NCLEX practice questions

What is the most common SE of Metformin to include in pt teaching for a newly dx T2DM pt prescribed this med?

GI disturbances

What does the lipid panel include and what is it used for?

Includes: HDL, LDL, Triglycerides, and Total Cholesterol Key part of ambulatory care when the goal is to establish adequate lipid levels to reduce the risk of clients having a serious atherosclerotic disease such as heart disease and stroke. ***Something key to note is that HDL values are better when higher while the other values should be lower.

A nurse provides teaching to a pt who is prescribed spironolactone. The nurse should limit the intake of which of the following foods? (Select all that apply) A) Bananas B) White rice C) Tomatoes D) Avocados E) Sweet potatoes

A) Bananas C) Tomatoes D) Avocados E) Sweet potatoes Limit foods high in potassium - spironolactone is K-sparing diuretic

Which foods are appropriate recommendations for a pt on phenelzine? A) Broccoli B) Yogurt C) Cream cheese D) Bologna sandwich E) Pepperoni pizza

A) Broccoli B) Yogurt C) Cream cheese Phenelzine - MAOI - should avoid foods containing tyramine such as fermented meats

Which of the following lab tests should be ordered for a client who presents with symptoms such as fever, difficulty breathing, and altered mental status? A) CBC and BNP B) Coagulation panel C) Acetaminophen drug level screen D) INR

A) CBC and BNP

Which condition is a risk factor for glaucoma? A) Cardiovascular disease B) Frequent UTIs C) Hx of migraines D) Frequent upper respiratory infections

A) Cardiovascular disease

The nurse is preparing to care for a pt who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube? A) Deflate the cuff on the tube B) Place the inner cannula into the tube C) Ensure the pt is able to speak D) Ensure pt is able to swallow

A) Deflate the cuff on the tube Plugging off the trach tube allows airflow and respirations to occur normally through the nose and the mouth. The cuff must be deflated before plugging. If it remains inflated, ventilation cannot occur and respiratory arrest could result. The ability to swallow or speak in unrelated to weaning and plugging of the tube.

A pt is prescribed clozapine. The nurse should monitor for which of the following complications? A) dyslipidemia B) osteoporosis C) HTN D) thrombocytopenia

A) Dyslipidemia Clozapine (2nd generation antipsychotic) can cause a group of closely linked metabolic effects: - dyslipidemia - weight gain - DM

A nurse provides care to a pt who is admitted for sepsis. Which of the following circumstances requires an occurrence report? (Select all that apply) A) Eye glasses are lost B) Visitor falls in hallway C) Syncopal episode occurs D) Oxygen therapy is refused E) Blood cultures are positive

A) Glasses lost B) Visitor falls in hall Occurrence reports: for unexpected or unusual events not consistent with the operations of the health care unit or routine care of a pt - Include: loss of property, injuries, medical errors, needlestick injuries, accidental omission of therapies, and circumstances that risk client injury

A pt has a documented allergy to sulfamethoxazole-trimethoprim. The nurse should question the prescription for which of the following meds? A) Glipizide B) Sertraline C) Amoxicillin D) Loratadine

A) Glipizide Allergy to sulfonamide= - Contraindication to sulfonylurea-type oral hypoglycemic agents (glyburide, glipizide) - As well as thiazide diuretics (hydrochlorothiazide) - And loop diuretics (Furosemide)

A nurse should prepare to notify public health officials about which of the following pt infections? (Select all that apply) A) Gonorrhea B) Hep C C) Clostridium difficile D) Chlamydia trachomatis E) Meningococcal disease

A) Gonorrhea B) Hep C D) Chlamydia trachomatis E) Meningitis NOT: C. diff

Which of the following foods can be included in a clear-liquid diet? (Select all that apply) A) Hard candy B) Chicken broth C) Orange sherbet D) Chocolate pudding E) Vanilla milkshake F) Fruit-flavored gelatin

A) Hard candy B) Chicken broth F) Fruit-flavored gelatin *** clear liquid does not mean COLORLESS Hard candy is included because a pt can suck on it to relieve dry mouth and provide carbs in the form of sugar

To perform CPR, the nurse should use the method pictured to open airways in what situation? (Picture of a jaw thrust without the head tilt maneuver) A) If neck trauma is suspected B) In all situations requiring CPR C) If the pt has hx of seizures D) If the pt has hx of headaches

A) If neck trauma is suspected Using the maneuver of the jaw thrust without the head tilt opens the airway while maintaining proper head and neck alignment, reducing the risk of further damage to the neck.

A nurse is monitoring a pt for the development of paralytic ileus. Which piece of assessment should alert the nurse of this condition? A) Inability to pass flatus B) Loss of anal sphincter control C) Severe, constant pain with rapid onset D) Firm, nontender mass palpable at the lower R costal margin

A) Inability to pass flatus - Paralytic ileus is a non-mechanical bowel obstruction

Which of the following diseases require droplet precautions? (Select all that apply) A) Mumps B) Measles C) Varicella D) Pertussis E) Pneumonia

A) Mumps D) Pertussis E) Pneumonia

The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? Select all that appy. A) Nocturia B) Incontinence C) Enlarged prostate D) Nocturnal emissions E) Decreased desire for sexual intercourse.

A) Nocturia B) Incontinence C) Enlarged prostate These are characteristics of BPH and should be assessed for all males > 50 yrs. Nocturnal emissions (wet dreams) are associated with prepubescent males. This should not affect desire for sex; low testosterone levels would do this.

A nurse is caring for a pt who is at risk for suicide. What is the priority nursing action for this pt? A) Provide authority, action, and participation B) Display an attitude of detachment, confrontation, and efficiency C) Demonstrate confidence in the pt's ability to deal with stressors D) Provide hope and reassurance that the problems will resolve themselves

A) Provide authority, action, and participation This is a crisis that is acute, and time-limited resulting from stress. A person in this state is temporarily unable to cope or adapt to the stressor by using previous coping mechanisms. The person who intervenes in this situation "takes over" for the pt (authority) who is not in control and devises a plan (action) to ensure and maintain the pt's safety. When this has occurred, the nurse works collaboratively with the pt (participates) in developing new coping strategies. Key word: priority - A pt who experiences a suicidal crisis is in a state of acute disequilibrium - In a crisis, an authority figure must emerge to take action.

Before removing an NG tube, what statement should be made to the pt? A) Take a deep breath when I tell you, and hold it while I remove the tube B) Take a deep breath when I tell you, and bear down while I remove the tube C) Take a deep breath when I tell you, and slowly exhale while I remove the tube

A) Take a deep breath when I tell you, and hold it while I remove the tube Bearing down could inhibit removal of the tube, exhaling is not possible during removal, and breathing normally could result in aspiration of gastric secretions. Take a deep breath and hold it because the airway will be temporarily obstructed.

