NCLEX Study Guide 2024

The nurse has taught a client with anemia who is receiving ferrous sulfate. Which of the following statements by the client would indicate a correct UNDERSTANDING of the teaching? A. " I should take this medication in between mealtimes." B. " If I have black stools, I will notify my health care provider." C. " O can take an antacid with this medication if it gives me heartburn." D. " The liquid medication should be taken undiluted in a medicine cup."

A. " I should take this medication in between mealtimes." Explanation: Ferrous iron salts (e.g., ferrous sulfate, ferrous fumarate) are iron supplements given to treat and prevent iron-deficiency anemia which can result from blood loss, malnutrition, malabsorption and pregnancy. Manifestations of iron deficiency anemia include fatigue, pallor, and inflammation of the tongue (glossitis) and lips (cheilitis). Teaching was effective id the client understands the following concepts: * while taking ferrous sulfate with food an reduce associated gastrointestinal upset, it also significantly reduces iron absorption. Therefore, this medication should be taken on an empty stomach if possible (e.g., in between meals) CORRECTED TEACHING: * Ferrous sulfate can cause stool to appear a black or greenish color which is a common and benign side effect. * The color change should not be confused with blood in the stool.. * Liquid ferrous sulfate preparations can cause permanent teeth staining, To prevent this, the dose should be diluted and taken through a straw. * Additionally, the client should be educated to rinse their mouth after taking the dose. The common side effect of ferrous sulfate include nausea, heartburn, bloating, constipation, and diarrhea. These effects are typically dose-dependent and diminish over time. Antacids should NOT be taken with ferrous sulfate to mitigate these symptoms as co-administration with calcium decreases iron adsorption. Liquid ferrous sulfate preparations can cause permanent teeth staining. To prevent this the dose should be diluted and taken through a straw. Additionally the client should be educated to rinse their mouth after taking the dose. Takeaway Ferrous sulfate teaching includes: Take on an empty stomach to maximize absorption. Avoid taking with calcium. Common side effects (e

The nurse is carting for a 8kg, 1 year old client who underwent a complete cardiac repair for tetralogy of pallor 8 hours ago. Which of the following findings would REQUIRE IMMEDIATE follow-up? Select all that apply A. 1+ radial and femoral pulses B. Temperature of 100 F (37.7 C) C. Urine output of 5 mL in the last hour D. Pinkish-tan colored chest tube drainage E. Chest tube drainage of 19 mL in one hour F. Median sternotomy dressing has 2 mL of dried blood.

A. 1+ radial and femoral pulses C. Urine output of 5 mL in the last hour Explanation: Complete tetralogy of fallot repair requires a heart-lung machine and anticoagulantion for the duration of the surgery. These interventions increase the risk for bleeding and inadequate perfusion in the postoperative period. Weak radial and femora pulses and inadequate urine output indicate poor perfusion and require immediate follow-up to assess for possible hemorrhage TETRALOGY IS a combination of four congenital (present at birth) heart defects. The defects occur together and change the way blood flows through the heart and lungs. Takeaway: Cardiac surgery

The nurse receives report on four assigned pediatric clients. Which client should the nurse ASSESS first? A. A 2 year old client with a history of Kawasaki disease who just began vomiting and appears restless B. A 12 year old client with acute rheumatic fever who is making sporadic arm movements and grimacing C. A 3 month old client with coarctation of the aorta (COA) on a ventilator who is pale and has weak femoral pulses D. A 6 month old client with ventricular septal defect (VSD) who experiences labored breathing when placed supine.

A. A 2 year old client with a history of Kawasaki disease who just began vomiting and appears restless Explanation: Kawasaki disease (KD) is an acute, self resolving vasculitis affecting mostly small and medium-sized vessels, especially the coronary arteries. KD weakens vessel was and can cause coronary aneurysm (abnormal bulging of the vasculature) and myocarditis (inflammation of the myocardium) Coronary artery aneurysm increases the risk for coronary thrombosis and myocardial infarction (MI), making KD the most common cause of MI in children. Vomiting and restlessness can indicate MI in young children. Key takeaway: KD can cause MI form coronary artery aneurysm or thrombosis Vomiting and restlessness are signs of MI in young children Topic: Establishing Priorities

The nurse enters a client's room for the first time during the shift and realized that the IV fluids are infusing 100 mL/hr faster than prescribed rate. Which of the following actions should the nurse take FIRST? A. Adjust the infusion rate to the prescribed rate B. Assess the client's lungs sounds and vitals signs C. Complete an incident repot documenting the error D. Notify the primary health care provider about the error.

A. Adjust the infusion rate to the prescribed rate Explanation: Medication errors are most common cause of clients har and occur due to a failure in the right of medication administration either by the prescribing healthcare provider, pharmacist, or administering nurse. When responding to a medication error, the nurse's highest priority is always clients safety. The nurse should FIRST prevent further harm to this clients by correcting the infusion rate. Takeaway: When responding to any medication error, the nurse should always prioritize preventing further harm and assessing the client. Next, the nurse should contact the HCP to communicate assessment findings. Finally, the nurse should complete an incident report

The nurse is caring for a client with pneumonia who spikes a fever and has a drop in blood pressure to 88/58. Which order should the nurse implement FIRST? A. Administer IV fluids bolus B. Administer IV antibiotics C. Draw 2 sets of blood cultures D. Initiate IV norepinephrine infusion

A. Administer IV fluids bolus Explanation: Septic shock occurs when inflammatory mediators (e.g., cytokines) are released in response to infection, inducing widespread vasodilation and increased capillary permeability. Priority treatment includes aggressive fluid resuscitation to improve intravascular fluid volume and tissue perfusion. Recommendations include the rapid administration of a 30 mL/kg bolus of crystalloid IV fluids (e.g., 30 mL x 100 kg = 3000 mL) Takeaway: Aggressive fluid resuscitation is a priority intervention for clients in septic shock to improve intravascular volume and tissue perfusion Collecting blood cultures, administering antibiotics, and giving vasopressor are indicated after IV fluid administration.

A client with type I diabetes mellitus has a Glasgow coma scale of 9, only responds to painful stimuli, and a blood glucose level of 35 mg/dL (1.9 mmol/L). What should the nurse do FIRST? A. Administer dextrose 50% IVP now B. Assess sweating, pallor or shakiness C Help the patient to eat 15 grams of carbohydrates D. Obtain the patients heart rate and blood pressure

A. Administer dextrose 50% IVP now Answer & Rationale: Ask Priority action of what to do FIRST Problem: Type I diabetes, Glasgow coma scale of 9 , blood glucose 35- hypoglycemic Solution: Interventions to do now to prevent worst possible outcome Explanation: Stab client with IV push

The nurse is caring for a client hospitalized with heart failure. Which meal item would be APPROPRIATE to include on this clients lunch tray? A. Broiled cod with roasted potatoes and carrots B. Deli turkey and cheddar sandwich with baked chips C. Chicken Caesar salad with croutons and ranch dressing D. Vegetable stir fry from a takeout restaurant seven with brown rice

A. Broiled cod with roasted potatoes and carrots Explanation: Clients with heart failure are limited to 2 grams of sodium and 2 liters of fluid intake daily Broiled cod with roasted potatoes and carrots is a goos choice because it is low-sodium, nutrient-dense meal that is low in saturated fat and high in protein Takeaway: Broiled cod with roasted potatoes and carrots is an appropriate meal choice for a client with heart failure, as it is low-sodium, nutrient-dense meal that is low in saturated fat and high in protein

The nurse has received information about assigned clients. Which of the following clients has an increased risk for hypocalcemia? A. Client recovering from recent thyroidectomy B. Older adult client who has viral gastroenteritis infection C. Client who has breast cancer newly metastasized to the ribs D. Client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH)

A. Client recovering from recent thyroidectomy Explanation: Calcium okays a key role in muscle contraction and relaxation (e.g., cardiac function, neuromuscular function. When serum calcium levels drop (I.e., hypocalcemia), the parathyroid gland releases parathyroid hormones (PTH), and kidney release calcitriol. These hormones increases the amount of serum calcium by triggering a release of calcium from bones and increasing the absorption of calcium in the intestines; therefore, increasing the amount of calcium in the bloodstream During a thyroidectomy the parathyroid glands or blood supply to the glands can become damaged, resulting in low PTH levels and hypocalcemia. Takeaway: Parathyroid hormone and calcitriol increase serum levels of calcium. Parathyroid glands can become damaged during a thyroidectomy, which can cause hypocalcemia. Topic: Health promotion/ disease prevention or fluid and electrolytes

The nurse is caring for four postpartum clients. Which of the following clients should the nurse see FIRST? A. Client who delivered 1 day ago experiencing scant reddish-brown purulent lochia B. Client who delivered 1 hour ago experiencing moderate vaginal bleeding and is receiving oxytocin IV C. Client who delivered 8 hours ago experiencing increased vaginal bleeding while breast-feeding D. Client who delivered 12 hours ago who is experienced a gush of vaginal blood while ambulating for the first time

A. Client who delivered 1 day ago experiencing scant reddish-brown purulent lochia Explanation: Postpartum vaginal discharge (ie. LOCHIA) occurs up two 6 weeks after delivery. The lochia starts as bright red and transitions to pink, brown, and then to white discharge. IMMEDIATELY following delivery, vaginal bleeding can be moderate but should be continually decrease. Lochia should smell like normal blood. PURULENT discharge indicates an infection that can led to serious complications, like sepsis, if left untreated. Therefore, the nurse should first nurse assess the client experiencing scant reddish-brown purulent lochia. Take away: Purulent lochia can indicate an infection and require probity assessment.

The charge nurse has received a change of shift report on the following laboring clients. The nurse should give PRIORITY for treatment to a A. Client who is 41 weeks pregnant, G2P1, pushing, facial presentation. B. Client who is 39 weeks pregnant, G3P2, amniotic performed, thin, green fluid. C. Client who is 38 weeks pregnant, G1P0, oxytocin infusion, no cervical dilation in 3 hours. D. Client who is 28 weeks pregnant, G2P1, uterine contractions every 5 minutes, 4 centimeters dilated.

A. Client who is 41 weeks pregnant, G2P1, pushing, facial presentation. Ex: Facial presentation: for a successful vaginal delivery, the fetus should be in vertex position (I.e parallel with maternal spine), flexed (I.e chin to chest), and cephalic (I.e, head down ), presentation. Takeaway: facial presentation indicates a fully extended fetal head, requiring an emergent cesarean delivery to prevent fetal harm.

