Practice Question Banks 16-30 (Not Required)

The nurse is caring for a client who is being treated at home for chronic renal failure. During weekly home visits, which method is the most accurate indicator of fluid balance? Trends in daily weights Skin turgor over at least two areas of the body Difference between intake and output Changes in mucous membrane moistness

Trends in daily weights The most accurate indicator of changes in fluid balance is the daily weight. Any client who has a diagnosis that effects the ability of the body to manage fluid balance should weigh themselves every morning and report a gain of 3 pounds in one week or 1 to 2 pounds overnight. A 1-kilogram (or 2.2 pounds) of weight gain is equal to approximately 1000 mL of retained fluid. Skin turgor, mucous membranes and the net difference between intake and output are not accurate indicators of fluid balance. Correct! LESSON Physiological Adaptation Fluid and Electrolyte Imbalances COURSE RN & PN Review BODY SYSTEM urinary KEYWORDS renalfluid balanceweight

After receiving report on the following clients, which client should the nurse assess first? A client diagnosed with peptic ulcer disease (PUD) who reports feeling dizzy A client reporting gastric distress after taking ibuprofen A client who underwent a partial gastrectomy and reports feeling lightheaded A client diagnosed with emphysema with questions about a new medication

A client diagnosed with peptic ulcer disease (PUD) who reports feeling dizzy Dizziness with PUD may indicate hemorrhaging. This client should be assessed including a symptom assessment and vital signs. The findings in the other options are expected and not life-threatening. A client may feel lightheaded due to dehydration and pain management related to a gastrectomy. Ibuprofen is a nonsteroidal anti-inflammatory drug, which has a common side effect of gastrointestinal symptoms. While educating the client on the new medication is important, it is not a priority for assessment. LESSON Management of Care or Coordinated Care Establishing Priorities COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS peptic ulcerPUDgastrectomyGERDgastroesophageal reflux diseaseibuprofen

The nurse is providing discharge education to a client who is prescribed alprazolam for a panic disorder. What concept should the nurse emphasize concerning the drug action? The medication acts as a stimulant If you miss a dose, double the next scheduled dose Short-term relief can be expected The medication works by suppressing dopamine

A sprain is excessive stretching of the ligament with tearing of the ligament fibers. Twisting motions from a fall or sports activity typically precipitate the injury. A second-degree sprain is classified as moderate. Second-degree sprains require immobilization with an elastic bandage and ankle brace, splint or cast. Recommendations for caring for a client with a sprain include rest, use of ice for the first 24 to 48 hours, application of a compression bandage for a few days to reduce swelling and provide joint support and elevation of the affected extremity (RICE). It is recommended not to stretch or use the sprained joint for approximately a week, sometimes longer, to allow it to heal properly. The nurse should follow up and advise the client not to perform stretching and range of motion exercises.

A nurse is caring for a client following a Computed Tomography (CT) scan of the kidneys with contrast. Which of these findings would require prompt intervention by the nurse? Elevated serum creatinine above baseline Soreness reported at the IV site The client states that the urethra feels irritated and sore from the catheter The client states they have felt mild nausea since the procedure

A; A CT scan provides three-dimensional information about structures within the body. Oral or injected dye (contrast) is generally used during this scan to provide detailed images. After the scan, the nurse should monitor for complications associated with the contrast including anaphylaxis or contrast-induced nephropathy. Contrast-induced nephropathy is defined as a 25% increase of the serum creatinine above baseline within 48 hours of the procedure. While mild nausea and soreness at the IV site are problems requiring intervention, they are not the immediate concern. A catheter is not required for this procedure. LESSON Physiological Adaptation Unexpected Response to Therapies COURSE RN Review BODY SYSTEM urinary KEYWORDS urogram anaphylaxis dye test allergy

The nurse is providing discharge education to a client who is prescribed alprazolam for a panic disorder. What concept should the nurse emphasize concerning the drug action? The medication acts as a stimulant If you miss a dose, double the next scheduled dose Short-term relief can be expected The medication works by suppressing dopamine

Alprazolam is a short-acting benzodiazepine, which works quickly to control panic symptoms by enhancing the effects of the neurotransmitter Gamma-amino butyric acid (GABA). This produces a calming effect. The drug does not suppress dopamine like dopamine antagonists and some antipsychotic medications. Alprazolam will not be increased as tolerated, the lowest dose that controls the symptoms will be maintained. ; c LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM nervous KEYWORDS panic disorder Xanax alprazolam teach

