year old client who reports bloating and pelvic pressure for the past two months. Ovarian cancer results in more deaths than other gynecologic cancers. Symptoms are subtle may present with bloating, early satiety, urinary symptoms (pressure on the bladder), and pelvic pressure.

The nurse is caring for a client diagnosed with a DVT 1 day ago. Which action by the client would require immediate intervention by the nurse? A) Ambulates through the hallway several times per day B) Applies a warm compress to the site of inflammation C) Elevates the limb above the level of the heart when in bed D) Massages the affected leg to reduce pain and swelling

D) Massages the affected leg to reduce pain and swelling Massaging the site might lead to development of a life threatening pulmonary embolism. DVT interventions include anticoagulants, warm compress, elevation of limb, early ambulation.

A client with borderline personality disorder says to the nurse, What is the priority nursing action? A) Assign different staff members to care for the client each day B) Assign the client's stated preferred nurse to care for the client C) Reassure the client that all staff members are competent in their jobs D) Reinforce unit guidelines and appropriate boundaries with the client

D) Reinforce unit guidelines and appropriate boundaries with the client BPD is characterized by intense impulsivity and emotional dysregulation combined with unstable relationships and self image. They fear abandonment and rejection. Use manipulative behavior for control (flattery or distancing) Splitting is a defense mechanism where BPD patients hold opposing thoughts and perceive people or events as "all good" or "all bad." Staff should prevent this by calmly reinforcing unit guidelines and appropriate boundaries.

A 4 year old admitted with Wilms tumor is scheduled for a right nephrectomy in the morning. Which nursing action is PRIORITY pre-operatively? A) Assessment of the child's emotional maturity level B) Auscultating for adventitious breath sounds C) Monitoring BP closely D) Reinforcing instructions not to palpate the abdomen

D) Reinforcing instructions not to palpate the abdomen Diagnosis is made by ultrasound and the ABDOMEN SHOULD NOT BE PALPATED as this can disrupt the encapsulated tumor. Wilms tumor is noted as bulging/swelling on one side of a child's abdomen.

A client being discharged with pans to return home alone. The client can not get up from a chair without help and is very unsteady, even with a walker. The nurse expresses concern, but the PHP is adamant that the client be d/c today. What team member would be most appropriate to assist the nurse with advocating? A) Clinical psychologist B) Occupational therapist C) Physical therapist D) Social worker

D) Social worker Social worker and case manager have expertise in d/c planning, goal is for safe, effective discharge planning. Like exploring alternative discharge methods home.

A Spanish speaking client is admitted for a small bowel obstruction. The surgeon explains to the client's child, who speaks both English and Spanish, that a exploratory laparotomy is needed to determine the cause of obstruction and the possible causes include intestinal adhesion and ovarian or colon cancer. The surgeon asks the client to translate this information for the client and assist with translating the consent ,For, Which action of the nurse would be most appropriate? A) Act as a witness for informed consent B) Reinforce information about what the client can expect C) Report the surgeon to the ethics board for using inappropriate consent process D) Talk to the surgeon privately about using a trained Spanish language medical interpreter.

D) Talk to the surgeon privately about using a trained Spanish language medical interpreter. Advocating for clients includes the use of interpreters for client's who speak a different language, family members should not be used as an interpreter should have fluency in the language, an understanding of cultural beliefs and nuances, training in medical terminology and procedures, and an ability to understand and protect the client's rights (HIPPA)

The nurse is monitoring a client who had an esophagogastroduodenoscopy 2 hour ago. Which findings requires immediate report to the RN. A) BP drop from 122/88 to 106/72 mm Hg B) Gag reflex has not returned C) Sore throat when swallowing D) Temp spike to 101.2 F

D) Temp spike to 101.2 F Sign of infection!

The nurse inserts a small-bore NG tube and prepares to initiate enteral feedings for a client hospitalized with laryngeal cancer. Which action should the nurse take first? A) Crush and administer medications B) Dilute the enteral formula as prescribed C) Flush the tube with 30 mL of water D) Verify tube placement with an x-ray

D) Verify tube placement with an x-ray x-ray is the standard protocol for ensuring tube placement prior to initiating tube feedings.

The nurse is caring for an ambulatory client who has a new order for continuous cardiac monitoring via a portable unit. It would require follow-up if the nurse. A) verifies that gel is present on each electrode and is not dried out B) cleanses and dries skin before placing the electrodes on the client C) clips excessive hair off the client before applying the electrodes D) places on electrode each on the client's upper and lower extremities.

D) places on electrode each on the client's upper and lower extremities. The electrodes are placed on the client's torso, avoiding irritated skin, scare, or implanted devices. They are not placed on the limb dues to movement causes a false reading on the monitor. This is only for 12-lead ECG, while the client is stationary.