The charge nurse has received a change of shift report on the following laboring clients. The nurse should give priority for treatment to a A. Client who is 41 weeks pregnant, G2P1, pushing, facial presentation. B. Client who is 39 weeks pregnant, G3P2, amniotomy performed, thin, green fluid. C. Client who is 38 weeks pregnant, G1P0, oxytocin infusing, no cervical dilation in 3 hours. D. Client who is 28 weeks pregnant, G2P1, uterine contractions every 5 minutes, 4 centimeters dilated.

A. Client who is 41 weeks pregnant, G2P1, pushing, facial presentation. Explained: for successful vaginal delivery, the fetus should be in a vertex position (I.e., parallel with maternal spine), flexed (I.e., chin to chest), and cephalic (I.e., head down) presentation Facial presentation occurs when the fetal head is fully extended, requiring immediate intervention (e.g., emergent cesarean section). delivering vaginally can cause trauma, spinal cord injuries, fetal distress, and demise.

Client with ulcerative colitis ... INTERVENTIONS? select all that apply A. Discuss plans to decrease client's stress B. Give analgesics as prescribed C. Limit fluids to 500ml per day D. Increased protein foods with meals E. Monitor input and output closely F. Recommend high fiber and low calorie diet

A. Discuss plans to decrease client's stress B. Give analgesics as prescribed D. Increased protein foods with meals E. Monitor input and output closely Explanation: We want a low fiber and high calorie diet for clients with UC Ulcerative Colitis is an inflammatory bowel disease (IBD) that causes inflammation and ulcers (sores) in your digestive tract Sysptoms: Pain in the abdomen (belly area) and cramping. A gurgling or splashing sound heard over the intestine. Blood and possibly pus in the stools. Diarrhea, from only a few episodes to very often. Fever. Feeling that you need to pass stools, even though your bowels are already empty. ... Weight loss FOODS TO AVOID: Watch Out For Fiber. Whole grain cereals and breads are difficult to digest and lead to flare ups if you have UC. ... Nuts And Seeds. These foods are difficult to digest and aggravate the symptoms. ... Dairy. ... Unhealthy Fats. ... Caffeine. ... Alcohol. ... Certain Vegetables. ... Spicy Foods. Limit fluids to 500ml per day (needs at least 2L or more per day) The cause of ulcerative colitis is unknown. People with this condition have problems with their immune system.

Which of the following can act as enzymes in the body? Choose ALL answers that apply. A. Globular Proteins B. Lipase C. Amylase D. Glucagon

A. Globular Proteins B. Lipase C. Amylase

The nurses is caring for an 8-month old client diagnosed with pertussis Which of the following INTERCEPTIONS should the nurse ANTICIPATE implementing? Select all that apply. A. Initiating droplet precautions B. Providing humidified oxygen C. Administering a bronchodilator D. Providing suctioning as needed E. Administering antiviral medications F. Encouraging frequent, small feedings

A. Initiating droplet precautions B. Providing humidified oxygen D. Providing suctioning as needed F. Encouraging frequent, small feedings Explanation: Pertussis (whooping cough) is a highly contagious bacterial upper respiratory infection that causes coughing spells filled by sharp inhalation that creates a characteristic crow-like sound (whoop). Coughing spells may result in the explosion of thick mucus plugs and posttussive vomiting. Nursing care center around controlling the spread of infection (e.g., initiating droplet precautions) and supportive care. Clients experience increased mucus productions and secretions that can affect respiratory efforts. Providing humidified oxygen thins respiratory secretions promoting explosion. Suctioning is provided to improve airway clearance. Infants rely on nasal breathing during feedings; therefore, respiratory symptoms (e.g., frequent coughing, increased secretions, tachypnea) increase their work of breathing which causes fatigue and difficulty feeding. Small frequent feedings promote breaks to achieve successful feedings sessions to maintain hydration and nutrition while conserving energy. Key takeaway: Pertussis is a highly contagious bacterial infection that requires droplet precautions Increased secretions are managed with humidified oxygen and suctioning Small, frequent feedings promote hydration and nutrition for pediatric clients Topic: Alterations in body systems

The nurse is caring for a client with hypertension who is taking lisinopril. Which of the following client findings is MOST concerning? A. Itchy lips and tongue B. Persistent dry cough C. Blood pressure of 142/92 mmHg D. Feeling lightheaded when standing quickly

A. Itchy lips and tongue Explanation: Angiotensin-convetting enzyme (ACE) inhibitors (e.g., lisinopril, benazepril) lower blood pressure by inhibiting renin-angiotensin-aldosterone system (RAAS) function. Itch lips and tongue may be the first symptoms of angioedema, a severe side effect of ACE inhibitors that can process to airway obstruction and respiratory failure if not prompts treated. Angioedema occurs due to inhibition of the breakdown of bradykinin, a vasodilator. Increased levels of bradykinin can trigger an immune and inflammatory response, causing swelling go the face, lips, tongue, or throat. Takeaway: Angioedema is a life-threatening side effect of ACE inhibitors that may present initially as itchy lips and tongue Dry cough and orthostatic hypotension are expected effect of ACE inhibitors

The nurse is planning care for a client who underwent a hip arthroplasty and requires one-person assist when ambulating. The client is alert and fully-oriented. Which of the following interventions is MOST important to promote client safety? A. Keep the call light within reach B. Apply a yellow fall risk wristband C. Ensure the client is wearing non-skid socks D. Keep a gait belt available in the client's room

A. Keep the call light within reach Explanation: Risk factors Impaired mobility - muscle weakness musculoskeletal conditions (e.g., arthritis) Impaired balance - Orthostatic hypotension mediations ( e.g., Benzodiazepines, opioids) Impaired mental status - confusion and disorientation impulsivity Impaired sensory perception - Visual impairment Impaired bladder or bowel function - Incontinence urgent, frequency Environmental hazards - Throw rugs, cords, dark, poorly lit rooms A client who underwent a hip arthroplasty (I.e., hip replacement) has an impaired gait and requires staff assistance when ambulating The most important intervention to prevent falls is to ensure the call light is always kept within reach. If the call light is out of reach, the client is unable to call for assistance (e.g., when needing to ambulate to the restroom) and might attempt to get out of bed unassisted. Keeping the call light within reach ensures the client always has assistance from a nurse or unlicensed assistive personnel when ambulating. Takeaway: Keeping the call light within reach ensures the client always has assistance from a nurse or UAP when ambulating. Topic: Falls

Which organs and/or glands are superior to the liver? Choose ALL answers that apply. A. Lungs B. Parathyroid Gland C. Kidney D. Thymus

A. Lungs B. Parathyroid Gland

The nurse is reviewing new prescriptions for a client with end-stage renal disease. The nurse should clarify the prescription for? A. Metformin B. Erythropoietin C. Acetaminophen D. Phosphate binder

A. Metformin Explanation: Metformin: used to treat high blood sugar levels that are caused by a type of diabetes mellitus or sugar diabetes called type 2 diabetes (helping to restore the body's response to insulin) metformin is something you would want to clarify as it is absorbed mostly through the kidneys Erythropoietin: (EPO) is a glycoprotein hormone, naturally produced by the peritubular cells of the kidney, that stimulates red blood cell production. (stimulates the production and maintenance of red blood cells) Acetaminophen: used to treat minor aches and pains, including headache, backache, minor pain of arthritis, toothache, muscular aches, premenstrual and menstrual cramps. It is absorbed through the liver Phosphate binder: work by binding (attaching) to some of the phosphate in food. (for people with chronic kidney disease (CKD) with the aim to prevent progression of chronic kidney disease‐mineral and bone disorder (CKD‐MBD). absorbed through the GI tract Topic: Medications

The nurse is caring for a postoperative client who has voided 125 mL since the removal of the indwelling urinary catheter 6 hours ago. Which of the following actions should the nurse take? A. Perform a bladder scan B. Reassess urine output in 1 hour C. Administer 40 mg of furosemide D. Administer a 500 mL IV fluid bolus

A. Perform a bladder scan Explanation: Client is experiencing decreased urinary output (<30mL/hr) and requires further assessment to determine the cause. It is most appropriate for the nurse to perform a bladder scan. A bladder scan is non-invasive bedside procedure that uses an ultrasound probe to measure the amount of fluid in the bladder. It is indicated if there is suspicion or risk for urinary retention, such as with the use of anesthesia, indwelling urinary catheters, and anticholinergics. It should be performed within 5-15 minutes of a void to obtain an accurate post-void-residual volume. Takeaway: A bladder scanner is used to assess for a post-void-residual caused by anesthesia, indwelling urianry catheters, and anticholinergics. Topic: Urinary catheterization

The nurse care for a client with a complete (3rd-degree) heart block and hypotension. The nurse should take which appropriate action? A. Prepare the client for temporary transcutaneous pacing. B. Obtain a prescription for an esmolol infusion. C. Begin chest compressions. D. Instruct the client to perform the Valsalva maneuver.

A. Prepare the client for temporary transcutaneous pacing Explanation: Third-degree AV block indicates a complete loss of communication between the atria and the ventricles (This is when the atria and the ventricles get a divorce lol they are no longer talking to each other). Valsalva maneuver is a breathing technique that can be used to unclog ears, restore heart rhythm or diagnose an autonomic nervous system (ANS)

The nurse enters a client's room and finds the client unresponsive, not breathing, and without a pulse. The nurse should FIRST? A. Start chest compressions B. Get the crash cart and defibrillator C. Obtain a 12-lead electrocardiogram D. Try to wake the client with a sternal rub

A. Start chest compressions Explanation: If a client is unresponsive, not breathing, and without a pulse, the immediate priority is to initiate cardiopulmonary resuscitation (CPR) by starting chest compressions. By providing high-quality chest compressions, the nurse manually pumps the heart to maintain blood flow until more advanced interventions can be implemented. If the client is pulseless, the nurse should immediately begin CPR and call for help ( eg.g, press the code button) so that's other staff can bring the crash cart and defibrillator to the bedside. The nurse should not leave the client to obtain equipment; the priority immediate chest compressions while others obtain equipment; the priority is to provide immediate chest compressions while others obtain equipment. Takeaway: When a nurse encounters a client who is unresponsive, not breathing, and without a pulse, the immediate action is to start CPR to ensure circulation and oxygen delivery to vital organs until further advanced measures can be implemented.