The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include what in the action plan? A) Ensure the knots are at the pulleys B) Check the weights to ensure they are off the floor C) Ensure HOB is kept 25-90 degrees D) Monitor the weights to ensure they are resting on a firm surface

B) Check the weights to ensure they are off the floor To achieve proper traction, weights need to be free-handing with knots kept away from the pulleys. The HOB is usually kept low to provide countertraction

A nurse participates in quality improvement to decrease hospital readmissions for clients who have HF. Which of the following actions should the nurse expect to perform? A) Discuss staff performance appraisals with the team B) Compare performance to current practice standards C) Reinforce evidence-based practice guidelines to staff D) Interview all nurses caring for clients who are readmitted

B) Compare performance to current practice standards The quality improvement process is designed to correct discrepancies between developed standards and actual performance. Once a standard is developed, approved, and made available to staff, quality issues can then be identified.

An infant born with an imperforate anus returns from surgery after requiring a colostomy. The nurse assesses the stoma and notes that it is red and edematous. Based on these findings, which action should the nurse take? A) Elevate the buttocks B) Document the findings C) Apply ice immediately D) Call the primary health care provider

B) Document the findings You would expect a fresh colostomy to be red and edematous, although this would decrease over time. After it has healed, a normal stoma should be pink without evidence of abnormal drainage, swelling, or skin breakdown.

Which of the following are risk factors for breast cancer? Select all that apply. A) Multiparity B) Early menarche C) Early menopause D) Family hx of breast cancer E) High-dose radiation exposure to chest F) Previous cancer of breast, ovaries, or uterus

B) Early menarche D) Fam hx E) Radiation E) Personal hx Risk factors for breast cancer include: - nulliparity or 1st child born after age 30 - early menarche (period) - Late menopause - family or personal hx - exposure to radiation - inherited mutations in BRCA 1 and 2 (BReast CAncer genes)

A pt who has COPD is prescribed ipratropium bromide. The nurse should instruct the pt to report which of the following symptoms immediately. A) Nausea B) Eye pain C) Dry mouth D) Constipation

B) Eye pain Ipratropium bromide = anticholinergic agent - can cause worsening of narrow-angle glaucoma - acute eye pain could indicate this AE

Which of the following should be included in teaching about the use of a cane? A) Move the stronger leg forward with the cane B) Hold the cane with the stronger side of the body C) Keep the cane handle within 5 cm (2inches) of waist level D) Place cane 30 cm (12 inches) in front of foot

B) Hold cane with stronger side of body Also: - hold at level of the greater trochanter - place 15-25 cm (6-10 inches) in front of foot

Which of the following lab tests should be ordered for a client who presents with extensive bruising on their arms and legs with bloody urine and stool? A) Phenytoin drug level screen B) INR and aPTT C) Lipid panel D) A1C screening

B) INR and aPTT

A pt who has DVT is receiving a heparin infusion. Current lab values include an aPTT of 40 seconds. Which of the following actions should the nurse take? A) Stop the infusion B) Increase the infusion C) Decrease the infusion D) No change in the infusion

B) Increase the infusion Normal range for aPTT = 30-40 seconds - BUT therapeutic levels are usually 1.5 to 2x normal control levels ?????

A client with HIV gives birth to a newborn. The nurse provides instructions to help the care with care for her infant. Which client statement indicates the need for further instruction? A) "I will be sure to wash my hands before and after bathroom use." B) "I need to breastfeed, especially for the first 6 weeks postpartum" C) " Support groups are available to assist me with understanding of my dx of HIV" D) My newborn infant should be on antiviral meds for the first 6 weeks after delivery"

B) "I need to breastfeed, especially for the first 6 weeks postpartum." HIV transmission can occur during breastfeeding. HIV positive moms are encouraged to bottle-feed. The rest of the answers are TRUE (looking for false statement)

During the first few hours post-op thoracic surgery in which chest tubes were placed, the nurse should expect what type of drainage? A) Serous B) Bloody C) Serosanguineous D) Bloody, with frequent small clots

B) Bloody Within the first few hours after thoracic surgery, drainage will be bloody. After several hours, it will become serosanguineous. There should never be frequent clotting.

Which of the following indicates understanding of DC teaching for a client newly dx with T1 DM about storing Humulin N insulin? A) "I should keep the insulin in the cabinet during the day only" B) "I know I have to keep my insulin in the fridge at all times" C) "I can store the open insulin bottle in the kitchen cabinet for 1 month" D) "The best place for my insulin is on the windowsill"

C) "I can store my open insulin bottle in the kitchen cabinet for 1 month" Direct sunlight and heat should be avoided. The insulin should be kept in the fridge, but once opened can stay good in the cabinet at room temperature for 1 month.

A client received 20 units of Humulin N insulin SubQ at 08:00. At what time should the nurse plan to assess the client for a hypoglycemic reaction? A) 10:00 B) 11:00 C) 17:00 D) 24:00

C) 17:00 Humulin N is an intermediate acting insulin with a peak of 6-14 hours, which is the time that you check for hypoglycemia.

What does the "coagulation panel" include and what is it used for?

Includes: INR (warfarin) & aPTT (heparin) Commonly ordered for clients on anticoagulation therapy like warfarin, direct oral anticoagulants, heparin, and in clients at risk for developing a clot. -Overdosing can lead to serious bleeding and potentially death. -Underdosing can also lead to increased risk of clot formation causing MI, stroke, or pulmonary embolism.

What to do for a child with a lead level of 3? - Initiate chelation therapy - Notify poison control - Refer family to social services - Set up rescreening in one year

Rescreen in one year - 3 is still within normal range - refer to social services if higher than 5 - chelation therapy if over 45 - poison control notified if over 20

A nurse is caring for a client with Addison's disease. Which of the following diets should the nurse teach the client to follow? a. Low Sodium, high potassium and decreased fluids. b. Low Sodium, high calcium and decreased fluids. c. High Sodium, low potassium and increased fluids. d. High Sodium, low calcium and increased fluids.

c. High sodium, Low K, Increased fluids Low sodium, high K, decreased fluids: for Cushing's

A nurse is caring for a client with a new onset bowel obstruction. What assessment finding would be anticipated when completing an abdominal assessment? a. Hypoactive bowel sounds. b. Normal bowel sounds. c. Hyperactive bowel sounds. d. Absent bowel sounds.

c. Hyperactive bowel sounds A - Hypoactive bowel sounds may be found in later stages of obstruction, but hyperactive bowel sounds are typical in early stages of obstruction.