The home health nurse is evaluating the plan of care for a 15-year-old male client with muscular dystrophy. The client is mostly immobile and unable to care for himself. The client is at risk for depression due to which issue? Lack of trust Dependence Loss of control Insecurity

Dependence Correct! A 15-year-old adolescent would be in the stage of development Identity vs. Role Confusion (Erikson). Since this adolescent is dependent on others, it will be difficult for him find his own identity. Adolescents may react to dependency with rejection, uncooperativeness, or withdrawal. LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS illgrowthdevelopmentdependency

The nurse is caring for a child diagnosed with seizures. While teaching the family and the child about the medication phenytoin, which concept should the nurse emphasize? Omit the medication if the child is seizure-free Maintain good oral hygiene and dental care Serve a diet that is high in iron A rash is normal with this medication

B; Gingival hyperplasia may occur with this medication. It is important that good oral hygiene is maintained. The medication should never be stopped, even if the child is seizure-free. A sudden discontinuation could result in status epilepticus. A diet high in iron interferes with phenytoin absorption and will reduce the effectiveness. A blister-like rash is not normal with this medication and could indicate medication-related Stevens-Johnson syndrome, which is a serious disorder of the skin and mucous membranes. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS phenytoin Dilantin gums seizure child teach

The nurse is reviewing the previous assessment findings for a newborn. The nurse notes that the first APGAR score was 8 and the next score was 9. Which category of the APGAR test is most likely the reason for the improved score? Color Muscle tone Heart rate Cry

Color; The APGAR test is an assessment used to evaluate and monitor a newborn's physical condition at 1 minute and 5 minutes after birth. The APGAR test evaluates five categories including: A- appearance (skin color) P- pulse (heart rate) G- grimace (reflex irritability) A- activity (muscle tone) R- respiratory (respiratory effort) These categories are rated on a 0 to 2 scale. A score of 0 indicates absent or poor response and 2 indicates a normal response. A normal APGAR score ranges from 8 to 10 and no medical intervention is needed other than supporting respiratory effort and thermoregulation. It is common for the newborn to experience acrocyanosis. This occurs when the body is pink and the extremities are blue and would be scored a 1. This is the most common APGAR score deduction. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS APGARscoreskincolor

A nurse is educating a client about the use of warfarin at home. The nurse should reinforce the need for the client to monitor which of the following? Limit of strenuous physical exercise Avoidance of public transportation and large groups of people Extended exposure to outdoor sunlight Consistent intake of foods high in vitamin K

Consistent intake of foods high in vitamin K Correct! Warfarin, an oral anticoagulant, works by causing a decrease in the vitamin K-dependent clotting factors produced by the liver. Due to this mechanism of action, vitamin K is used as the antidote for warfarin overdose. A diet high in vitamin K could counteract the therapeutic effect of warfarin. Foods high in vitamin K include dark green leafy vegetables, tomatoes, bananas, cheese and fish. Best practice no longer recommends limiting the intake of Vitamin K-containing foods, instead it is recommended to keep the intake of foods high in Vitamin K 'consistent'. The other actions do not pertain to warfarin. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS vitamin KwarfarinCoumadin

The nurse is reviewing the written orders for a newly admitted client. The nurse has difficulty reading the health care provider's handwriting. Which action should the nurse take first? Leave the order for the oncoming staff to follow up on Contact the charge nurse for an interpretation Call the provider for clarification of the order Ask the pharmacy for assistance in the interpretation

Call the provider for clarification of the order The nurse should call the health care provider to clarify this order. Relying on another person's interpretation of the order is risky. It is not appropriate to leave the order for the oncoming shift to follow up. Order entry systems are minimizing these types of problems. Incorrect LESSON Safety and Infection Control Accident, Error, Injury Prevention COURSE RN Review KEYWORDS readshiftorder

The nurse and client discuss the progress that has been made toward the client's goal of quitting smoking. This is a typical step in which phase of the therapeutic relationship? Orientation Termination Working Incorrect Pre-interaction

b. During the termination phase, the nurse and client will discuss progress towards the goal and feelings about the termination of the therapeutic relationship. In the orientation phase, the nurse and client will become acquainted and discuss roles and goals. In the working phase, the nurse and client strategically work towards the set goals and discuss any concerns that may arise. LESSON Psychosocial Integrity Therapeutic Environment COURSE RN Review KEYWORDS therapeutic relationship progress stress