How are carbohydrates used by the body? Choose ALL answers that apply. A. Structure B. Communication C. Storage D. Recognition

A. Structure B. Communication C. Storage D. Recognition

Which of the following are disaccharides? Choose ALL answers that apply. A. Sucrose B. Glucose C. Cellulose D. Lactose

A. Sucrose D. Lactose NOTE: A disaccharide (also called a double sugar or biose) is the sugar formed when two monosaccharides are joined by glycosidic linkage.

A botanist wants to determine if environmental temperature affects root growth. In her experiment, she creates 4 rooms at temperatures that vary 5 degrees F. Each room gets 20 seedling of the same species, which she grows on agar plates for 60 days. Once a day she measures the length of the seedling's root. At the end of 60 days, she compares the length of the roots with the room temperature. She finds the room with the lowest temperature produced the longest roots. Which is the independent variable in this study? A. Temperature B. Seedlings C. Light D. Root length

A. Temperature

Which of the following are TRUE about water? NEED TO GET THE REST OF THIS QUESTION.... A. Water has solar covalent bonds B. Water has a neutral pH of 7 C.

A. Water has solar covalent bonds B. Water has a neutral pH of 7.

The nurse has been name aware of the following client situations. The use should FIRST assess the client? A. With congestive heart failure who has restlessness and a productive cough B. With obesity and obstructive sleep apnea who is sleeping in the supine position C. Who has right-sided pneumonia and is in high-fowler's position on the left side D. Who has chronic obstructive pulmonary disease and an oxygen saturation of 88%

A. With congestive heart failure who has restlessness and a productive cough Explanation: Restlessness is the earliest sign of hypogea. In a client with heart failure, restlessness and productive cough are concerning for pulmonary edema and hypoxemia. The client has a potential breathing issue and require a full set of vital signs and focused respiratory assessment to determine the need for supplemental oxygen, ventilatory support, and IV diuretics. Takeaway: In a client with heart failure, restlessness and productive cough are concerning for pulmonary edema and hypoxemia.

The nurse is assessing a newborn client born vaginally 22 hours Aho at 36 weeks gestation. Which of the following findings requires IMMEDIATE follow-up? A. Yellow tinge to the sclera B. Soft edema on occupant area of head C. Erytematous spots and white vesicles on the trunk D. Gas and spilts ip clear mucus three times in one hour

A. Yellow tinge to the sclera Explanation: Bilirubin is a byproduct of red blood cells (RBC) destruction that is processed it into bile and exerted in urine and stool. Factors tat increase RBC hemolysis (e.g birth trauma) or decrease bilirubin excretion (e.g immature liver) can cause hyperbilirubinemia The presence of jaundiced (I.e., yellow-tinged) skin and/or sclera within the first 24 ours of life indicates hyperbilrubinemia and possibly pathologic jaundice, hyperbilirubinemia can cause neurological damage (e.g., cerebral palsy, hearing loss) and may require phototherapy to convert bilirubin to an excitable form. Physiological jaundice occurs ages 24 hours of life and typically resolves without treatment. Take away: Yellow tinged skin or sclera indicate jaundice caused by hyperbilirubnemia Topic: Hyperbilirubinemia

The nurse is caring for a client with suspected benign prostatic hyperplasia. Which of the following client statements SUPPORTS the diagnosis of benign prostatic hyperplasia? Select all that apply. A. "I am having frequent constipation" B "I recently noticed some blood in my urine." C. "I wake up several times at night to urinate." D. "I have had urinate more frequently lately." E. "When I try to urinate, I have difficulty getting started." F. "When I am urinating, it is more of a dribble than a stream." G. "I have noticed that my scrotum feels more swollen than normal."

B "I recently noticed some blood in my urine." C. "I wake up several times at night to urinate." D. "I have had urinate more frequently lately." E. "When I try to urinate, I have difficulty getting started." F. "When I am urinating, it is more of a dribble than a stream." Explanation: Benign prostatic hyperplasia (BPH) is enlargement of the prostate gland that results in storage/irritative and obstructive symptoms, together termed lower urinary tract symptoms (LUTS). Obstructive symptoms occurs as the urethra is compressed, which requires the bladder to contract more forcefully to excrete urine and can cause urinary retention . the earliest sign of BPH is diminished caliber and force of urine when voiding. other obstruction symptoms include delay or hesitancy when clients attempt to urinate, difficulty in maintaining the urine stream (I.e. intermittency), and dribbling after voiding. Store/irritative symptoms are caused by irritation, inflammation, or infection and include urinary frequency, nocturne (3 or more voids during the night), urgency, dysuria, or hematuria Ket takeaway: Clinical manifestation of benign prostatic hyperplasia include: Nocturia Hematuria Urinary retention Urinary hesitancy Urinary frequency Diminished urine stream

The nurse discusses developmental milestones with the caregivers pod several clients. Which finding REPORTED by a caregiver REQUIRES follow-up by the nurse? A. A 19 month old who often falls while running through the house B. A 22 month old who can say 4 words including "mom" and "more" C. An 18 month old who is able to build a tower containing 3 wooden blocks D. A 24-month who plays with a doll bedside a friend without asking the friend to play

B. A 22 month old who can say 4 words including "mom" and "more". Explanation: Language development is rapid in toddler (age 18 months- 3years old) By 10 months, children should speak > 10 words and begin to combine words, this number increases to about 300 words by 24 months. Knowledge of only 4 words at 22 months could indicate a hearing, social, or cognitive impairment (e.g., autism) and require further investigation Key takeaway: Language develops rapidly; delays could indicate hearing, social or cognitive impairment. Parallel play is anticipated Topic: Developmental stages and transitions

The nurse in the emergency department is caring for a client with burn injuries to the torso and lower extremities who has 32% of their total body surface area (TBSA) burned, Which of the following actions should the nurse take FIRST? A. Inser an indwelling urinary catheter B. Administer warmed crystalloid fluids IV C. Cover the burn injuries with sterile dressing D. Obtain blood for an arterial blood gas (ABG) analysis

B. Administer warmed crystalloid fluids IV Ex: Clients with large surface area burns (greater than 20-25%) are at high risk for hemodynamic instability. Priority intervention focus on airway maintaining adequate perfusion (e.g. IV insertion, warmed crystalloid fluids IV) Large burns increase capillary permeability, allowing large amounts of fluid to leak from capillaries into surrounding tissue. This fluid shift decreases intravascular pressure and causes hypovolemic shock. Takeaway: Clients with large burn injuries require aggressive fluid volume resuscitation to maintain adequate perfusion prevent hypovolemic shock

Which condition can lead to blood clots and stroke? A. Aneurysm B. Arrhythmia C. Asthma D. Hypertension

B. Arrhythmia NOTE: When the upper chambers of the heart (atria) do not pump efficiently, as in atrial fibrillation, there's a risk of blood clots forming. These blood clots may move into the lower chambers of the heart (ventricles) and get pumped into the blood supply to the lungs or the general blood circulation If it blocks an artery in the brain, it will cause a stroke

The nurse is caring for a client who received a kidney transplant 12 hours ago. Which of the following findings would require IMMEDIATE follow-up? A. A low serum sodium level B. Blood pressure 89/52 mmHg C. Urine output of 400 mL.hr for 2 hours D. Pink-tinged urine in the catheter drainage bag

B. Blood pressure 89/52 mmHg Explanation: during the postoperative period following a kidney transplant, the priority is ensuring adequate perfusion to the new kidney. Initially, the client may produce up to 1 L/hr of urine as the new kidney eliminates excess accumulated fluid and wastes. This diuresis can cause dehydration, hyponatremia, and hypokalemia severe dehydration reduces perfusion to the kidney and can cause acute organ rejection and renal failure, causing the transplant to fail. If the client becomes hypotensive (I.e., systolic BP <90 or mean arterial pressure <65), the nurse should immediately notify the health care provider and anticipate administering an IV fluid bolus Key takeaway: after kidney transplant, the recipient may digress large volumes of urine as renal function stabilizes hypotension causes renal hypo perfusion, which can cause rejection and organ failure if not treated immediately

A nurse is assessing a client at 34 weeks gestation and auscultates a fetal heart rate of 90 bpm via doppler. Which of the following should the nurse do FIRST? A. Notify the healthcare provider B. Check the maternal heart rate C. Document the fetal heart rate D. Initiate a fetal non-stress test.

B. Check the maternal heart rate Explanation: A fetal heart rate (FHR) of 90 bpm (normal 110-160) indicated fetal bradycardia and requires intervention. When auscultating the FHR via doppler, the nurse may inadvertently auscultate the maternal pulse. Prior to initiating interventions for fetal bradycardia, the nurse should FIRST auscultate the apical pulse to assess the maternal pulse rate. If the FHR detected via doppler and material heat rate are equal, it is likely that the nurse has auscultated the maternal pulse, and the nurse should perform Leopold's maneuver to determine fetal position and reassess FHR. Key takeaway: If fetal bradycardia is detected, the nurse should first obtain the maternal pulse and compare with the FHR to ensure accuracy. If the FHR is confirmed as bradycardia (ie.g, <110), the nurse should contact the health car provider, document the findings, and anticipate a non-stress test. Topic: Changes/Abnormalities in Vital Signs

A patient is experiencing Digoxin toxicity. What is the antidote for this medication? A. Naloxone B. Digibind C. Acetycysteine D. Protamine sulfate

B. Digibind Explanation: Digibind: an antidote to treat a life-threatening overdose of digoxin or digitoxin.

The nurse is applying a nonrebreather mask for a hypoxic client admitted with carbon monoxide poisoning. Which INTERVENTION by the nurse is correct? A. Ensures the reservoir bag fully deflates during each inhalation B. Ensures mask valves open with exhalation and close with inhalation C. Adjusts the straps so the 2 fingers fit between the client's face and the mask D. Sets the oxygen flow rate to 5 L/min and titrates up to 8 L/min if needed

B. Ensures mask valves open with exhalation and close with inhalation Explanation: Non-rebreather masks are used to deliver oxygen therapy to clients who are experiencing severe hypoxemia and require high concentration of oxygen (e.g., carbon monoxide poisoning smoke inhalation). The mask has an oxygen reservoir bag and external one-way valves which close with inhalation so that oxygen is inhaled from the bag and open with exhalation to allow CO2 to escape from the mask. Takeaway: Non-rebreather masks: Should fit snugly Have vents that open with exhalation and close with inhalation Retire oxygen flow rates of 10-15 L/min to maintain a partially inflated reservoir bag at all times Topic: Alterations in body systems