What color drainage from the NG tube would you report to the doctor 24hrs post-op gastric surgery?

dark red -First 12 hrs: should expect dark red to dark brown - Later: should change to light-yellowish brown - Presence of bile could cause green tinge - Dark red at 24 hrs could indicate hemorrhage

A nurse is providing education to a client diagnosed with glaucoma. The nurse should instruct the client to avoid which of the following medications? Select all that apply. a. Methylphenidate b. Acetazolamide c. Timolol maleate d. Scopolamine e. Diphenhydramine

e. Diphenhydramine, a. Methylphenidate, d. Scopolamine Methylphenidate is a sympathomimetic amine; cholinergic inhibition (avoid) Acetazolamide: Used to treat glaucoma: carbonic anhydrase inhibitor; decrease the rate of aqueous humor production Scopolamine: Atropine derivative, causes pupil dilation, anticholinergic (avoid) Diphenhydramine: blocks the action of acetylcholine; anticholinergics (avoid)

A client is recovering from acute respiratory distress syndrome (ARDS). Which clinical manifestation requires immediate attention by the nurse? a. A decrease in temperature b. Increase in pulse rate c. A decrease in blood pressure d. Increased oxygen saturation

c. Decrease in BP B - An increase in a client's pulse rate is a finding that needs additional data collection because it may be indicative of an autonomic response to pain, anxiety, and other

Which anatomical area provides the best data regarding the presence of jaundice in a child?

Nail beds - Jaundice is best assessed (for anyone) in the sclera, nail beds, or mucous membranes

The nurse is contributing to a staff education program about advance directives. Which of the following information should the nurse suggest including in the program? Select all that apply. 1. "A living will provides information about the client's wishes regarding medical treatment." 2. "Health care facilities are required to provide clients with information about advance directives." 3. "Advance directives are legally binding and cannot be changed by the client once they are written." 4. "It is unnecessary to have a power of attorney for health care if the client already has a living will." 5. "A power of attorney for health care allows a designated person to make health care decisions for the client when the client is unable to do so."

1) "A living will provides info about the client's wishes regarding medical tx" 2) "Health care facilities are required to provide clients with info about advanced directives 5) "A power of attorney for health care allows a designated person to make health care decisions for the client when the client is unable to do so"

The nurse is assisting to evaluate the coping strategies of the spouse of a client who had a stroke 5 days ago. Which of the following statements by the spouse would indicate ineffective coping? 1. "I sleep only for short periods of time since my spouse became ill." 2. "I feel frustrated when my spouse turns away and will not talk with me." 3. "I eat meals in my spouse's room so my spouse will not have to eat meals alone." 4. "I have been performing a few household chores each day before visiting my spouse."

1) "I sleep only for short periods of time since my spouse became ill"

The nurse has reinforced teaching with a client with schizophrenia who is receiving prescribed olanzapine. Which of the following statements by the client would indicate a correct understanding of the teaching? 1. "The medication may cause dry mouth." 2. "I should consume a low-residue diet while taking olanzapine." 3. "Restlessness and agitation are common side effects of olanzapine." 4. "I will have a blood specimen obtained to monitor the therapeutic level of the medication."

1) "The med may cause dry mouth"

The nurse has reinforced teaching with the parents of a 2-day-old, full-term newborn. Which of the following statements by a parent would indicate a correct understanding of the teaching? 1. "The swollen area on the side of my baby's head will go away on its own." 2. "The primary health care provider will measure my baby's head circumference every week." 3. "The elevated, red birthmark on my baby's head will be removed if the birthmark gets bigger." 4. "The fontanel at the front of my baby's head should be indented when my baby is held upright."

1) "The swollen area on the side of my baby's head will go away on its own"

Which drug levels does "Simple Nursing" recommend knowing for the NCLEX?

1) Acetaminophen: 10-25 2) Digoxin: 0.8-2 3) Lidocaine: 1.5-5 4) Lithium: 0.6-1.2 5) Phenobarbital: 10-40 6) Phenytoin: 10-20 7) Theophylline: 5-15 8) Vancomycin: 10-20

The nurse notes that the primary health care provider has prescribed sulfamethoxazole and trimethoprim for a client. Which priority action should the nurse take before administering this medication? 1. Ask the client about an allergy. 2. Call the pharmacy to obtain the medication. 3. Inform the client about the need to increase fluid intake. 4. Check the medication supply room to find out whether the medication needs to be obtained from the pharmacy.

1) Ask the client about an allergy

A pt is to receive morphine 4mg IV bolus through an existing continuous infusion. Identify the correct sequence of actions the nurse should follow when administering the med. A) Inject medication B) Withdraw syringe C) Aspirate for blood return D) Connect syringe to IV E) Clean port with antiseptic swab F) Pinch tubing above injection port

1) Clean port with antiseptic swab 2) Connect syringe to IV line 3) Pinch tubing above injection port 4) Aspirate for blood return 5) Inject medication 6) Withdraw syringe

What precautions to take for pneumonia? 1) Droplet 2) Airborne 3) Contact 4) Protective environment

1) Droplet - place pt in private room and wear surgical mask during care 2 - Airborne for varicella zoster (shingles) or measles 3 - Contact for infection with multi-drug resistant organisms or major wound infections (MRSA) 4 - Protective environment for immunocompromised

A client taking amitriptyline hydrochloride calls the nurse at the primary health care provider's office and reports that he has an upset stomach whenever he takes the medication. What information should the nurse provide to the client? 1. Take the medication with food. 2. Take the medication with an antacid. 3. Take the medication on an empty stomach. 4. Stop the medication for 2 days and then resume the medication schedule.

1) Take the medication with food - Data in question=client's complaint of an upset stomach - Recall that antacids interfere with absorption: eliminates 2 - Nurse should not recommend discontinuation for nausea: eliminates 4 - Data in question of "upset stomach": eliminates 3

A nurse should monitor a pt for which adverse effects of PEEP? 1) Hypoxia 2) Tension pneumothorax 3) Malignant HTN 4) Atelectasis

2) Tension pneumothorax - monitor lung sounds hourly and assess for s/s such as tracheal deviation, absent breath sounds, and distended neck veins 1 - PEEP treats hypoxia 3 - Pt on mechanical ventilation is at risk for hypotension r/t increased chest pressure and decreased blood return to heart 4 - PEEP treats atelectasis

The nurse is caring for a client with peptic ulcer disease (PUD) who vomited 150 mL of blood-tinged green liquid. Which of the client's laboratory test results would be a priority to check? 1. serum pH 2. hematocrit (HCT) 3. serum sodium level 4. blood urea nitrogen (BUN)

2) hematocrit (HCT)

The nurse is reinforcing teaching about daily exercise with a client with diabetes mellitus (type 2). The nurse should reinforce which of the following as benefits of daily exercise? Select all that apply 1. prevents hypoglycemia 2. improves blood circulation 3. reduces the need for insulin 4. decreases the need to regulate food intake 5. lowers serum cholesterol and triglyceride levels

2) improves blood circulation 3) reduces the need for insulin 5) lowers serum cholesterol and triglyceride levels

The nurse is caring for a client with hypercalcemia. The following nursing intervention should be included to minimize complications for the client. 1. cough and deep-breathe 2. increase the oral fluid intake 3. eat high-protein, between-meal snacks 4. perform active range-of-motion (ROM) exercises

2) increase the oral fluid intake

Instructions to give mom 24 weeks gestation before a 3 hour oral glucose tolerance test 1) restrict fat for 72 hours before 2) will need to fast the night before 3) will need to collect urine sample day after 4) blood sample will be taken every 15 minutes during test

2) will need to fast the night before - prevents inaccurate results

The nurse is reinforcing teaching with a female client who is receiving prescribed atorvastatin. Which of the following information should the nurse reinforce? 1. "Maintain your usual diet while taking the medication." 2. "Continue to take atorvastatin if you become pregnant." 3. "Report muscle aches to your primary health care provider." 4. "Take the medication 1 hour before or 2 hours after a meal."