A new nurse is delegating tasks to the unlicensed assistive personnel (UAP). If delegated, which task would require intervention by the nurse manager? Feed a 2-year-old with a broken arm Bathe a woman receiving brachytherapy with an internal radon device Empty the urethral collection bag and provide perineal care Assist an elderly client to the restroom

Caring for a client receiving brachytherapy with a radon implant and the associated hardware is complex. Additionally, movement of this client and exposure of healthcare workers to the radiation should be limited. The other tasks are simple and within the expectations of a UAP's duties. LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS managerinterventionUAPcharge nurse

The nurse is providing prenatal education to a client who has just found out she is 8 weeks pregnant. The woman asks how the health care provider (HCP) knew that she was pregnant by just looking inside her vagina. Which response is the best explanation for this? Pronounced softening of the cervix Bluish coloration of the cervix and vaginal walls Plug of very thick mucus Slight rotation of the uterus to the right

Chadwick's signs is a bluish-purple coloration of the cervix and vaginal walls. It develops at 6 to 8 weeks of gestation and is caused by an increased blood supply to the area. Other early signs of pregnancy include Hegar's signs (a softening of the cervical isthmus) and Goodwell's sign (a softening of the cervix). While these are early signs of pregnancy, the HCP would need to compress and palpate the tissue to assess these findings. The HCP would not see the mucus plug. The mucus plug dislodges and passes out of the body just prior to labor. LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN & PN Review BODY SYSTEM reproductive KEYWORDS pregnantChadwickbluish

A nurse is preparing to assist a mother with breastfeeding for the first time. Which of the following is a priority? Give the mother several illustrated pamphlets Darken the room and allow for privacy for the initial feeding Inform the client that breastfeeding is a skill for both the mother and newborn Assist the mother with helping the newborn to latch appropriately

Immediate breastfeeding after birth is associated with physiological benefits for the newborn and mother. While educating about breastfeeding is important, it is essential to ensure the infant has latched appropriately. Darkening the room may be appropriate for subsequent feedings, but it is important for the nurse to support the mother and newborn during the initial feeding.

The charge nurse is informed about a conflict between two unlicensed assistive personnel (UAP) on the unit. Which approach is most appropriate to achieve effective conflict resolution? Encourage the UAPs to '"vent" their anger. Deal directly with the conflict affecting the workplace. Explain the consequences of not resolving their differences. Require the UAPs to meet 1-on-1 until they reach a compromise.

Deal directly with the conflict affecting the workplace.;, When managing conflict in the workplace, it is most important to deal with the issue directly. The conflict occurs, it should not be minimized or ignored. When there is a conflict, people tend to feel angry and although "venting" may feel good, is is usually counterproductive. Forcing the UAPs to reach a compromise is not appropriate. If necessary, potential consequences of not resolving the conflict between the UAPs should be discussed. LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS UAP conflict resolve issue

The nurse is caring for a newly admitted 6 month-old infant diagnosed with nonorganic failure-to-thrive (NOFTT). What findings would the nurse expect to observe during the initial assessment? Pale skin, thin arms and legs and uninterested in surroundings Irritable and "colicky," making no attempts to turn or sit up Dusky in color with poor skin turgor over abdomen Alert, laughing, playing with a rattle and sitting with support

Diagnosis of NOFTT is weight consistently below the 3rd to 5th percentile for age and gender, progressive decrease in weight to below the 3rd to 5th percentile, or a decrease in the percentile rank of two major growth parameters in a short period of time. The nurse would expect to see a child who avoids eye contact, has pale skin, thin arms and legs, and is easily fatigued. NOFTT is due to psychosocial problems such as neglect, lack of knowledge about proper feeding or of the infant's needs. Many times the child engages in self-stimulatory behaviors (head banging or rocking) and is wary of close contact with people. Pale skin, thin arms and legs and uninterested in surroundings ; LESSON Physiological Adaptation Alternations in Body Systems COURSE RN & PN Review KEYWORDS infant failure to thrive NOFTT

The nurse is caring for a client diagnosed with heart failure who will begin treatment with digoxin. Which therapeutic effect would the nurse expect to find after administering this medication? Increased heart rate with increased respirations Decreased chest pain with decreased blood pressure Improved respiratory status with increased urinary output Diaphoresis with decreased urinary output

Digoxin (Lanoxin), a cardiac glycoside, is used in clients with heart failure to slow and strengthen the heartbeat. As cardiac output is improved, renal perfusion is improved and urinary output increases. Clients can become toxic on this drug, indicated by findings of bradycardia or tachycardias above 120, arrhythmia, visual or gastrointestinal disturbances. Clients being treated with digoxin should have the apical pulse evaluated for one full minute prior to the administration of the drug. LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS digoxin lanoxin urine output