The nurse is screening clients for those at increased risk doe developing metabolic acidosis. At highest risk for developing metabolic acidosis is the client who? A. Has nausea and vomiting B. Has sepsis and hypertension C. Is taking large doses of thiazide diuretics D. Has decreased oral intake and is dehydrated

B. Has sepsis and hypertension Explanation: Acid-base balance is necessary for homeostasis and is characterized by a blood pH level between 7.35- 7.45. Acid -base imbalance are categorized as either respiratory or metabolic and occur when there is a shift in acidic (e.g., carbon dioxide [CO2]) and alkaline (e.g., bicarbonate [HCO3]_) compounds in the body. Metabolic acidosis is caused by an accumulation of an acid other than CO2 or when bicarbonate is lost through the excretion of body fluids. Sepsis deprives cells of oxygen (hypoxia), forcing them to switch to anaerobic metabolism. This shift produces lactic acid, leafing to lactic acidosis and metabolic acidosis (ie., pH <7.35 and high CO2) as lactic acid accumulates. Takeaway: A client with sepsis will experience lactic acidosis due to tissue hypoxia. The increase in lactic acid levels results in metabolic acidosis. Topic: Acid-base

The nurse is screening clients for those at increased risk for developing metabolic acidosis? At highest risk for developing metabolic acidosis is the client who A. Has nausea and vomiting B. Has sepsis and hypotension C. Is taking large doses of thiazide diuretics D. Has decreased oral intake and is dehydrated

B. Has sepsis and hypotension Explained: acid base balance is necessary for homeostasis and is characterized by a blood pH level between 7.35-7.45. acid base imbalance fare categorized as with respiratory or metabolic and occur when there is a shift in acidic (e.g., carbon dioxide (CO2) and alkaline (e.g., bicarbonate (HCO3) compounds in the body) metabolic acidosis is caused by an accumulation of acid other than CO2 or when bicarbonate is lost through the exertion of the bod fluids. Sepsis deprives cells of oxygen (hypoxia), forcing them to switch to anaerobic metabolism. This shift produces lactic acid, leafing to lactic acidosis and metabolic acidosis (I.e., pH <7.37 and high CO2) as lactic acid Key takeaway: a client with sepsis will experience lactic acidosis due to tissue hypoxia. The increase in lactic acid levels result in metabolic acidosis

The nurse is preparing to administer medication to a client with pneumonia who had five liquid bowel movements so far today. Which action by the nurse is MOST appropriate? A. Request an order for loperamide B. Hold the client's schedules docusate C. Hold the client's scheduled antibiotics D. Changed the client's diet order to a "bland" diet/

B. Hold the client's schedules docusate Explanation: Antibiotics can cause diarrhea (e.g., C . diff) due to disruption of the normal intestinal bacterial flora. If a client develops diarrhea during hospitalization, the nurse should HOLD or DISCONTINUE stool softeners or laxatives (e.g., decussate, polyethylene glycol). Administering docusate would worsen diarrhea and could contribute to fluid, electrolytes and acid-base imbalance Takeaway: Hold of discontinue any stool softeners or laxatives

The intensive care unit nurse is caring for a client with septic shock who has a pulmonary artery catheter and whose blood pressure is being supported with continuous IV fluids and a titratable IV infusion of norepinephrine. Which FINDING would cause the nurse to request an order to increase the rate of continuous IV fluids? A. High cardiac output B. Low central venous pressure C. High pulmonary artery pressure D. Low systemic vascular resistance

B. Low central venous pressure Explanation: Parameter (cardiac output) (CO) range is 4-8 L/min, Interpretation (amount blood leaving the left ventricle per min) Central venous pressure (CVP) range 1-8 mmHg, Interpretation (indicator of volume status (preload) measured at the right atrium Pulmonary artery pressure (PAP) range 15-30 mmHg systolic/diastolic, interpretation (amount of resistance in the pulmonary circulation) Systemic vascular resistance (SVR) rate 800-1400 dynes/sec/cm-5, Interpretation (Amount of resistance (after load) in the systemic circulation) A pulmonary artery catheter is used to monitor certain hemodynamic parameters that guide treatment in shock Takeaway: CVP is an indicator of preload, or volume status A low CVP indicates a low volume status and need for IV fluid administration.

A client diagnosed with a head injury undergoes preparation for a lumbar puncture. Which action will the nurse take FIRST? A. Obtain informed consent B. Measure pre-procedure vital signs C. Explain the procedure to client D. Locate a lumbar puncture tray.

B. Measure pre-procedure vital signs Explanation:

Your patient is receiving morphine post-op. The patient is now exhibiting severe respiratory depression. What medication do you anticipate the HCP to order for this patient? A. Atropine B. Naloxone C. Lisinopril D. Flumazenil

B. Naloxone Explanation: Respiratory depression is a sign of morphine toxicity/overdose, therefore the reversal agent/antidose of naloxone (Narcan)O will be the anticipated medication ordered by the HCP

The nurse is caring for a 76-year old female client who was recently prescribed hydrochlorothiazide. Which client finding would be MOST concerning? A. Increased triglyceride levels B. Nausea, headache, and lethargy C. Client has been urinating frequently at night D. Rash on sun-exposed skin of the face and arms

B. Nausea, headache, and lethargy Explanation: Nausea, headache, and lethargy are symptoms of hyponatremia hyponatremia is a side effect of thiazide diuretics (e.g., hydrochlorothiazide) that occurs when too much sodium is lost in the urine. Thiazide diuretics treat edema or hypertension by blocking the reabsorption of sodium and chloride in the distal convoluted tubules. These symptoms are most concerning, as hyponatremia can progress to confusion or seizures if the electrolyte disturbance is not corrected. Takeaway: Side effects of thiazide diuretics include hyponatremia, increasedtriglyceride levels, and photosensitivity. Nausea, headache, and lethargy are symptoms of hyponatremia that require follow-up.

The nurse administers oral levothyroxine to a client with hypothyroidism. Which of the following would be the PRIORITY for the nurse to monitor for? A. Diarrhea B. Palpitations C. Diaphoresis D. Weight loss

B. Palpitations Explanation: Thyroid replacement is used to treat hypothyroidism a condition in which the thyroid gland produces insufficient thyroid hormones to support the metabolic functions of the n=body. Autoimmune disease (Hashimoto thyroiditis), surgical removal, destruction, by irradiation, cancer, medications (amiodarone), and a poorly functioning thyroid gland are all causes of hypothyroidism Levothyroxine is a synthetic thyroid hormone use to treat hypothyroidism. It is an isomer of thyroxine (T4) that stimulates T4 receptors in the body, effectively "replacing" the client's thyroid hormone. Side effects of overdose can be serious and resemble an extreme hyperthyroid state. symptoms indicating possible cardiac toxicity (e.g., chest pain, hypertension tachycardia), should be reported immediately to the healthcare provider. Palpitations are a sign of toxicity that can indicate arrhythmias, including atrial fibrillation. Takeaway: Serious cardiovascular side effects of levothyroxine monitored for and report include: Palpitations Chest pain Hypertension Tachycardia

The nurse is caring for a client with severe chronic obstructive pulmonary disease (COPD). Which of the following FINDINGS would require IMMEDIATE follow- up? A. Lower extremity edema B. Paradoxical respirations C. Increased hemoglobin levels D. Pulse oximetry reading 88%

B. Paradoxical respirations Explanation: Respiratory failure is a key complication of COPD characterized by hypoxia (low oxygen levels in the blood) or hypercapnia (elevated levels of carbon dioxide in the blood). Paradoxical respiration, also known as seesaw respirations, occur when the chest wall moves inward during inspiration rather than pushing outward. This is often a sign of impending respiratory failure from fatigued respiratory muscles, primarily the diaphragm. The nurse should IMMEDIATELY assess their client and anticipate providing mechanical ventilation. Takeaway: Paradoxical respiration are the most immediately concerning sign of potential respiratory failure in a client with COPD and would require immediate follow-up

The experienced pediatric intensive care registered nurse is preempting a newly licensed registered nurse who received repot on 4 clients. Which of the following ACTIONS taken by the new nurse REQUIRES the experienced nurse to intervene? A. Placing a client with varicella in a negative pressure isolation room. B. Performing oropharyngeal suctioning on a drooling client with croup. C. Placing an infant in prone position following myelomeningocele repair. D, Drawing up insulin lisper before NPH insulin in the same syringe for a client with diabetes.

B. Performing oropharyngeal suctioning on a drooling client with croup. ?????? Explanation:

Which of the following carry oxygenated blood? Choose ALL answers that apply. A. Pulmonary artery B. Pulmonary vein C. Aorta D. Superior Vena Cava

B. Pulmonary vein C. Aorta NOTE: Your pulmonary artery is the only artery that carries deoxygenated blood. This artery takes blood from your heart to your lungs to get oxygen Heart sends the impure blood to the lungs for oxygenation. The oxygenated blood means the blood that is rich in oxygen with very less carbon dioxide. The deoxygenated blood means the blood which is received to the heart and has greater concentration of carbon dioxide as compared to oxygen Arteries carry blood away from the heart, and veins carry blood towards the heart. With the exception of pulmonary blood vessels, arteries carry oxygenated blood and veins carry deoxygenated blood

The nurse is caring for a client who is experiencing left-sided weakness after a stroke. Where should the nurse stand to safely assist the client out of the ned to a chair? A. Behind the client B. The client's left side C. The client's right side D. Directly in front of the client

B. The client's left side Explanation: When assisting a client with left-sided weakness to move from the ned to the chair, the nurse should: 1. Position the chair next to the bed so that the client only has to stand and pivot to sit in the chair. 2. Stand on the client's weak side (I.e., left side) to provide support and stability to the affected side. 3. The client should push down on the bed (or another sturdy surface) with their unaffected arm, while the nurse strides the weaker side. If another healthcare worker is available to assist, one should stand on either side of the client and secure a gait belt or a transfer belt for additional safety. Takeaway: The nurse should stand on the client's weakest side when assisting with transfers in clients with hemiparesis. If the client has equal left and right-sided strength, the nurse should be positioned in front of the client during transfers. Topic: Mobility

The charge nurse is observing the following client situations. The charge nurse should INTERVENE if the staff member rooms together two clients who both have? A. Influenze B. Varicella C. Pertussis D. Clostridium difficile

B. Varicella Explanation: Don't group Air borne diseases together (varicella patients need to be in a negative pressure room) Topi: Disease process

The nurse has been made aware of the following client situations. The nurse should FIRST assess the client? A. With COPD who has diminished lung sounds B. Who had a hip replacement yesterday and is restless with a petechial rash on the neck C. Who had an indwelling urinary catheter discontinued 6 hours ago and has not yet voided D. With chronic live cirrhosis who has a prolonged prothrombin time and low platelet count

B. Who had a hip replacement yesterday and is restless with a petechial rash on the neck Explanation: Restlessness and petechial rash indicated possible fat embolism syndrome. Fat embolism syndrome is a complication of long-bone fracture that occurs when fat globules from the bone marrow enter the circulation and occluding pulmonary perfusion, impairing gas exchange. Petechial rash on the upper body is a hallmark sign of this condition. Takeaway: Restlessness and a petechial rash indicates possible fat embolism syndrome. Fat embolism syndrome is a compilation of long-bone fracture that occurs when fat globules are released from bone marrow and enter the circulation, occluding pulmonary perfusion and impairing gas exchange. Topic: Establishing priorities

The nurse is providing a training inservice on chest tube management to staff nurses in the cardiothoracic surgery intensive care unit. Which statement should the nurse iINCLUDE in the training? A. "It's safe to gently strip the tubing regularly to prevent clots from forming." B. "It's normal to have up to 250 mL/hr of drainage in the drainage chamber." C. "Gentle, intermittent bubbling is expected if the client has a pneumothorax." D. "If the chest tube falls out of the client's chest, place the end of the tube in sterile water."