The nurse is reinforcing teaching for a client who is a college athlete and was recently diagnosed with moderate persistent asthma. The nurse should instruct the client to avoid. A) penicillin B) latex products C) strenuous physical activity D) second hand smoke exposure

D) second hand smoke exposure

The nurse should prioritize interventions for acute decompensated heart failure to reduce the risk of the client developing ____________ and ____________. Disseminated intravascular coagulation Bacterial endocarditis Empyema Dysrhythmias Acute kidney injury (AKI)

Dysrhythmias and Acute kidney injury (AKI). Dysrhythmias are due to structural changes altering the electrical activity of the heart. AKI is due to hypo-perfusion (decreased perfusion) of vital organs secondary to decreased cardiac output. Both complications of decompensated HF. Empyema is pus in the pleural cavity due to bacteria in the lungs, HF can cause pleural effusions, but empyema is not an expected finding. Bacterial endocarditis can precipitate HF, but this client shows no signs of infection. DIC is a life threatening condition from abnormal blood clotting. Caused by sepsis and trauma, HF is not a common cause.

For each potential intervention, click to specify if the intervention is expected or not expected for the care of the client. Potential interventions: Daily weights, IV furosemide, Fluid restriction, Supplemental oxygen, Antihypertensive medications, nebulized albuterol breathing treatments.

Expected: Daily weights, IV furosemide, Fluid restriction, Supplemental oxygen, Antihypertensive medications. Not expected: nebulized albuterol breathing treatments Expected interventions for decompensated HF focus on reducing the cardiac workload and improving oxygenation. Nebulized albuterol is a bronchodilator to improve oxygenation in clients with reactive airway disease (COPD, asthma). They will not improve oxygenation in clients with pulmonary edema and are NOT expected for treatment of HF.

The nurse is caring for a 63-year-old. ED (1 week ago) client is admitted to the hospital with dyspnea orthopnea bilateral leg swelling. The client has HTN, HF, and CKD. Meds include furosemide, hydrochlorothiazide, lisinopril, metoprolol Today client is discharge from the hospital after treatment for HF symptoms improved after treatment with diuretics. Today new onset muffled hearing and difficulty understanding speech. Bilateral hearing loss. Which med should be clarified with the HCP

Furosemide Ototoxicity is an adverse effect of loop diuretics that can lead to permanent hearing loss. ACE risk fx (dry cough, hyperkalemia) BETA BLOCK (Bradycardia, bronchospasm, rebound HTN) Thiazide (electrolyte abnormalities)

The nurse is caring for the schizophrenic client 6 days after admission. For each finding click to specify whether the finding indicates that the client's status had Improved or Not Improved. Client is seen talking alone in the hallway Client is seen playing board games with peers Client asks the technician for hygiene supplies Client states, "The voices are a part of my illness." Client refuses to take medication from a new nurse

IMPROVED: -Client is seen playing board games with peers, -Client asks the technician for hygiene supplies, -Client states, "The voices are a part of my illness." NOT IMPROVED: -Client is seen talking alone in the hallway -Client refuses to take medication from a new nurse

The nurse is preparing to obtain the newborn's first capillary blood glucose level. For each nursing action, specify if it is INDICATED or NOT INDICATED for the newborn heel stick. Warm the heel prior to initiating the procedure Collect the first drop of blood for blood glucose testing Draw blood by pricking the skin with a small needle Obtain the specimen from the lateral aspect of the heel Clean the heel with alcohol prep pad prior to obtaining the specimen.

INDICATED: -Warm the heel prior to initiating the procedure (promote vasodilation), -Obtain the specimen from the lateral aspect of the heel (side to prevent injury to nerves), -Clean the heel with alcohol prep pad prior to obtaining the specimen NOT INDICATED: -Collect the first drop of blood for blood glucose testing (falsely low reading) -Draw blood by pricking the skin with a small needle (automatic lancet controls depth of puncture)

The nurse is caring for a 28-year old client in the maternal health clinic. The client has had right breast pain, fever, chills, fatigue, and increased pain while breastfeeding her newborn for the past two days. Physical assessment shows erythema, induration, and tenderness of the right breast. the left breast has no abnormalities. For each potential intervention, click to specify if the intervention is indicated or not indicated for the care of the client. Administer antibiotics Increase daily fluid intake Encourage the client to take NSAIDs for pain Apply a warm compress to the affected breast Discontinue breastfeeding until symptoms resolve

Indicated: -Administer antibiotics, -Increase daily fluid intake, -Encourage the client to take NSAIDs for pain , -Apply a warm compress to the affected breast Not indicated: Discontinue breastfeeding until symptoms resolve Lactation mastitis is infection and inflammation of breast tissue that may result from inadequate milk duct drainage or poor breastfeeding technique. Staphylococcus aureus is the most common causative organism and requires treatment with antibiotics. For lactational mastitis increase daily fluid intake, relieve pain with NSAIDs or acetaminophen, apply a warm compress to facilitate emptying, ensure proper breastfeeding technique. Discontinue breastfeeding until symptoms resolve is NOT INDICATED. continue breastfeeding frequently to ensure adequate milk drainage and to relieve milk duct obstruction. The infant can safely breastfeed from the infected breast because they already have colonized with maternal microorganisms.

For each potential intervention, click to specify of the intervention is indicated or not indicated for the care of the client with preeclampsia. Initiate seizure precautions Encourage frequent ambulation Start a magnesium sulfate infusion Prepare to administer antihypertensive

Indicated: -initiate seizure precautions, -Start a magnesium sulfate infusion, -Prepare to administer antihypertensive Not indicated: -Encourage frequent ambulation