The nurse is caring for a 4-year-old child. The parents state they must leave the hospital, but will return at 6pm. After they leave, the child asks when he will be able to see his parents. Which option is the best response by the nurse? "When the clock hands are on the numbers 6 and 12." "They will be back right after you eat supper." "After you play awhile, they will be here." "In about two hours, you will see them."

b. Time is not completely understood by preschoolers. Preschoolers interpret time with their own frame of reference of activities that they have experienced. Thus, it is best to explain time in relationship to a known and common event. LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS childpreschooltime

The nurse is assessing a client who takes a prescribed antipsychotic medication. Which findings require immediate discontinuation of this medication? Cheek puffing and involuntary movements of extremities and trunk Involuntary rhythmic stereotypic movements and tongue protrusion Agitation and constant state of motion Hyperthermia and severe muscle rigidity

LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS discontinueantipsychoticNMShyperthermiarigidity d; Hyperthermia, severe muscle rigidity and malignant hypertension are findings associated with neuroleptic malignant syndrome (NMS). NMS is a serious complication associated with the use of antipsychotic drugs. Repetitive, involuntary movements of the face or body may be a sign of tardive dyskinesia related to antipsychotic use. This is a serious concern, but not an emergency. Tardive dyskinesia may be irreversible, even after the medication has been discontinued. Agitation and being in a constant state of motion are most likely related to the illness being treated, such as bipolar disorder or schizophrenia.

The nurse is performing a respiratory assessment on a newborn. Which assessment finding would require intervention by the nurse? Symmetric chest movement Short periods of apnea (<10 seconds) Rapid, shallow respirations Nasal flaring

Nasal flaring Correct! Submit Newborn respirations are often rapid, shallow and irregular with short periods of apnea (<15 seconds). The respiratory rate of a newborn is dependent on their activity level but ranges from 30 to 60 breaths per minute and chest movement should be symmetrical. While rapid, the respirations should not be labored. Nasal flaring, cyanosis, sternal retractions and expiratory grunting are signs of respiratory distress and should be further evaluated. LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM respiratory KEYWORDS airway obstruction retraction accessory muscle distress infant nasal flaring

The nurse is teaching a group of women in a community clinic about osteoporosis. Which explanation should the nurse include? Ice, rest and ibuprofen will help with the symptoms of osteoporosis. It is best to avoid foods high in purine, such as bacon, liver and shellfish. It is important to increase calcium intake and weight-bearing exercise. Performing regular range-of-motion exercises will help with inflamed joints.

Osteoporosis (OP) is a chronic, progressive metabolic bone disease marked by low bone mass and the deterioration of bone tissue, leading to bone fragility and an increased risk of fractures. Care focuses on proper nutrition, calcium supplementation, exercise, drugs and the prevention of falls.Osteoporosis is often mistaken for osteoarthritis (OA). Ice, rest, NSAIDs and range-of-motion exercises are used to treat symptoms of OA and/or Rheumatoid Arthritis (RA).Purine-rich foods need to be avoided with gout. Purine-rich foods increase uric acid production, which worsens the symptoms of gout. LESSON Physiological Adaptation Alterations in Body Systems COURSE RN & PN Review BODY SYSTEM musculoskeletal KEYWORDS osteoporosisteaching

A nurse is caring for a client diagnosed with an obstructing renal calculus. Which focus of the health care provider's orders would the nurse prioritize?

Push oral fluids Morphine sulfate for pain control Start intravenous antibiotics Apply warm compress over flank area The priority action for an obstructing renal calculus (kidney stone) is to provide prompt relief for the severe pain. Oral hydration or intravenous fluids will help move the stone though the urinary system, but would be prioritized after pain management. Applying a warm compress over the flank may help pain, but would be prioritized after narcotic analgesics for this diagnosis. A kidney stone is not an infection and does not indicate the need for intravenous antibiotics LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM urinary KEYWORDS renalcalculipainnarcotic

The nurse is caring for a client who is the victim of domestic violence. The client states, "If I just could follow directions, this would not have happened." This statement indicates the client is experiencing which feeling? Helplessness Rejection Self-blame Fear