3) "Report muscle aches to your primary health care provider" ^^Rhabdomyolysis

The nurse is contributing to the plan of care of a client with mild Alzheimer's disease (AD) who has recently started wandering and spends approximately 6 hours each day sleeping. Which of the following outcomes would be appropriate for the nurse to recommend for the client's plan of care? 1. The client will stop wandering. 2. The client will take 2 to 3 naps during the day. 3. The client will wander within designated areas. 4. The client will identify the impact of activity on the sleep cycle

3) The client will wander within designated areas

The nurse is reinforcing teaching with a client about using crutches. Which of the following information should the nurse reinforce? 1. "The stairs should be avoided while using crutches." 2. "The elbows must stay straight while ambulating with crutches." 3. "Three finger widths should separate the axillae and the crutches." 4. "Bearing weight on the affected leg should be avoided when using the four-point crutch gait."

3) Three finger widths should separate the axillae and the crutches 4> incorrect because four-point-gait requires some weight bearing on all 4 limbs (both crutches and both limbs)

The nurse is reinforcing teaching with a client about the signs of hunger in a newborn. Which of the following signs should the nurse reinforce? Select all that apply. 1. open hands 2. quivering bottom lip 3. rooting movements 4. sucking on the hands 5. hand to mouth movements

3) rooting movements 4) sucking on hands 5) hand to mouth movements

The nurse is talking with a client who had a subtotal gastrectomy 1 month ago. Which of the following statements by the client would be a priority to follow up? 1. "I occasionally take an over-the-counter (OTC) laxative." 2. "I eat several small meals each day." 3. "I avoid drinking liquids with meals." 4. "I feel tired all the time."

4) "I feel tired all the time"

Priority nursing action 24 hrs post-op abdominal surgery 1) Monitor incision site for s/s infection 2) Assess fluid intake Q24H 3) Ambulate 3x a day 4) Assist with deep breathing and cough

4) Assist with deep breathing and cough ABCs- deep breathing / coughing helps prevent post-op pneumonia

The nurse is caring for a client who has an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which of the following infection control precautions should the nurse implement? 1. Wear a surgical mask when changing the client's abdominal wound dressing. 2. Limit the amount of time that visitors spend with the client to 30 minutes each shift. 3. Place a surgical mask on the client when transporting the client to the radiology department. 4. Check the client's blood pressure by using a stethoscope designated for the client's use only.

4) Check the client's BP by using a stethoscope designated for the client's use only

What action should the nurse take for a pt with continuous bladder irrigation and decreased UO through their catheter with continuous bladder spasms? 1) Remove the catheter immediate 2) Assist the pt to ambulate 3) Increase tension on the catheter 4) Irrigate the catheter with 0.9% sodium chloride irrigation

4) Irrigate cath with 0.9% sodium chloride - these s/s indicate internal obstruction, therefore irrigate then notify doc if it doesn't clear it - removing cath can cause further harm - should keep pt in bed

A client with a history of duodenal ulcer is admitted to the hospital with status asthmaticus. Which of the following medications should the nurse question? Select all that apply. 1) furosemide 2) prednisone 3) sucralfate 4) Lisinopril 5) naproxen

5) Naproxen 2) prednisone Naproxen (NSAID) can contribute to gastric irritation Corticosteroids such as prednisone are associated with an increased incidence of peptic ulcers and thus should be questioned if prescribed to a client with a history of duodenal ulcer.

A pt with hypothyroidism is prescribed levothyroxine. The client's chart shows they also are taking warfarin. Which modification should the nurse suggest to the primary health provider?

A decreased dosage of warfarin

A client presents to the ED with upper GI bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? A) Assessment of VS B) Completion of abdominal examination C) Insertion of the prescribed NG tube D) Thorough investigation of precipitating events

A) Assessment of VS VS should be checked before performing procedure; will provide info about amount of blood loss and provide a baseline to monitor tx prioritization: ABC's

The nurse has reviewed with the pre-op pt the procedure for administering an enema. Which statement by the pt would indicate the need for further instruction? A) "The enema will be given while I am sitting on the toilet" B) "I should try and hold the fluid as long as possible after it is run in" C) "I know there will be some cramping after the enema solution is run in" D) "I should tell the nurse if cramping occurs when the fluid is running in"

A) "The enema will be given while I am sitting on the toilet" An enema is never administered while on the toilet. It is always administered with the pt L side-lying (Sims' position) with the R knee flexed. It is important for the pt to retain the fluid for as long as possible for it to have the most effect. A faster flow into the rectum could cause cramping.

Which of the following are appropriate topics for a school nurse to teach during a course about heath and safety for 11-year-old students? (Select all that apply) A) Activity and exercise B) STIs and pregnancy C) Alcohol and drug use D) Memory and cognition E) Peer pressure and violence F) Eating disorders and nutrition

A) Activity and exercise B) STIs and pregnancy C) Alcohol and drug use E) Peer pressure and violence F) Eating disorders and nutrition All of the options EXCEPT memory and cognition > not relevant to this age group Middle schoolers: - Puberty between 9-12 yrs > may become sexually active - activity and exercise duh - peer pressure in middle school > also crosses over into pressure to use alcohol and drugs - Eating disorders most common in females during adolescence

A pt who has acute pulmonary edema is to receive furosemide 40 mg IV. Which of the following is an appropriate action by the nurse? A) Administer over 2 minutes B) Dilute with NS C) Monitor the pt for hyperkalemia D) Determine if the pt has peripheral edema

A) Administer over 2 minutes - furosemide is administered, undiluted, over 1-2 minutes for this low dose - higher doses require continuous infusion at a rate of 4mg/min Furosemide: may cause hypokalemia (not hyperkalemia)

The home care nurse is visiting a pt who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the pt to the cast. Which is the most appropriate assessment for this pt? A) The need for sensory stimulation B) The amount of home care support available C) The ability to perform ADLs D) The type of transportation available for f/u care

A) The need for sensory stimulation A psychosocial assessment of a pt who is immobilized should include the need for sensory stimulation, as well as body image, past and present coping skills, and coping methods used during this period. The others are not related to specifically the psychosocial adjustment.