C. "Gentle, intermittent bubbling is expected if the client has a pneumothorax." Explanation: The chest tube removes fluid or air from the pleural space in effusion or pneumothorax. A water seal chamber (I.e., air leak monitor) in the chest drainage unit (CDU) forms a one-way seal, allowing air to exit the pearl space without re-entering. Gentle, intermittent bubbling is expected in the water seal chamber as air escapes during coughing and exhalation Vigorous or continuous bubbling would indicate an air leak. Normal to have up 250 mL/hr of drainage If the chest tube falls comes out, cover the site with a sterile dressing to prevent air from evening the pleural space. Placing the tubing in sterile water is done to re-establish a water seal if the tubing becomes disconnected from the CDU. Takeaway: Gentle, intermittent bubbling is expected as air escapes the pleural space. Vigotous or continuous bubbling indicates an air leak Normal to ahem up 250 mL/hr of drainage

The nurse is teaching a client who has radioactive iodine therapy 1 hour ago. Which of the following statements by the client would require follow-up? A. "I should avoid contact with my 3-year-old child." B. "I should flush the toilet 2 to 3 times after each use." C. "I will ask my spouse to disinfect our share bathroom daily." D. "I will wash my clothing separately from my family's clothing."

C. "I will ask my spouse to disinfect our share bathroom daily." Explanation: Make sure to not expose yourself to family or friends.

The charge nurse is teaching the student nurse how to follow standard precautions. Which off the following statements by the student nurse demonstrates an understanding of teaching? select all that apply A. "I will apply sterile gloves before giving an injection." B. "I need to wear gloves before taking the redial pulse of a client with diaphoresis." C. "I will wash my hands with soap and water after transfusing blood products." D."I will wear a gown, gloves, mask, and protective eyewear when irrigating wounds." E. "I can use an alcohol-based hand sanitizer for hand hygiene before entering a clients room."

C. "I will wash my hands with soap and water after transfusing blood products." D."I will wear a gown, gloves, mask, and protective eyewear when irrigating wounds." E. "I can use an alcohol-based hand sanitizer for hand hygiene before entering a clients room." Explanation: Standard precautions are measures implemented to prevent infection transmission that are appropriate for all clients regardless of infection status. Standard precautions assume that all body fluids ( except sweat) and moist membranes or tissues might be source of infection. Therefore, healthcare workers should select appropriate personal protective equipment (PPE) based on the potential for exposure. Standard precautions include hand hygiene before entering a room and before and after contact with body fluid (e.g., blood, secretions, non-intact skin, mucous membranes) Topic: precautions

A charge nurse is making client assignments for a critical care step=down unit. Which client would be MOST appropriate to assign to a new graduate registered nurse (RN)? A. A client admitted for diabetic ketoacidosis that is on a insulin drip B. A client that is scheduled for discharged today that has a new colostomy C. A client admitted for a postoperative infection that is receiving IV antibiotics D, A client that is scheduled for a pacemaker insertion procedure during the shift.

C. A client admitted for a postoperative infection that is receiving IV antibiotics Explanation: The skills, education, experience of nursing staff, ins addition to client acuity, must be considered when making client assignments. Caring for any of these clients is within the new RN's scope of practice; however, the client receiving IV antibiotics is most appropriate as car includes administration of IV antibiotics, monitoring vital signs, and assessing for signs of infection. These are skills that could reasonable be expected of a new RN. New graduate nurses have least amount of experience and specialized knowledge and therefor should be assigned the least complex clients. Takeaway: The complexity of care and competency of nursing staff must be considered when making client care assignments. The most appropriate client assignment for a new graduate nurse is one that does not require specialized training or knowledge. Topic: Assignment

The nurse is providing a staff training on nurses' legal responsibilities to clients. Which of the following should the nurse provide as an example of malpractice? A. A nurse's license expires, but the nurse completes two shifts before renewing the license B. A nurse does not document a client's fall because the client caught himself and was not injured C. A nurse does not reposition an immobile client and the client develops a pressure injury on the sacrum D. A nurse tells a client, "If you don't agree to take this medicine, then we will need to restrain you and give it."

C. A nurse does not reposition an immobile client and the client develops a pressure injury on the sacrum Explanation: Legal liability in Nursing: Negligence - Conduct that falls below the reasonable, prudent standard of care Malpractice - Negligence by a professional (e.g., a nurse) that results in client harm Assault - Threat of harm or action that makes a client fear harm by the nurse Battery - Intentional touching of a client's body without client's consent Malpractice is professional negligence that occurs when a nurse fails to meet the standard of care and causes client harm. The standard of care is the care that a reasonable and prudent nurse would provide in similar circumstances. Four criteria for malpractice must be met: 1. Duty - to the client (e.g., nurse is assigned to care for the client) 2. Breach of duty - by the nurse 3. Injury - as result of the breach of duty 4. Causation - of the injury by the breach of the duty If an at-risk client develops a pressure injury because the nurse neglects to reposition the client, this is an example of malpractice. Takeaway: Malpractice is professional negligence that occurs when a nurse fails to meet the standard of car and causes client harm. A client developing a pressure injury because the nurse neglects repositioning is an example of malpractice.

The charge nurse is observing a staff nurse perform tracheostomy suctioning. Which of the following actions by the staff nurse would require the charge nurse to intervene? A. Inserts the catheter until resistance is felt B. Places the client in semi-Fowler's position C. Applies suction while inserting the catheter D. Hyperoxygenates the client between suctioning passes

C. Applies suction while inserting the catheter Explanation: A tracheostomy is an artificial airway created by an opening in the trachea. Client with tracheostomies may require suctioning to clear secretions and prevent respiratory complications. 1. Gather supplies for sterile technique to prevent the introduction of pathogens into the airway. 2. Position the client in semi-Folwer's position 3. Hyperoxygenate the client before and between suctioning passes to prevent suction-induced hypoxia 4. Suction intermittently during catheter withdrawal, not insertion. Suctioning during insertion can cause airway tissue trauma and increase the risk for hypoxia. Takeaway: Semi-Fowler's position Using sterile technique Inserting the catheter until resistance is felt Suctioning during catheter withdrawal, not insertion Hyperoxygenating before and between suction passes Topic: Tracheostomy suctioning

The nurse is working with a new graduate nurse to perform a contraction stress test on a pregnant client Which action by the new graduate nurse requires INVENTION by the nurse? A. Discontinues the test if late decelerations of the fetal heart rate occur. B. Refuses to perform the test if the client report a history of uterine surgery C. Continues the stress test until all contractions are at least 90 seconds long D. Teaches the client how to use the breast pump to stimulate uterine contractuion

C. Continues the stress test until all contractions are at least 90 seconds long Explanation: A contraction stress test (CST) assesses (FHR) in response to uterine contractions to determine if the fetal can tolerate labor. During contractions, uterine muscles compress blood vessels, intermittently obstructing uteroplacental blood flow (deliver of oxygen and nutrients), which can cause fetal hypoxia, indicated by FHR decelerations. Contractions >90 seconds furthers reduce uteroplacental blood flow, impairing repercussion. Prolonged contractions also prevent adequate uterine rest. The contraction stress test should be stopped if contractions exceed 80 seconds Takeaway: Nursing interventions for a CST include: Assess for contraindications, such as pervious uterine surgery Using a breast pump to stimulate uterine contractions. Discontinuing test for contrition _>90 seconds or for late decelerations.

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is MOST appropriate? A. Clamp the T-tube B. Irrigate the T-tube C. Document the findings D. Notify the health care provider

C. Document the findings Explanation: its to be expected to have green-brown drainage

A patient is admitted to the hospital for Diazepam overdose. What its the antidote for this medication? A. Naloxone B. Fomepizole C. Flumazenil D. Protamine sulfate

C. Flumazenil Explanation: Naloxone: a medication approved by the Food and Drug Administration (FDA) designed to rapidly reverse opioid overdose (such as heroin, morphine, and oxycodon) Fomepizole: is used as an antidote in confirmed or suspected methanol or ethylene glycol poisoning (alcohol) Flumazenil" is a benzodiazepine antagonist. The primary FDA-approved clinical uses for flumazenil include reversal agents for benzodiazepine overdose and postoperative sedation from benzodiazepine anesthetics Protamine sulfate: to counteract the effect of heparin given before and after surgery and after dialysis.

The nurse observes a coworker who is inserting a nasogastric tube. Which of the following actions by the staff member would require the nurse to intervene? A. Uses slight pressure and rotates the tube during insertion B. Advance the nasogastric tube while the client swallows water C. Flushes tube with normal saline after insertion to confirm potency D. Measures tube length from nose, to the earlobe, and then to the xiphoid process

C. Flushes tube with normal saline after insertion to confirm patency Explanation: Nasogastric (NG) tube are flexible tubes placed in the nares down to the stomach. They provide enteral nutrition directly to the stomach or remove gastric contents, decompressing the stomach. NG tube insertion include: 1. Position the client in high-Fowler. 2. Determine the needed tube length 3. Lubricate and inset the tube, aiming towards the back of the throat and down towards the ear. 4. Instruct the client to put chin to chest and repeatedly swallow during insertion. 5. Stop insertion once the desired length is reached. Remove and start over if the tube meets resistance or the client experiences respiratory distress. 6. Secure with tape. 7. Confirm tube placement is in the stomach and not the lungs with an X-ray before utilizing. Without confirmation, aspiration could occur. After initial verification with an X-ray, tube placement is verified before each use by aspirating gastric contents or pH testing aspirated contents. Takeaway: Nasogastric tubes enter the nares and end in the stomach. Nasogastric tube placement must be confirmed with X-ray prior to use to avoid aspiration.