Self-blame.\;\\\ Intimate partner violence is defined as physical, sexual, stalking and psychological aggression by a current or former partner. The nurse is often the first health care worker in contact with these victims. Victims of domestic violence may be immobilized by a variety of affective responses with one being self-blame. The nurse's responsibility is to make a safety plan with the victim and follow any facility policies or procedures concerning victims. However, the victim has a right to self-determination without judgement. LESSON Psychosocial Integrity Abuse, Neglect COURSE RN Review KEYWORDS domesticviolencevictim

The nurse on the mental health unit is assigned to a client diagnosed with post-traumatic stress disorder (PTSD). What priority interventions shall the nurse include in the client's plan of care? Select all that apply. Stay with the client during periods of flashbacks and nightmares. Medicate the client with a sedative while they experience flashbacks. Place the client in a secluded area away from others. Discuss the coping strategies the client is using in response to the trauma. Encourage the client to talk about the trauma at their own pace. Assign the same staff to the client as often as possible.

Stay with the client during periods of flashbacks and nightmares. Discuss the coping strategies the client is using in response to the trauma. Encourage the client to talk about the trauma at their own pace. Assign the same staff to the client as often as possible. Trauma-related disorders such as PTSD can be described as the client's reaction to an extremely distressing experience, such as natural or man-made disasters, combat, serious accidents, witnessing the violent death of others, or being the victim of torture, terrorism, rape or other crimes that cause severe emotional shock and have long-lasting psychological effects.Interventions that are considered trauma-informed highlight the importance of respect for the client, collaboration and connection, providing information about the connections between trauma and other health concerns, instilling hope and empowering the trauma survivor to guide and direct their recovery plan.A PTSD client may be suspicious of others in their environment. It is a priority to facilitate building a trusting relationship. The presence of a trusted individual may reassure the client and calm their fears for their personal safety. Debriefing or talking about the traumatic event is the first step in the client's progression toward resolution. The long-term resolution of the client's post-traumatic response is largely dependent on the effectiveness of the client's coping strategies.Interventions such as seclusion may be retraumatizing to a client with a history of trauma and are only indicated if the client exhibits behavior that presents imminent risk of harm to themselves or others.Administering a sedative without a clear, clinical indication is considered a chemical restraint. This should never be used for the convenience of the staff or as a punishment. The nurse should first try other measures to decrease agitation such as talking down (verbal intervention). Incorrect LESSON Psychosocial Integrity Mental Health Concepts COURSE RN & PN Review KEYWORDS PTSD sedative trauma restraint

The nurse is providing pre-operative care for a 2-month-old diagnosed with a congenital heart defect. Which intervention is best for meeting the child's nutrition and health needs? Provide bottle feedings every 2 hours Supplement bottle feedings with water Support the mother who breastfeeds Mix medications with formula or breastmilk in a bottle

Support the mother who breastfeeds Infants with congenital heart defects have increased nutrition needs and tend to tire quickly during feeding. Breastmilk offers the optimal nutrition and requires less effort from the infant when compared to bottle feeding. Infants with congenital heart disease usually do better when fed more often and on demand. This is usually 8 to 12 times a day. The nurse should support the mother's efforts to breastfeed. The infant should not be given water since there are no calories or vitamins in water. Medication should never be mixed with milk or formula. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS infant heart defect congenital

The nurse is monitoring the level of consciousness for a client who experienced a head injury. During the last assessment, the client scored a 15 on the Glasgow Coma Scale (GCS). Now, the client opens eyes to verbal command (GCS 3), has purposeful movement to painful stimulus (GCS 5) and is using inappropriate words (GCS 3). Which intervention by the nurse should be implemented first? Call the rapid response team and health care provider Raise the head of the bed Increase the flow of oxygen Continue to monitor level of consciousness

The GCS measures the client's highest motor response, verbal response, and eye response with scores ranging from 3 to 15. The GCS can be used to monitor progress and predict a client's outcome or prognosis. In the last assessment, this client was scored a 15 on the GCS, which indicates the baseline. Upon reassessment, the client's responses have decreased indicating a worsened neurological state. This requires urgent intervention and the rapid response team and health care provider should be notified. If the nurse continues to monitor the level of consciousness without notifying the HCP and the rapid response team, the client's condition could worsen. It is possible the change is related to increased intracranial pressure (ICP), but this needs to be determined before the other actions are taken. LESSON Reduction of Risk Potential System Specific Assessments - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS brain injury assessment Glasgow

The home health nurse is educating the parent of a child who has a chronic condition that limits mobility. Which statement best describes the effects of immobility in children? Immobilized children quickly develop confusion and mental status changes The physical effects of immobility are similar in both children and adults Children are more susceptible than adults to the multisystem effects of immobility Immobility promotes independence and self-reliance in children