After performing an initial abdominal assessment on a pt with n/v, the nurse should expect which finding? A) Waves of loud gurgles auscultated in all 4 quadrants B) Low-pitched swishing auscultated in 1 or 2 quadrants C) Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants D) Very high-pitched, loud rushes auscultated especially in 1 or 2 quadrants

A) Waves of loud gurgles auscultated in all 4 quadrants - Normal bowel sounds: relatively high-pitched clicks or gurgles - Loud gurgles (borborygmi) = indicate hyperperistalsis & are common with n/v - Swishing or buzzing = turbulent blood flow (bruit) - Very high-pitched and loud = intestines are under tensions (ex: intestinal obstruction) Remember: bowel sounds are normally audible in all 4 quadrants > so eliminate B and D

Where should you assess a 2 month old for Hirschsprung's disease? (hot spot)

Abdomen - for distension and visible peristalsis (s/s)

A nurse is caring for a pt who is agitated. Which of the following actions would be appropriate to implement? (Select all that apply) A) Restrain the pt B) Reduce room noise C) Play soothing music D) Assess for urinary retention E) Administer a benzodiazepine

All except restrain - Urinary retention, constipation, and pain are reversible causes of agitation to assess for - Administration of a benzo may be necessary if cannot decrease agitation by reversing physical causes - Reducing room noise can reduce agitation - Soothing music promotes relaxation and reduces agitation ***Pt is not said to be violent > no reason to restrain

What is an ABG used for?

Arterial blood gases are important lab values to understand, especially when evaluating clients in critical condition. These labs determine the acidity and alkalinity of the blood and can help in the diagnosis of many different types of conditions.

Is threatening assault or battery?

Assault : threatening or attempting to injure

Which lab result should the nurse expect if a pt does have appendicitis? A) Leukopenia with a shift to the L B) Leukocytosis with a shift to the L C) Leukopenia with a shift to the R D) Leukocytosis with a shift to the R

B) Leukocytosis with a shift to the L With appendicitis, there is often an elevation of WBC (leukocytosis) with a shift to the L (an increased number of immature WBCs)

The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care for a pt with laryngeal cancer who had a laryngectomy. Which instructions should be included? Select all that apply. A) Restrict fluid intake B) Obtain a MedicAlert bracelet C) Keep the humidity in the home low D) Prevent debris from entering the stoma E) Avoid people with infections F) Avoid swimming and use care when showering

B) Obtain a MedicAlert bracelet D) Prevent debris from entering stoma E) Avoid infected people F) Avoid swimming and use care when showering Instructions would include these as well as: - wearing a stoma guard or high collared clothing to protect the stoma - increasing humidity in the home - increasing fluid intake to 3000 to keep secretions thin

Which of the following rituals may be practiced by a family of Chinese heritage following the death of a family member? A) Bed will be placed facing east B) Oldest child will bathe the body C) Window will be opened by partner D) Priest will place an amulet on the pillow

B) Oldest child will bathe the body

Which of the following instructions should the nurse discuss when providing teaching to a pt with a new short-arm fiberglass cast? (Select all that apply) A) Expect injured areas to be warm and painful B) Report numbness or tingling C) Keep arm elevated above heart during rest D) Blow cool air from hair drier to relieve itching E) Wrap cast in plastic covering to shower

B) Report numbness or tingling C) Keep arm elevated above heart during rest D) Blow cool air from hair drier to relieve itching E) Wrap cast in plastic covering to shower

The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client? A) Urinary incontinence B) Signs of skin breakdown C) Presence of bowel sounds D) Signs of infection around the pin sites

B) Signs of skin breakdown Skin traction is achieved by Ace wraps, boots, or slings that apply direct force on the client's skin. Urinary continence is not related. There are not pin sites with skin traction.

A pt with TB asks when it is permissible to return to work. What factor should the nurse include when responding to the pt? A) Five blood cultures are negative B) Three sputum cultures are negative C) A blood culture and a CXR are negative D) A sputum culture and a TB skin test are negative

B) Three sputum cultures are negative A pt with TB must have sputum cultures performed every 2-4 weeks after initiation of anti-TB medication therapy. The pt may return to work when 3 sputum results are negative, because at this point the pt is non-infectious. (remember the mode of transmission of TB: airborne droplets) (also remember that skin cultures only show positivity for TB not negativity)

A pt is prescribed sucralfate for tx of a duodenal ulcer. The nurse recognizes which of the following statements indicates effective teaching? (Select all that apply) A) "Tx will be completed in 2 weeks" B) "I should drink 2000mL water each day" C) "Exercise should be limited during tx" D) "This will turn into paste and cover the ulcer" E) "My diet will include more fruits and vegetables" F) "The med will be taken 1 hour before meals"

B) drink 2000mL water daily D) will turn into paste & cover ulcer E) more fruits & veggies F) take 1 hr before meals - SE is constipation: increased fluid, fruit, and veggie intake will help prevent AS WELL AS exercise (don't limit) - turns into paste & covers ulcer - Typically taken 4x a day, 1 hour before meals and at bedtime

Which action should the nurse take when giving an IM injection to an obese pt? A) Use 1 inch needle B) Use the ventrogluteal site C) Pinch the skin D) Use 45 degree angle

B) use the ventrogluteal site This is a thick area of muscle that contains no large nerves or blood vessels A - I inch needle is too short for an obese pt

Which of the following statements indicate effective DC teaching about lisinopril? (Select all that apply) A) "I can continue using a salt substitute on food" B) "It is an emergency if my mouth starts to swell" C) "If I develop a cough, my Dr will be notified" D) "My K+ level will need to be monitored" E) "Getting up quickly may cause me to feel dizzy"

B-E: mouth swelling is emergency, notify Dr of cough, monitor K+ levels, may have dizziness if stand quickly DO NOT: continue using a salt substitute when taking lisinopril >> contributes to hyperkalemia Lisinopril = ACE inhibitor - can cause angioedema, dry cough, hyperkalemia, and orthostatic HTN

The nurse should include which interventions in the plan of care for a pt with hypothyroidism? Select all that apply. A) Provide a cool environment B) High fat diet C) Instruct about thyroid replacement therapy D) Encourage fluids and high-fiber foods E) Inform pt that iodine preparations will be prescribed to tx disorder F) Instruct pt to contact Dr if episodes of chest pain occur

C) Ed about thyroid replacement therapy D) Encourage fluids and high-fiber foods F) Contact Dr if episodes of chest pain occur A- pt is cold intolerant (bc of slow metabolism>low temp) > would encourage warm environment B - would encourage low fat diet for weight reduction C - this is a tx for hypothyroid (CORRECT) D - fluid and fiber prevent constipation (slowed GI tract) (CORRECT) E - these are not used for tx F - chest pain could be an indication of over-replacement of thyroid hormone (CORRECT)

A client with a hx of lung disease is at risk for developing respiratory acidosis. The nurse should assess the pt for which s/s of this disorder? A) Bradycardia and hyperactivity B) Decreased RR and depth C) Headache, restlessness, and confusion D) Bradypnea, dizziness, and paresthesia

C) Headache, restlessness, and confusion When a pt is experiencing respiratory acidosis, the RR and depth increase in an attempt to compensate. The pt also experiences headache, restlessness, mental status changes, visual disturbances, diaphoresis, cyanosis, hyperkalemia, rapid irregular pulse, and dysrhythmias.