Which of the following is the carbohydrate monomer? A. Disaccharide B. Lactose C. Monosaccharide D. Thymine

C. Monosaccharide

The home care nurse cares for a 70 year old Male client who reports feeling hungry, weak, and "shaky" and is found to have a low blood glucose level. Which action by the nurse is APPROPRIATE at the time? A. Turn the client onto the his left side B. Give the client crackers with cheese C. Offer the client half a cup of orange juice D. Administer 1 mg of glucagon intramuscularly

C. Offer the client half a cup of orange juice Ex: The client is demonstrating signs of mild hypoglycemia Takeaway: The first intervention for a alert client experiencing mild hypoglycemia (blood glucose <70mg/dL [3.9 mol/L] is administering 15 grams of carbohydrate Fast-acting carbohydrates include fruit juice, glucose tablets or gel, and hard candies.

The nurse is reviewing new medication prescription for a client who is receiving clopidogrel. The nurse should clarify the prescription for? A. Metoprolol B. Furosemide C. Omeprazole D. Levothyroxine

C. Omeprazole Explanation: Clopidogrel: an antiplatelet medicine. Clopidogrel is used to prevent heart attacks and strokes in persons with heart disease (recent heart attack), recent stroke, or blood circulation disease (peripheral vascular disease Metoprolol (Lopressor®) is a medication that lowers your blood pressure and heart rate, making it easier for your heart to pump blood to the rest of your body. It treats high blood pressure. It also prevents chest pain or further damage after a heart attack. Furosemide belongs to a group of medicines called loop diuretics (also known as water pills). Furosemide is given to help treat fluid retention (edema) and swelling that is caused by congestive heart failure, liver disease, kidney disease, or other medical conditions. Omeprazole (protein pump inhibiter) is used to treat certain conditions where there is too much acid in the stomach. It is used to treat gastric and duodenal ulcers, erosive esophagitis, and gastroesophageal reflux disease (GERD). GERD is a condition where the acid in the stomach washes back up into the esophagus Levothyroxine is a medicine used to treat an underactive thyroid gland (hypothyroidism). The thyroid gland makes thyroid hormones which help to control energy levels and growth. Levothyroxine is taken to replace the missing thyroid hormone thyroxine. Takeaway: Clopidogrel: is usually giving after an MI or to prevent stoke. Most "olol" medicine are used for heart disease, Topic: Heart disease

The nurse receives a prescription for IV push 2 mg diazepam and is unsure whether this is the appropriate dose for this medication. Which of the following is the BEST action for the nurse to take? A. Verify the medication dosage in the hospital's online medication reference. B. Ask the charge nurse whether no not this is a safe dose for this medication C. Page the primary health care primary to clarify the intended correct dosage. D. Contact the hospital pharmacist to confirm the correct dosage was prescribed.

C. Page the primary health care primary to clarify the intended correct dosage. Explanation: 10 rights of medication administration verify Key takeaway: the nurse should always clarify an order with the prescribing health care provider (HCP) if there is ever uncertainty about any part of a medication order (e.g., medication, dose, route, or frequency) topic: safety

The nurse is caring for a client with a right radial arterial line. Which finding is MOST concerning? A. Stopcock positioned at the level of the client's head B. Blood oozing from the insertion site under the dressing C. Pallor and coolness of the rich thumb and second finger D. Dampened waveform with noninvasive cuff pressure 118/94

C. Pallor and coolness of the rich thumb and second finger Explanation: Arterial line pressure monitoring is an invasive method of continuous blood pressure monitoring directly from the an artery. Arterial lines are used in hemodynamically-unstable clients requiring careful titration of vasoactive medications (e.g., norepinephrine). Arterial occlusion occurs when the arterial catheter obstructs perfusion to the distal extremity (I.e., thumb and second finger), causing neurovascular impairment. The nurse should immediately notify the healthcare provider and anticipate discontinuing the line. Takeaway: Arterial occlusion occurs when an arterial catheter obstructs perfusion to the distal extremity causing neurovascular impairment.

Who needs the private room? A. Patient with non stop diarrhea B. Patient with new surgical wound. C. Patient with Cushing's syndrome D. Patient with new cellulitis

C. Patient with Cushing's syndrome Explanation: This patient is immunocompromised Topic: Isolation

The nurse is giving instructions to the client who has a new prescription for phenelzine. What should the nurse instruct the client to AVOID eating? A. Cottage cheese B. Cooked chicken C. Pepperoni D. Yogurt

C. Pepperoni Explanation: used to treat depression is a MAOI they can cause hypertension know the side effects of Phenelzine: Feeling weak or tired; tremors, muscle twitching; dry mouth, stomach discomfort, constipation; swelling, weight gain AVOID: foods that have dopamine and a high tyramine content cheese (especially strong or aged kinds), caviar, sour cream, liver, canned figs, soy sauce, sauerkraut, fava beans, yeasts, and yogurt.

The nurse is caring for a client with a pneumothorax. The nurse notes the client is experiencing dyspnea. Which of the following ACTIONS should the nurse take FIRST? A. Prepare the client for intubation B. Administer supplemental oxygen C. Place the client in high Flower's position D. Prepare the client for chest tube insertion

C. Place the client in high Flower's position Ex: A pneumothorax is a life-threatening respiratory emergency caused by air entering the pleural space, resulting in negative pressure, resulting in negative pressure and lung collapse. Prompt intervention is crucial to prevent dyspnea, severe respiratory distress, and decrease cardiac output caused by increased thoracic pressure. Takeaway: Management of pneumothorax administering oxygen chest tube insertion positioning the client in a Folwer's position

The nurse is planning care for a client with acute hepatitis A. Which of the following should be included in the plan of care for an infant with an acute hepatitis A virus (HAV) infection? A. Place the client on droplet precautions B. Inform caregiver there is no current vaccine for HAV C. Recommend caregivers wear gloves during diaper changes D. Offer the mother HAV testing to be sure she didn't infect infant during childbirth

C. Recommend caregivers wear gloves during diaper changes Explanation: Hepatitis A - Fecal oral (contaminated food or water, close contact with infected person) Hepatitis B - Blood and body fluids ( Sexual contact, sharing needles or other drugs injection equipment, mother-to-baby during childbirth. Hepatitis C - Blood Sharing needles or other drugs injections equipment, mother-to-baby during childbirth, sexual contact Hepatitis D - Blood and body fluids (only occurs in those infected with hepatitis B) (Sharing needles or other drug injection equipment Hepatitis E - Fecal and oral ( contaminated food or water, close contact with infected person Acute hepatitis is inflammation of the liver that can be caused by an infectious or noninfectious process. Acute hepatitis A resolves in <2 months and causes fever, jaundice, anorexia, and abdominal pain. Hepatitis A and B both have vaccines to prevent infection in children Topic: Hepatitis

The charge nurse is supervising a registered nurse (RN) in the care of a client with hypertension. The charge nurse should INTERVENE if the RN asks the unlicensed assistive personnel (UAP) to? A. Document the client's blood pressure and heart rate every 8 hours B. Report systolic blood pressure levels below or above a specific pressure C. Show the client the correct way to measure a pulse before taking carvedilol D. Measure orthostatic vital signs supine, 3 minutes after sitting, and 3 minutes after standing.

C. Show the client the correct way to measure a pulse before taking carvedilol need to check but I think its right because client teaching is left for RN

The nurse is caring for a client who is sedated and receiving mechanical ventilation when the client suddenly becomes agitated and is coughing as the ventilator alarm is going off. Which assessment is the nurse's PRIORITY? A. Auscultate client's bilateral breath sounds B. Check the endotracheal tube insertion depth C. Verify there are no kinks or disconnections in the tubing D. Assess whether the alarm is due to high or low pressure.

C. Verify there are no kinks or disconnections in the tubing Explanation: Mechanical ventilator alarm states are triggered by either a problem wit the client (e.g., coughing, secretions) or the mechanical ventilator circuit (e.g., tubing kinked, disconnected). The nurse should always assess the client before the equipment. A client who is agitated and coughing can accidentally dislodge the endotracheal tube (ETT) and cause the balloon to obstruct the airway, which is an emergency. The nurse should first assess the client by checking the marked ETT insertion depth (displayed in centimeters on the tube) and performing a focused respiratory assessment. If the client's airway is secure, the nurse can move on to troubleshoot the equipment. Takeaway: The nurse should always assess the client before assessing mechanical ventilation equipment, beginning with assessing the marked ETT insertion depth to ensure the airway is patent.

The nurse is notified of the following client situations. The nurse should FIRST assess the client? A. With a sickle cell disease crisis who is reporting joint pain that is 7/10 B. With acute otitis media who reports decreased hearing in the affected ear C. With appendicitis who is awaiting surgery and has abdominal rigidity and T 101.2 (38.4 C) D. With aerial fibrillation with rapid ventricular response (RVR) on diltiazem with a hear rate of 98

C. With appendicitis who is awaiting surgery and has abdominal rigidity and T 101.2 (38.4 C) Explanation: Perforation of appendix is a complication of appendicitis that causes intestinal contents to leak into the peritoneal cavity, resulting in peritonitis, a life- threatening emergency. Manifestations of perforation include increased abdominal pain, abdominal rigidity, and high fever. Tachycardia and hypotension may occur as the condition worsens. The nurse should immediately report signs of perforation to the healthcare provider and anticipate immediate surgery. Clients with sickle cell disease crises typically experience sever and persistent generalized pain. The nurse should administer an analgesic. However a client with possible perforated appendicitis take priority Takeaway: Abdominal rigidity, increased abdominal pain, and high fever with appendicitis indicates perforation, a medical emergency requiring immediate surgical intervention. Prioritization

The nurse has been made aware of the following clients situations. The nurse should FIRST assess the client who? A. Has erythema and swelling to the left leg with purulent drainage at the site B. Has a history of migraines who report pain behind the right eye and nausea C. Woke up with decreased vision and repeats seeing "flashes of light" in their visual field D. Is 6 weeks pregnant, reporting mild stomach cramping, nausea, and an episode of vomiting

C. Woke up with decreased vision and repeats seeing "flashes of light" in their visual field Explanation: A sudden decreased in vision with visual field abnormalities (e.g., floaters, light flashes, or "a black curtain across the visual field") is a clinical manifestation of a retinal detachment, a medical emergency that causes permanent blindness if left untreated. If a retail detachment is confirmed, the nurse should prepare the client for surgery. The nurse should apply an eye patch to the attested eye to prevent further ocular stress and movement, which can worsen the detachment. Takeaway: A sudden loss of vision with visual field abnormalities (e.g., floaters, light flashes) is a manifestation of a retinal detachment, a medical emergency requiring immediate intervention to prevent permanent blindness.