The physical effects of immobility are similar in both children and adults The physical effects of immobility are similar for clients of almost any age. Care of the immobile child includes efforts to prevent complications of muscle atrophy, contractures, skin breakdown, constipation, bone demineralization and cardiopulmonary complications. Immobility can negatively impact self-image and having to rely on others to meet their basic needs, especially in adolescents. Planning and providing nursing care in creative ways, and involving children in their care and providing age-appropriate diversion can help reduce the effects of immobility. Older adults with chronic conditions are at greatest risk for developing confusion. LESSON Basic Care and Comfort Mobility, Immobility COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS childmobilityimmobility

An inpatient psychiatric client diagnosed with schizophrenia is observed talking to unseen people and urinating on the floor. Which action by the nurse is appropriate to address the client urinating on the floor? Restrict the client's fluids throughout the day Withhold privileges each time the voiding occurs Require the client to mop the floor after each incident Toilet the client more frequently with supervision

Toilet the client more frequently with supervision Correct! Submit With a client that has altered thought processes, the appropriate nursing approach to change behaviors is to take an active role in attending to the physical needs of the client. The other options are incorrect approaches. LESSON Psychosocial Integrity Behavioral Interventions or Behavioral Management COURSE RN Review KEYWORDS behavior void

A nurse is caring for a child who underwent a tonsillectomy an hour ago. The child's parents report to the nurse that the child feels very warm. Which intervention should the nurse do first? Reassure the parent that this is normal after surgery. Administer the prescribed acetaminophen. Measure the child's temperature. Offer the child cold oral fluids.

While a low-grade fever (>101°F or 38.3°C) is common after surgery, the nurse should assess the child's temperature prior to any action. The health care provider (HCP) should be contacted if the temperature is higher than 101.5° (38.6°C). After evaluating the child's temperature, the other options may be implemented. However, the child should not drink fluids until they are alert and should not be given straws, acidic juices, or red/brown fluids. Straws and acidic juices may cause surgical site damage and red/brown fluids may be confused with blood in emesis. Correct! Measure the child's temperature. ; LESSON Reduction of Risk Potential Changes, Abnormalities in Vital Signs COURSE RN & PN Review BODY SYSTEM lymphatic KEYWORDS postoperative carefever

The nurse is providing care for a client who is diagnosed with schizophrenia and treated with clozapine. The client reports that his leg has developed an involuntary movement and he can feel his heart beating. Which other assessment findings should the nurse gather before calling the health care provider (HCP)? Bowel sounds in all four abdominal quadrants Glasgow Coma Scale (GCS) to measure level of consciousness Vital signs including oral temperature Total urinary output for the last 24 hours

Vital signs including oral temperature; Clients taking clozapine and other medications that have a direct effect on the central nervous system (CNS) are at risk for developing Neuroleptic Malignant Syndrome (NMS). NMS is a generalized syndrome that includes hyperthermia, hypertension, tachycardia, slowed reflexes and involuntary movements. This is an emergency and the nurse should notify the health care provider. Bowel sounds, level of consciousness and urinary output are not warranted for this focused assessment. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS schizophrenia quetiapine stiff agitated sweating temperature

The nurse is caring for a client who is prescribed lithium for bipolar disorder. Which clinical manifestations would indicate the client may be experiencing lithium toxicity? Pruritus, rash and photosensitivity Vomiting, diarrhea and lethargy Ataxia, agnosia and coarse hand tremors Electrolyte imbalance, tinnitus and cardiac dysrhythmias

Vomiting, diarrhea and lethargy Serum lithium levels should be between 0.8 and 1.2 mEq/L (remember, the exact numbers may vary slightly depending on the lab). Diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination may be early signs of lithium toxicity. Toxicity increases with increasing serum lithium levels, but clients may exhibit toxic findings at lithium levels below 2.0 mEq/L. Dehydration, other medications and other conditions can interfere with lithium levels. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS lithiumtoxicity

The nurse receives a client who was transported to the emergency department for severe hypertension. Which finding requires immediate action by the nurse? Cough with frothy, pink sputum Weakness in the left arm Jugular vein distension Crackles in the lung bases