A pt arrives to the ED and reports headache, neck stiffness, and sensitivity to light. Which of the following is the priority nursing action? A) Notify recent contacts B) Administer acetaminophen C) Implement droplet precautions D) Decrease environmental stimuli

C) Implement droplet precautions These are s/s of meningitis. Droplet precautions should be implemented until dx is made. Bacterial meningitis is highly contagious and life-threatening so must prevent exposure to others.

What is correct instruction for a malnourished pregnant pt taking iron supplement? A) Iron supplements will cause diarrhea B) Meat does not provide iron and should be avoided C) Iron is best absorbed if taken on an empty stomach D) On the days you eat leafy green veggies or calf liver, you can skip the iron supplements

C) Iron is best absorbed if taken on an empty stomach

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? A) Engaging in immoral acts B) Always reinforcing self-approval C) Observing rigid rules and regulations D) Having the need always to make the right decision

C) Observing rigid rules and regulations Rules and rituals help these clients manage their anxiety - Eliminate B and D because of the word "always" - A is not related to anorexia nervosa

Which of the following actions should the nurse implement prior to administering levothyroxine to a pt with continuous enteral feeding? A) Place in high-Fowler's position B) Flush the tube with 60mL of water C) Pause the infusion pump for 30 minutes D) Inject air into the tube to verify correct placement

C) Pause the infusion pump for 30 minutes Infusion pump should be paused for 30 minutes before and after administration of levothyroxine - temporarily pausing feedings is necessary for adequate absorption of some meds - Levothyroxine is best absorbed on an empty stomach

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. The nurse finds the client is disoriented. What is the best nursing action based on this info? A) Apply restraints B) Ask family to stay with pt C) Place a clock and calendar in the client's room D) Ask the lab to perform electrolyte studies

C) Place a clock and calendar in the client's room It is not within the scope of the nurse to prescribe lab studies. An inactive older adult may become disoriented because of lack of sensory stimuli. The most appropriate action would be to reorient the pt frequently and place objects such as a clock or calendar in the room to maintain orientation.

A mom of a 6-yr-old pt who was just dx with Hodgkin's disease asks why chemotherapy is planned to begin immediately, but radiation therapy was not prescribed as a part of the tx? What is the nurse's best response? A) "It's very costly, but chemo works just as well" B) "I'm not sure. I'll discuss it with the doctor" C) Sometimes age has to do with the decision for radiation therapy" D) The doctor would prefer that you discuss the tx options with the oncologist"

C) Sometimes age has to do with the decision for radiation therapy Radiation therapy is usually delayed until a child is 8 years old if possible, to prevent retardation of bone growth and soft tissue development

What teaching should be included for a pt on oxygen therapy at home? A) Apply petroleum-based gel to nares when needed B) Store full O2 tanks on their side C) Wear cotton-based clothing while using D) Check the functioning of O2 equipment at least once a week

C) Wear cotton-based clothing while using - woolen and synthetic fabrics can generate electricity and increase risk for fire A - products containing oil are flammable; use water based lubricants B - risk for injury to pt or family D - check functioning of equipment daily

Effective use of the defense mechanism of sublimation

Channeling negative energy into new hobby Definition: Rechanneling of drives or impulses that are personally or socially unacceptable into activities that are constructive.

A nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The pre-op teaching instructions should include which statement? A) "Your hair will need to be shaved" B) "You will receive spinal anesthesia" C) "You will need to ambulate after surgery" D) "Brushing your teeth should be avoided for at least 2 weeks after surgery"

D) "Brushing your teeth should be avoided for at least 2 weeks after surgery" This surgery uses the nasal sinuses and nose for access to the pituitary gland. Although ambulating after surgery is important, the teaching of avoiding brushing your teeth is specific to this procedure, to prevent disruption of the surgical site.

Which statement indicates need for further instruction for an adolescent dx with conjunctivitis r/t their contact lenses. A) "I should obtain new contact lenses" B) "I should not wear my contact lenses" C) "My old contact lenses should be discarded" D) "My contact lenses can be worn if they are cleaned as directed"

D) "My contact lenses can be worn if they are cleaned as directed" The patient should discontinue the use of contact lenses until the infection is over, and then obtain new ones.

When creating an assignment for a team consisting of an RN, 1 LPN, and 2 APs, which is the best pt for the LPN? A) Pt requiring frequent temperature checks B) Pt requiring assistance with ambulation Q4H C) A pt on mechanical ventilation requiring frequent assessment and suctioning D) A pt with a spinal cord injury requiring urinary catheterization Q6H

D) A pt with a SCI requiring urinary catheterization Q6H **This question is assuming that each of these pt's gets assigned to each of the team members. - Therefore the first 2 can be done by the 2 APs. The word "assessment" for C should clue you into this needing to be done by the RN.

During a prenatal visit, a pt complains of gums that bleed easily when she brushes her teeth. Which teaching depicts proper nutrition to minimize this problem? A) Drink 8 oz of water with each meal B) Eat 3 servings of cracked wheat bread daily C) Eat 2 saltine crackers before getting up each morning D) Eat fresh fruits and veggies for snacks and desserts each day

D) Eat fresh fruits and veggies for snacks and desserts each day These provide vitamins and minerals for healthy gums

Which should a pt with Crohn's disease and an enteroenteric fistula decrease in their diet? A) Calories B) Protein C) Potassium D) Fiber

D) Fiber - to reduce diarrhea and inflammation Calories: needed to promote healing of fistula Protein: needed to promote healing of fistula Potassium: Crohn's pt at risk of hypokalemia

A charge nurse reviews abbreviations used in client documentation. Which of the following is an approved entry? A) Enoxaparin 30 mg SC BID B) Zolpidem 5.0 mg PO qhs C) Digoxin .125 mg IV q 24 h D) Furosemide 60 mg PO daily

D) Furosemide 60 mg PO daily - does not use trailing zero, PO is acceptable abbreviation, daily be spelled out is correct B- do not use trailing zeroes for whole numbers C - need leading zero A - SC not an acceptable abbreviation ?

A client presents with signs and symptoms of organ failure with suspected acute kidney injury, which of the following labs must be ordered for this client? A) Coagulation panel B) Theophylline drug level screen C) A1C screening D) Metabolic panel with CBC

D) Metabolic panel with CBC

Which prescription should the nurse anticipate for a pt with retinal detachment preparing for a repair procedure? A) Allow bathroom privileges only B) Elevate HOB to 45 degrees C) Wearing dark glasses to read or watch TV D) Placing an eye patch over the affected eye

D) Placing an eye patch over the affected eye - This reduces eye movement, protects, and rests the eye; some pt's may even require bilateral patching - Depending on the location and size of the retinal break, activity restrictions may be needed - Normally pt is required to lay flat - Reading and watching TV is not allowed

Prior to administering a pt's scheduled dose of enoxaparin sodium, which lab finding should the nurse evaluate? A) PT B) INR C) aPTT D) Platelets

D) Platelets Nurse should hold enoxaparin sodium (Lovenox - anticoagulant) if platelet count falls below 100K - this would mean deficit of clotting factors - nurse should also monitor bleeding

A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure? A) Side-lying with a pillow under the hip B) Prone with pillow under abdomen C) Prone in slight Trendelenburg's position D) Side-lying with the legs pulled up and the head bent down onto the chest

D) Side-lying with the legs pulled up and the head bent down onto the chest This position helps open the spaces between the vertebrae and allows for easier needle insertion

A pt has active TB? What precautions should the nurse take? A) wear a surgical mask while providing care B) have visitors keep 6 foot distance C) restrict fresh flowers D) place in private room with negative air pressure

D) place in private room with negative air pressure A - N95 or HEPA respirator required B - 6 feet is for pt with sealed radiation implant C - restrict flowers for immunocompromised pt

After a pt has had a right mastectomy, how should the nurse plan to position their R arm?