A charge nurse is making client assignments for a critical care step-down unit. Which client would be MOST appropriate to assign to a new graduate registered nurse (RN)? A. a client admitted for diabetic ketoacidosis that is on a n insulin drip B. a client that is scheduled for discharge today that has a new colostomy C. a client admitted for a postoperative infection that is receiving IV antibiotics D. a client that is scheduled for a pacemaker insertion procedure during the shift

C. a client admitted for a postoperative infection that is receiving IV antibiotics Explanation: The skills, education, and experience of nursing staff, in addition to client acuity, must be considered when making client assignments carting for any of these clients is within the new RN's scope of practice; however, the client receiving IV antibiotic is most appropriate as care includes administration of IV antibiotics for signs of infection. these are skills that could reasonable be expected ted of a new RN. New graduate nurses have the least amount of experience and specialized knowledge and therefore should be assigned the least complex clients Key takeaway: the complexity of care and complexity of nursing staff must be considered when making client care assignments the most appropriate client assignment for a new graduate nurse is one that does not require specialized training or knowledge

The charge nurse is supervising a new graduate nurse who is obtaining informed consent on clients. Which of the following situation would require follow-up? A. a trauma client who recently received ibuprofen provides consent for surgery B. a client with a history of schizophrenia provides consent for voluntary inpatient treatment C. a client who recently received morphine provided consent for an implantable port insertion D. the parent of a 6 year old client provides consent on behalf of the client to undergo a tonsillectomy

C. a client who recently received morphine provided consent for an implantable port insertion Explanation: Client competency must established prior to obtaining informed consent. The client must be alert, oriented able to understand the treatment information, and able to make a decision. A client is considered temporarily incompetent and unable to provide consent if they recently received a medication that could alter their cognitive functioning or mental status (e.g., opioids, benzodiazepines) Key takeaway: a client must be considered competed to provide informed consent clients who have received medications that affect cognitive functioning are unable to provide consent

The nurse is providing a staff training on nurses' legal responsibilities to clients Which of the following should the nurse provide as an example of malpractice? A. a nurse's license expire, but the nurse completes two shifts before renewing the license B. a nurse does not document a client's fall because the client caught himself and was not injured C. a nurse does not reposition an immobile client and the client develops a pressure injury on the sacrum D. a nurse tells a client, "if you don't agree to take this medicine, then we will need to restrain you and give it."

C. a nurse does not reposition an immobile client and the client develops a pressure injury on the sacrum Explanation: negligence - conduct that falls below the reasonable, prudent standard of care malpractice - negligence by a professional (e.g., a nurse) that results in client harm assault - threat of harm or action that makes a client fear harm by the nurse battery - intentional touching of a client's body without clients consent malpractice is professional negligence that occurs when a nurse falls to meet the standard of care and causes client harm. the standard of care is the care that is reasonable and prudent nurse would provide in similar circumstances. four criteria for malpractice must be met: 1. duty of the client (e.g., nurse is assigned to care for the client) 2. breach of duty by the nurse 3. injury as result of the breach of duty 4. causation of the injury by the breach of the duty if an at-risk client develops a pressure injury because the nurse neglects to reposition the client this is an example of malpractice

The charge nurse is supervising administration of a blood transfusion to client with a gastrointestinal bleed by a registered nurse (RN) who is assisted by a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) The charge nurse should INTERVENE if the RN? A. asks the LPN to report the color of the client's next bowel movement B. asks the LPN to draw blood from a repeat hemoglobin level after transfusion C. asks the UAP to sit with the client during the first 15 minutes of the transfusion D. ask the UAP to measurer the vital signs before beginning the transfusion

C. asks the UAP to sit with the client during the first 15 minutes of the transfusion Explanation: registered nurse (RN's) should only delegate tasks the satisfy the FIVE rights of delegation and are within the delegatee's scope of practice. Key takeaway: The RN must remain with a client during the first 15 mintues of a blood transfusion to recognize complication and intervene as needed tasks requiring assessment and clinical judgment cannot be delegated

The charge nurse is supervising a registered nurse (RN) in the care of client with hypertension. The charge nurse should INTERVENE if the RN asks the unlined assist personnel (UAP) to? A. document the clients blood pressure and heart rate every 8 hours B. reports systolic blood pressure levels below or above a specific pressure C. show the client the correct way to measure a pulse before taking carvedilol D. measure orthostatic vital signs supine, 3 minute after sitting, and 3 minutes after standing.

C. show the client the correct way to measure a pulse before taking carvedilol Explanation: RN perform ALL parts of the nursing process: assessment, diagnosis, planning, implementation, evaluation performing initial assessment and any action requiring clinical judgment provides intimal client education manages care for complex and acutely ill clients develops the nursing care plan intimates blood transfusions asministers vasoactive medication RN should only delegate tasks that satisfy the FIVE rights of delegation and are within the delegatee's scope of practice

The nurses has taught a client with newly diagnosed gastroesophageal reflux disease. Which of the following statements by the client DEMONSTRATES understanding of the teaching? A. :I can try following a ketogenic diet to lose weight." B. " I will suck on peppermint candy to masse the burning taste." C. " I can try eating two large meals daily since it is uncomfortable to eat." D. " I will take esomeparazole daily regardless of whether I have symptoms.

D. " I will take esomeparazole daily regardless of whether I have symptoms. Explanation: Gastroesophageal reflex disease (GERD) is a chronic condition that occurs when stomach acid flows back into the esophagus, leading to discomfort and potential complication as acidic stomach contents come into contact with the lining of the esophagus. Nurses should teach clients that: Proton pump inhibitors (PPls) (e.g., esomeprazole, omeprazole) are prescribed to decreased the production of stomach acid. This medication needs to be taken daily to be effective. The effects of PPls build over time, so they should be taken consistently, even if symptoms are not present. Takeaway: PPls decreased the production of stomach acid and must be taken daily to treat GERD symptoms effectively

The nurse had been made aware of the following client situations. The nurse should FIRST assess the client who is? A. 28 weeks pregnant with sharp pains in the left lower abdomen and groin while standing B. 48-year0old with hypothyroidism taking levothyroxine who reports fatigue, constipation and paresthesias C. 60-year-old who suddenly stopped their sertraline and is experiencing nausea, insomnia, and irritability D. 11 month-old who has been vomiting for 24 hours with nasal congestion and a temperature of 102.3 F (39.1 C)

D. 11 month-old who has been vomiting for 24 hours with nasal congestion and a temperature of 102.3 F (39.1 C) Explanation: Infants are at higher risks of sever dehydration due to their large body surface area to weight ratio, which leads to greater fluid loss through evaporation. Conditions like vomiting and diarrhea further increase this risk. Additionally infants with nasal congestion ,ay have difficulty consuming enough fluids due to breathing and swallowing challenges. The nurse should first assess the 11-month-old with vomiting, fever, and nasal congestion. If left untreated, dehydration can progress to hypovolemia and electrolyte imbalances. Takeaway: Young children are at higher risk for severe dehydration and hypovolemia

The pediatric nurse assesses multiple clients. Which of the following clients should the nurse INVESTIGATE further for potential child abuse? A. 1 year old client who has bright red cheeks and a raised, bumpy rash bilaterally on the arms and legs B. A 5 month old client who has influenza and a 4 cm bluish-gray asymmetrical marking on the left buttocks C. A 10 year old client who has scratched shins and a clavicle fracture and reports falling while skateboarding D. A 7 month old client with palm burns whose caregiver says the client climbed up the sink and grabbed a hot iron

D. A 7 month old client with palm burns whose caregiver says the client climbed up the sink and grabbed a hot iron Explanation: Caregiver reports in which the cause of injury or illness doers not correlate with the client's developmental age or physical ability indicate possible abuse and require further investigation. A 7-month-old client does not have the gross motor ability to climb onto a tall sink. Infants can pull up on furniture around 8-12 months but do not master the skill of climbing until toddlerhood (approximately 12-24 months of age). Takeaway: Report in which the cause of physical injury or illness does not correlate with the developmental age or physical abilities of the client require further investigation for potential abuse. Topic: Abuse/ Neglect

The nurse has become aware of the following client situations. For which client should the nurse recommend utilizing a restraint? A. A client with hypertension who appears agitated, is pacing, and states, "I want to go how now!" B. A client who is at risk for falling due to limited mobility frequently attempts to exit the ned unassisted C. A client being involuntarily committed for attempted self-harm who is anxious, fidgeting, and will not make eye contact with staff D. A disoriented client prescribed strict intake and output measurement who its attempting to remove the indwelling urinary catheter.

D. A disoriented client prescribed strict intake and output measurement who its attempting to remove the indwelling urinary catheter. Explanation: A restraint is any physical (e.g., mitts) or chemical (e.g., sedatives) method of restricting movements that temporarily protects the safety of the client or others. Several factors increase the likelihood of restraint use: Cognitive impairment Presence of irritation medical device (e.g., indwelling catheters) Psychiatric symptoms (e.g., hallucinations) Aggressive behaviors Substance abuse or withdrawal (e.g., alcohol) Fall risk Takeaway: Restraints are appropriate for clients at risk for harming themselves or others who cannot be deterred with alternative methods Topic: Restraints

Which client is at risk for developing syndrome of inappropriate antidiuretic hormone (SIADH)? A. A patient with rheumatoid arthritis B. A patient with diabetes mellitus C. A patient with a long history of sciatica D. A patient with small cell lung cancer

D. A patient with small cell lung cancer Answer & Rationale: Ask: which client Problem: Highest risk for SIADH, client had too much ADH Solution: Client with SIADH factor Explanation: Can secrete ADH which adds the H20

What type of immunity does vaccine provide? choose only ONE best answer. A. naturally acquired passive immunity B. Artificially acquired passive immunity C. Naturally acquired active immunity D. Artificially acquired active immunity

D. Artificially acquired active immunity

A charge nurse is supervising administration of blood transfusion to a client with a gastrointestinal bleed by a registered nurse (RN) who is assisted by a licensed practical nurse (LPN) and an unlicensed assistive personnel (UPA). The charge nurse should INTERVENE if the RN? A. Asks the LPN to report the color of the client's next bowel movement B. Asks the LPN to draw blood for a repeat hemoglobin levels after transfusion C. Ask the UAP to measure the vital signs before beginning the transfusion D. Ask the UAP to sit with the client during the first 15 minutes of the transfusion.