Weakness in the left arm; In a client who has uncontrolled hypertension, weakness in the extremities is a sign of cerebral involvement. Cerebral infarctions account for approximately 80% of the strokes in clients with hypertension. The remaining choices indicate fluid overload, which may be associated with heart failure related to the uncontrolled hypertension. While concerning, these are not medical emergencies. Jugular vein distension (JVD) is due to the elevated central venous pressure (CVP). Crackles in the bases of the lungs and a cough with frothy, pink sputum indicate pulmonary congestion. Crackles in all lung fields accompanied by dyspnea and orthopnea would indicate acute pulmonary edema, which would also be considered a medical emergency. LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS hypertensionweaknessstrokeCVA

The nurse is caring for a client who has suffered third-degree burns in a motor vehicle accident. The spouse of the client asks the nurse to clarify what is meant by third-degree burn. Which is the best response by the nurse? "The skin layers are inflamed. Blisters will appear and may weep." "All layers of the skin were destroyed in the burn." "Muscle, tissue, and bone have been injured." "The top layer of the skin is destroyed, exposing the dermis."

"All layers of the skin were destroyed in the burn. Burns are categorized based on the level of tissue damage. A first-degree burn is a superficial burn that may be pink or red, warm to the touch and painful. An example of a first-degree burn is a sunburn. A second-degree or partial thickness burn is characterized by a blistered appearance, red or pink and painful. An example of a second-degree burn could be a severe sunburn that has blisters. A third-degree burn or full thickness burn includes damage to all layers of the skin and underlying tissues. The area will appear leathery and the color could range from red to black. The area may lack sensation. A fourth-degree burn is also termed a full-thickness burn, but involves muscle, tissue and bone. Correct! LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM integumentary KEYWORDS burn pediatric full thickness

The nurse is preparing to assess a 3-year-old using the Denver II Developmental Test. The child's mother asks the nurse to explain the purpose of the test. Which statement by the nurse is correct? "It helps to determine the development of motor function." "It evaluates psychological responses to certain stimuli." "It assesses a child's development in several categories." "It measures a child's intelligence level and compares it to a standard."

"It assesses a child's development in several categories." LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS Denver II Testdevelopmental screeningchild The Denver II Developmental Test is a screening test to assess children from birth through six years of age in personal/social, fine motor adaptive, language and gross motor development. This screening test determines the highest level of functioning in these areas at the time of the examination. The screening is quick and inexpensive, but any low scores will need to be evaluated by more precise exams. The screening does not include psychological responses to stimuli or intelligence levels. It does not solely test for the development of motor function.

During a routine clinic visit, the nurse is providing education to a client with a history of Type 1 diabetes mellitus. The client's glycosylated hemoglobin (HbA1C) was 11%. Based on this result, which teaching concept should the nurse emphasize? Assess blood sugar and treat with insulin before meals and at bedtime Rotate injection sites with every injection Proper storage of oral medication used to decrease glucose level Continue with the current effective regimen

Assess blood sugar and treat with insulin before meals and at bedtime Type 1 diabetes mellitus is caused by an autoimmune destruction of the beta cells within the pancreas. These cells are responsible for making insulin. Because of this the client will be dependent on insulin and no oral antihyperglycemic agents will be effective. A glycosylated hemoglobin of 11% is elevated and indicates inadequate glucose control over a period of 2 to 3 months. Rotation of sites should be done regularly to prevent skin breakdown and to ensure proper delivery of the drug, but it is not a priority at this time.

The nurse is caring for a client receiving mechanical ventilation when the device signals a high-pressure alarm. The nurse should include what assessments in addressing this alarm? Select all that apply. Assess tubing to ensure it is not kinked Assess for obstructing secretions Assess client for partial or total extubation Assess client for signs of bronchospasm Assess the client's behavior (coughing, biting, gagging, etc.) (1 attempt remaining)

Assess tubing to ensure it is not kinked Assess for obstructing secretions Assess client for signs of bronchospasm Assess the client's behavior (coughing, biting, gagging, etc.) High pressure alarms are usually caused by something preventing or blocking air from being delivered by the ventilator to the lungs. Common causes for this include kinked tubing, secretions and/or bronchospasms, or the client fighting the tube. Low pressure alarms are usually caused by air escaping the closed unit. A total or partial extubation would cause a low-pressure alarm. LESSON Reduction of Risk Potential Diagnostic Tests COURSE RN & PN Review KEYWORDS mechanical ventilation high-pressure alarm

The nurse is providing discharge education to a client who will be starting daily atenolol for the treatment of hypertension. The nurse should emphasize to notify the health care provider if which of the adverse effects occur? Slow, irregular heart rate Dizziness in the morning Decreased exercise tolerance Decreased libido