Elevated on a pillow Incorrect answers: - Level w R atrium - dependent to the R atrium - elevated above shoulder level

What is the most appropriate nursing action if upon assessing a newborn, you find the ears are low-set?

Notify the pediatrician

What is the CBC?

The complete blood count lab (CBC) defines the number of cells present in the blood which may reveal the concentration of red blood cells, white blood cells, platelets, hemoglobin, and hematocrit. These values can help clinicians understand the presence of blood loss, anemia, infection, or medication overdose.

What is the metabolic panel?

The metabolic panel (BMP or CMP) is often used to evaluate a client's fluids, electrolytes, glucose, renal function, and liver function. These tests are useful when monitoring certain disease states as well as for side effects of medications in use.

Does informed consent need to be obtained before electroconvulsive therapy for a client who is involuntarily hospitalized to a mental health unit?

Yes: The informed consent needs to be obtained from the client Involuntary clients do not lose their right to informed consent Would have to be declared incompetent through couurt

A client diagnosed with diabetes mellitus reports feeing shaky. Further assessment reveals diaphoresis, tachycardia, and a glucose level of 70 mg/dL. Which of the following should the nurse administer to prevent a hypoglycemia reaction? a. 6 ounces of orange juice b. 2 pieces whole grain toast c. 1 tablespoon of peanut butter d. 1 cup of whole milk

a. 6 oz OJ C - Peanut butter is high in protein and fat. The recommendation for treatment of hypoglycemia is for 10 to 15 g of a fast-acting, simple carbohydrate orally such as: - 3 or 4 commercially prepared glucose tablets - 4 to 6 oz of fruit juice or regular soda - 6 to 10 hard candies - 2 to 3 tsp of sugar or honey.

A nurse is caring for a client who underwent a right below the knee amputation yesterday. Which of the following findings should the nurse report to the provider immediately? a. Blood glucose 200 mg/dL b. Redness of the incision site c. Quarter size spot of blood on dressing d. White blood cell count of 10,000 mm3

a. Blood glucose 200 Redness, quarter size spot of blood, WBC 10,000 all expected findings 1 day pot-op

A nurse is caring for a post-operative client who underwent thoracic surgery 7 hours prior, and now has in place a chest tube for drainage. What finding would require the nurse to contact the provider immediately? a. Chest tube drainage measures 80 mls an hour of red blood. b. Client complains of left-sided chest pain of 7 on pain scale when performing incentive spirometry. c. Diminished breath sounds auscultated in left lower lobe. d. Chest tube and tubing become disconnected during client transfer.

a. Chest tube drainage measures 80 mls an hour of red blood. - >50 or 70 ? is too much C - This is a normal occurrence with chest tubes lung sounds should gradually improve as lung re-inflates.

A client is admitted to the hospital with a diagnosis of Grave's disease. Which of the following findings should be reported to the provider immediately? a. Increase in temperature from 99.5 F to 100.5 F b. Increase in white blood cell count from 6,000 mm3 to 8,000 mm3 c. Hyperactive deep tendon reflexes d. Increased number of stools

a. Increase in temperature from 99.5 F to 100.5 F C- Hyperactive deep tendon reflexes are an expected finding of Grave's disease.

A nurse is evaluating placement of a nasogastric (NG) tube. Which of the following is the least reliable method to determine correct NG tube placement? a. Inject air into tube and listen over abdomen. b. Aspirate to collect gastric content. c. Ask the client to talk. d. Test pH of gastric contents.

a. Inject air into tube and listen over abdomen Other than X-ray, aspiration of gastric contents with pH testing is the most reliable method to determine correct NG tube placement. A pH of 4 or less is expected.

A nurse is providing care for a client with a Jackson-Pratt drain. Which of the following nursing interventions has the highest priority? a. Keeping the drainage bulb depressed to manual suction. b. "Milking" the tubing before emptying the drain. c. Securing the tubing and drainage bulb to the client. d. Cleansing the insertion site of the tube with betadine.

a. Keeping the drainage bulb depressed to manual suction D - Cleansing the insertion site is helpful in preventing infection, but is not a higher priority than keeping the drainage bulb depressed.

A nurse is caring for a client who is in diabetic ketoacidosis (DKA). Which of the following outcomes would the nurse expect to find in this client? Select all that apply. a. Kussmaul breathing b. Decreased blood glucose c. Decreased serum pH d. Increased urinary sodium e. Increased serum potassium

a. Kussmaul c. Decreased pH e. Increased serum K During diabetic ketoacidosis potassium shifts out of the cells to compensate for the increased hydrogen ion concentration which leads to an increase serum potassium. In acidosis the pH is decreased to less than 7.35. As the respiratory system attempts to compensate for the metabolic acidosis, the respiratory rate will increase blowing off the C02. Kussmaul breathing is the body's attempt to blow off as much carbon dioxide as possible in order to compensate for the metabolic acidosis from DKA.

A nurse is caring for a client who is beginning a warfarin regimen. What education should be provided to the client about this medication? Select all that apply. a. Oral contraceptives will decrease anticoagulant effects. b. Warfarin can be used safely in pregnancy. c. Intake of foods that are high in Vitamin K should be monitored. d. Concurrent use of glucocorticoids should be avoided while taking warfarin. e. Protamine sulfate will be administered in cases of warfarin overdose.

a. Oral contraceptives will decrease anticoagulant effects. c. Intake of foods that are high in Vitamin K should be monitored d. Concurrent use of glucocorticoids should be avoided while taking warfarin. Concurrent use of oral contraceptives OR glucocorticoids decreases anticoagulant effects of warfarin. Foods high in Vitamin K (such as dark green leafy vegetables, cabbage, broccoli, mayonnaise and canola may decrease anticoagulant effects of warfarin with excessive intake)

A client is admitted to the emergency room after falling outside his home. The client is complaining of a severe headache with pain above his left eye. The client is restless and intermittently losses consciousness. Pupils are dilated; pulse 56 and BP 168/98. An x-ray of the head confirms a skull fracture. Which of the following is a priority assessment? a. Respiratory Status b. Changes in level of consciousness c. Pupillary changes d. Blood alcohol and toxicology screening

a. Respiratory status Respiratory status is the priority assessment. The brain is dependent upon oxygen to maintain function and has little reserve available if oxygen is deprived. Brain function begins to diminish after 3 minutes of oxygen deprivation.