D. Ask the UAP to sit with the client during the first 15 minutes of the transfusion. Explanation: RN should only delegate tasks that satisfy the five rights (RIGHT PERSON, RIGHT TASK, RIGHT CIRCUMSTANCE, RIGHT DIRECTION & COMMUNICATION, RIGHT SUPERVISION & EVALUATION of delegation and are within the delegatee's scope of practice. During the first 15 minutes of a blood transfusion, the RN should assess the client's response to the transfusion and intervene to correct any development complications (e.g., slow or stop transfusion). Tasks requiring assessment and clinical judgment cannot be delegated to either a licensed practical nurse (LPN) or an unlicensed assistive personnel (UAP). Takeaway: The Rn must remain with a client during the first 15 minutes of a blood transfusion to recognize complications and intervene as needed. Takes requiring assessment and clinical judgment cannot be delegated. Topic: Managing care

The nurse provides care for a client diagnosed with pre-renal acute kidney injury. Which action will the nurse perform FIRST? A. Assess for history of prostate enlargement B. Insert an indwelling urinary catheter C. Monitor the clients daily weights D. Assess the client's blood pressure

D. Assess the client's blood pressure

The nurse is caring for a client with suspected chronic venous insufficiency. Which of the following findings would SUPPORT a diagnosis of chronic venous insufficiency? A. Absent pedal pulse B. Intermittent leg cramping with exercise C. Ulcers on the toes with well-defined edges D. Brown discoloration to the lower extremities

D. Brown discoloration to the lower extremities Explanation: CVI is a condition characterized by inadequate blood return from the lower extremities, resulting from elevated pressure in the veins that stretches the vessels and damages their valves over time. Manifestations of CVI include peripheral edema in the lower legs, which worsens with prolonged standing or sitting. CVI also causes skin changes, which include a thick, leathery appearance and brownish discoloration on the lower legs from hemosiderin deposits takeaway: CVI is caused by inadequate blood return from lower extremities.

Which body system is responsible for the transport of dissolved oxygen from the lungs to the spleen? A. Immune B. Endocrine C. Respiratory D. Cardiovascular

D. Cardiovascular NOTE: Oxygen is carried in the blood in two forms: (1) dissolved in plasma and RBC water (about 2% of the total) and (2) reversibly bound to hemoglobin (about 98% of the total). Inside the red blood cell, oxygen reacts chemically with hemoglobin and is transported by both free and hemoglobin-facilitated diffusion. Oxygen diffuses through the cell membrane and is transported in blood plasma by free diffusion and by convection.

A client is admitted with flammatory bowel syndrome (Crohn's disease). When planning care for the health care team, which would be included? Select all that apply? A. Lactulose therapy B. High-fiber diet C. High protein milkshakes D. Corticosteroid therapy E. Anti-diarrhea therapy

D. Corticosteroid therapy E. Anti-diarrhea therapy Explanation: Treat very all that apply as a true or false statement

A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should NEXT assess the client for the presence of which condition? A. Thirst B. Polyuria C. Decreased blood pressure D. Crackles on accusation of the lungs

D. Crackles on accusation of the lungs Explanation: To much fluid in there lungs and they are hyperbolic

The nurse is caring for a client who has thrombocytopenia Which of the following findings hold REQUIRE IMMEDIATE follow-up? A. Petechiae on forearms B. Client reports hematuria C. Client reports bleeding gums D. Decreased levels of consciousness

D. Decreased levels of consciousness ex: Thrombocytopenia is a platelet count below 150 x 10 (3) it is caused by low production from bone marrow suppression, destruction of platelets by autoimmune disorders Thrombocytopenia can cause bleeding, which manifest as ecchymoses, petechiae or bleeding from the nose and gums. As levels drop, bleeding may involve the kidneys, gastrointestinal tract, or brain. (HEMORRHAGING IS the major complications) Takeaway: The most serious complication of thrombocytopenia is intracranial bleeding, manifested by decreased levels of consciousness

The nurse is planning care for client with type 2 diabetes who is taking metformin. Which of the following would be a PRIORITY for the nurse to include in the plan of care? A. Monitoring the client's serum creatinine levels daily B. Checking the client's blood glucose four times daily C. Encouraging the client to eat whenever appetite is poor D. Hold metformin before the client has a CT scan with contrast

D. Hold metformin before the client has a CT scan with contrast Explanation: Metformin is a biguanide oral anti diabetic medication that is first-line in the treatment of type 2 diabetes. Metformin does not lower blood glucose directly, but helps control blood sugar by decreasing glucose production in the liver and increasing tissue responsiveness to insulin (I.e., insulin sensitivity). Combining metformin with IV contrast material poses an increased risk for renal toxicity and life-threatening lactic acidosis; therefore, metformin should be help 1-2 days before a CT with contrast and for 48 hours afterwards. Takeaway: Metformin should be withheld 1-2 days before a CT scan with contrast medium and for 48 hours afterwards to ensure optimal renal function

The nurse is planning care for a client who is at risk for increased intracranial pressure. Which of the following assessments should the nurse PRIORITIZE in the client's plan of care? A. Babinski reflex B. Presence of headache C. Pupil size and reactivity D. Level of consciousness

D. Level of consciousness Explanation: Altered level of consciousness (LOC) is the most reliable, sensitive, and often the earliest indicator of (ICP) that appears before changes in pupil assessment, which are a late finding. Changes in LOC are most accurately assessed by using the Glasgow Coma Scale (GCS). Even subtle changes in GCS may indicate increased ICP, which can cause brain herniation and death if left untreated. Takeaway: assessing LOC is the most reliable, sensitive, and often earliest sign of increased ICP.

Which medication does the expect the healthcare provider (HCP) to describe for a client who is diagnosed with heart failure and reports a nagging cough and ant incident of and an incident of angioedema with there use of enalapril? A. Alprazolam 0.7 mg PO daily B Guaifenesin 15 mg daily C. Captopril 40 mg PO daily D. Losartan 80 mg PO daily

D. Losartan 80 mg PO daily Answer & Rationale: Ask: Best medication substitution Problem: Nagging cough & angioedema with enalapril think side effects of ACE inhibitors end in "pril" which are the first line drugs for high blood pressure ARB's " Spartan" is nSSSecond line drug Solution: Substitution for ACE medication Explanation: Sartans are used SSSecond, after ACE inhibitors if the side effects are too much

The nurse is caring for a client who had an endovascular repair of an abdominal aortic aneurysm 2 hours ago. The of the following would be a priority for the nurse to include in the plan of care? A. Assess and document the client's hourly urine output. B. Measure the client's temperature and while blood cell count C. Measure the serum creatinine and blood urea nitrogen levels D. Palpate the pedal pulses and temperature of lower extremities

D. Palpate the pedal pulses and temperature of lower extremities Ex: An abdominal aortic aneurysm (AAA) is a localized enlargement of the abdominal aorta. If the AAA grows large enough, it could rupture, which is potentially fatal due to severe internal bleeding. One of the surgical treatments for AAA is an end-vascular repair, which involves stunting the aneurysm to prevent rupture. Following AAA repair, monitoring perfusion to the lower extremities is crucial sine the aorta supplies blood to the lower half of the body. Diminished or absent pedal pulses or cold or pale lower extremities indicate a clot or graft occlusion impairing blood flow Takeaway: Following endovascular repair of AAA, the nurse should prioritize munitioning lower extremities perfusion since the aorta supplies blood to the lower half of the body.

The nurse is performing a dressing change for a client recovering from lower abdominal surgery. After removing the old dressing, the nurse notices the edges of the surgical site are no longer approximated, and a small portion of the client's intestines is protruding through the opening. When action should the nurse take FIRST? A. Assess the client's vital signs B. Place client on strict NPO status C. Notify the surgical team to prepare for emergency surgery D. Place sterile gauze soaked in sterile saline solution one the intestines.

D. Place sterile gauze soaked in sterile saline solution one the intestines. Explanation: Evisceration occurs when all layers of a wound separated allowing protrusion of internal organs (e.g., intestines). This is a medical emergency that requires surgical correction to prevent infection and tissue death. The nurse should position the client supine with knees bent to decrease tension on the abdominal area and prevent the intestines from protruding further, and place sterile gauze soaked in sterile saline solution over the site. This creates a physical barrier that rescuers the risk of contamination the sterile peritoneum white the saline keeps tissues moist until surgical closure. After the wound opening is covered, the nurse should prepare the client for surgery. Takeaway: Evisceration is a medical emergency requiring surgical correction. Covering the wound and tissue with sterile saline-soaked sterile gauze is the priority to prevent infection and tissue death. Topic: Wound healing

The nurse is made aware of the following client situations. the nurse should FIRST assess the client who had? A. Glaucoma surgery and is reporting nausea and constipation B. Right-sided thoracotomy and has 9/10 pain with inspiration and coughing C. Laparoscopic cholecystectomy and is now reporting 6/10 right shoulder pain D. Reduction of a dislocated shoulder and has numbness and tingling of the fingers

D. Reduction of a dislocated shoulder and has numbness and tingling of the fingers Explanation: Numbness and tingling are concerning for neuromuscular impairment in a client with a musculoskeletal trauma (e.g., dislocation, fracture). This is a circulation issue requiring an urgent , focused neuromuscular assessment of the affected extremity. Takeaway: Numbness and tingling are concerning for neuromuscular impairment in a client with musculoskeletal trauma (e.g.,dislocation, fracture).

What cavity contains all of the frontal cavities? Choose only ONE best answer. A. Dorsal B. Thoracic C. Abdominal-pelvic D. Ventral

D. Ventral

How is lochia rubra described?

dark red (last 1-3 days) and consists mainly of blood and decimal and trophoblastic debris active bleeding from placental site, trophoblastic tissue debris

How is lochia serosa descr?

flow pales and becomes pink or brown; usually occurs after 3 to 4 days; consists of old blood, serum, leukocytes, and tissue debris (pinkish brown 4-10 days) Placental wound discharge, RBC, WBC's trophoblastic tissue debris