A nurse is caring for a client on the telemetry unit who is two days post coronary artery bypass grafting (CABG). The nurse recognizes a cardiac rhythm change from normal sinus rhythm to atrial fibrillation. Which of the following should be completed first? a. Prepare a diltizem drip. b. Assess the client's blood pressure. c. Prepare the client for cardioversion d. Notify the health care provider.

b. Assess BP It is necessary to assess the client to determine if the condition is stable or unstable. If the client becomes unstable the nurse would notify the health care provider and prepare the client for cardioversion.

A client with chronic obstructive pulmonary disease (COPD) has oxygen therapy ordered. Which principle should guide the nurse in managing the delivery of oxygen to this client? a. The concentration of oxygen should be low since the stimulus to breathe in clients with COPD is an elevated PaCO2. b. Clients with COPD should receive low concentrations (2-3 L) of oxygen since the stimulus to breathe is their low PaO2. c. Clients with COPD require higher concentrations (6-8 L) of oxygen since hypoxemia is their stimulus to breathe. d. The concentration of oxygen should be high since the stimulus to breathe in clients with COPD is an elevated PaCO2

b. Clients with COPD should receive low concentrations (2-3 L) of oxygen since the stimulus to breathe is their low PaO2.

A client presents to the emergency department with an abdominal stab wound. The nurse visualizes intestines protruding through the wound. Which of the following is an appropriate action for the nurse? a. Apply pressure to the wound with wet sterile sponges. b. Cover the wound with warm saline-soaked gauze. c. Irrigate the wound with a normal saline solution. d. Place sterile gauze and an abdominal binder over the wound.

b. Cover the wound with warm saline-soaked gauze. D- Dry sterile gauze would dry out the intestines, possibly leading to ischemia or necrosis.

A nurse is caring for a client with chronic renal failure. When assessing this client, the nurse should be alert for which of the following that may indicate hypocalcemia? Select all that apply. a. Constipation b. Fractures c. Decreased clotting time d. Trousseau's sign e. Seizures

b. Fractures d. Trousseau's sign e. Seizures Hypocalcemia can lead to brittle bones and pathologic fractures. Hypocalcemia causes increased neuromuscular irritability which can progress to seizure activity. Hypocalcemia causes increased neuromuscular irritability and repetitive muscle spasms. Signs and symptoms of hypocalcemia include Trousseau's sign. Positive Trousseau's sign: hand/finger spasms with sustained blood pressure cuff inflation. *Decreased clotting time is a sign of hypercalcemia*

A client asks "Why can't I take prednisone every day for my arthritis like my grandmother did?" The nurse correctly explains that corticosteroids can have which of the following adverse effects when used continuously? Select all that apply. a. Hypoglycemia b. Osteoporosis c. Truncal obesity d. susceptibility to infection c. bronze coloration of skin

b. Osteoporosis c. Truncal obesity d. Susceptibility to infection Continuous administration of high dose glucocorticoids will cause Cushing's syndrome. Cushing's syndrome includes fluid retention, hypertension, weight gain, and fat redistribution with truncal obesity, 'moon face', and 'buffalo hump.' Additional symptoms may include: susceptibility to infection, hyperglycemia, osteoporosis, menstrual irregularities, thin fragile skin, and hirsutism.

A nurse is caring for a client with a partial hearing impairment. The nurse understands which of the following is the best way to communicate with this client? a. Have a family member present. b. Speak slowly in a low-pitched voice. c. Conduct only the physical assessment at this time. d. Provide assessment questions in a written format.

b. Speak slowly in a low-pitched voice.

A nurse is caring for a client who is experiencing a sodium level of 119 mEq/L. Which nursing action would be most appropriate at this time? a. Encourage water and other fluids. b. Provide oral hygiene and comfort measures. c. Administer 0.9% Normal Saline. d. Monitor for diminished breath sounds

c. Admin NS D - Monitoring for diminished breath sounds is not the most appropriate nursing intervention at this time. Monitoring for shallow ineffective respirations and diminished breath sounds is a nursing intervention for client experiencing hypokalemia. ?????

A nurse is caring for a client at risk for atelectasis. Which of the following should the nurse monitor for manifestations of atelectasis? a. Intake and output b. Lung sounds c. Pulse oximetry d. Daily weight

c. Pulse ox

During a home visit, a 10-day postpartum client reports pain and tenderness with redness and swelling to her right breast. A localized hard mass is also noted upon palpation. How should the nurse respond to this client? a. This is normal breast engorgement and should subside within another week or two. b. Please mention this to your HCP at your 2-week check-up. c. These symptoms suggest an inflammatory or infectious process and require immediate notification to your health care provider (HCP). d. You will need to stop breastfeeding immediately until the swelling and redness subside.

c. These symptoms suggest an inflammatory or infectious process and require immediate notification to your health care provider (HCP). These symptoms are suggestive of mastitis and should be reported to HCP. These symptoms are not signs of normal breast engorgement.

A nurse is reviewing a client's lab results. Which finding would lead the nurse to suspect the client is experiencing dehydration? a. BUN 20mg/100mL b. Serum sodium 130 mEq/L c. Urine specific gravity of 1.025 d. Hematocrit 55%

d. HCT 55% (dehydration) C- With dehydration, an increased urine specific gravity (>1.030) is anticipated. - 1.025 is still normal range

A nurse is caring for a client following a spinal cord injury (SCI). Which of the following findings would alert the nurse to the development of neurogenic shock? a. Hypoglycemia b. Hypertension c. Hyperglycemia d. Hypotension

d. Hypotension

A client is prescribed TPN (total parenteral nutrition) to be infused through a single lumen PICC (peripherally inserted central catheter). Which of the following actions should the nurse take if the client is prescribed intravenous antibiotic therapy? a. Request the provider insert a second PICC line. b. Administer the antibiotic through the TPN line. c. Stop the TPN to administer the antibiotic as ordered. d. Identify alternative methods of administration.

d. ID alternative methods of admin C - TPN should not be abruptly stopped and started as hypoglycemia can occur.

A nurse is caring for a client with severe peripheral arterial disease of the right lower extremity. Which intervention is appropriate? a. Apply cold compresses to the affected extremity. b. Apply warm compresses to the affected extremity. c. Keep the affected extremity above the level of the heart. d. Keep the affected extremity below the level of the heart.

d. Keep the affected extremity below the level of the heart. The affected extremity should be kept lower than the level of the heart to enhance arterial blood flow to the feet.

A client is discharged following a cardiac catheterization procedure. Which of the following should the nurse include in the discharge teaching? a. Tub baths the night following the procedure are acceptable. b. Remove dressing the evening of the procedure. c. Notify provider if bruising is noted at the site. d. Limit activity for several days after the procedure.

d. Limit activity for several days after the procedure. C - Mild bruising at the insertion site is not unusual and will resolve after several days.

Which of the following is a s/s of hypoglycemia? A) flushed face B) polyuria C) Vomiting D) irritability

irritability