Atenolol is a Beta-1 selective adrenergic blocking agent or a "beta blocker." These medications are commonly used to treat hypertension or chronic angina. Due to their selectivity, they are the preferred medications for clients who have the comorbidities of Chronic Obstructive Pulmonary Disease (COPD). Common adverse effects often relate to the therapeutic action of the drug and include impotence, decreased libido, dizziness, decreased exercise tolerance, slowed heart rate, arrhythmias and heart failure. The client should be taught to assess their heart rate and to notify the health care provider of any changes to the heart rate or rhythm. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS hypertension atenolol tenormin bradycardia hypotension

The nurse in the primary care office is speaking with a client who has contact dermatitis on both hands. The client wants to know how to manage the condition. Which interventions should the nurse recommend to the client? Select all that apply. Frequent handwashing is important. Corticosteroid cream is acceptable to use. Applying a cold pack to the area can help. Rubbing the area can alleviate symptoms. Using soap without fragrance is recommended. Avoid heat that can exacerbate symptoms.

Corticosteroid cream is acceptable to use. Using soap without fragrance is recommended. Avoid heat that can exacerbate symptoms. Exposure to heat or cold may cause or exacerbate contact dermatitis. Rubbing the area may also exacerbate or spread symptoms. While washing hands after exposure to possible irritants is recommended, frequent handwashing is not. Soap with fragrance is an external irritant and may exacerbate symptoms, so fragrance-free soap is recommended. A barrier cream containing a corticosteroid is the most frequently prescribed topical ointment. LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN & PN Review BODY SYSTEM integumentary KEYWORDS contact dermatitis

A nurse is educating a client about digoxin toxicity. Which statement made by the client indicates that more teaching is needed? "I will let the health care provider know if my pulse feels uneven or misses beats." "High levels of digoxin can cause vision changes." "I should report nausea and vomiting lasting more than a few days." "I must report a strong pulse of 62 beats per minute to the health care provider."

Digoxin is used to increase the strength of heart contraction. The expected effect of digoxin use is a slower, strong pulse. The client should be instructed to check their pulse prior to taking this medication and to note the rate and if the rhythm is irregular. If the heart rate is less than 60 or greater than 100 the client should not take the medication. Therefore, a strong pulse of 62 is a therapeutic effect of this medication and would not warrant a call to health care provider. This needs to be clarified with the client. The other statements indicate understanding of the medication. Digoxin toxicity would cause irregular pulse, loss of appetite, nausea, vomiting and vision changes. The client should be alert to these clinical manifestations and call the health care provider if they experience any of these changes. "I must report a strong pulse of 62 beats per minute to the health care provider." LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS digoxin toxic pulseheart CONFIDENCE Need Help Fair Strong

The nurse is caring for a client who suffered second-degree burns over 50% of their body. The nurse understands that which medication is used for the prevention of stress ulcers for this client? Furosemide 40 mg IV daily Pantoprazole 40 mg IV daily Ibuprofen 400 mg PO every eight hours Bumetanide 2 mg PO every six hours

LESSON Physiological Adaptation Alternations in Body Systems COURSE RN & PN Review BODY SYSTEM gastroinstestinal KEYWORDS burns burn injury stress ulcer Curling's ulcers are stress ulcers that occur in clients with severe burns. These ulcers occur within 24 hours of the injury due to the decreased blood flow to the gastrointestinal tract. This leads to a reduction in the protective layer of mucosa, while a simultaneous increase in hydrogen ions occurs. Curling's ulcers generally manifest themselves as gastric bleeding and are prevented by administering proton-pump inhibitors, such as pantoprazole. Other factors that prevent these stress ulcers are early enteral feeding, H2 histamine blockers and medications that protect the mucosa. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, should be used with caution due to the risk of further decreasing the protective gastric mucosa. In severe burn clients the priority is fluid resuscitation and increasing cardiac output. Therefore, diuretics such as furosemide or bumetanide are contraindicated.

The nurse is caring for a client who is frequently admitted for acute exacerbations of asthma. The client admits that she does not use her medications as prescribed because she often does not feel short of breath. Which explanation by the nurse best describes the long-term consequences of uncontrolled airway inflammation? Chronic bronchoconstriction of the large airways will occur The client will experience frequent bouts of pneumonia Lung remodeling and permanent changes in lung function will result The alveoli will degenerate and balloon out

Lung remodeling and permanent changes in lung function will result; Asthma is categorized as a chronic, hyper-responsive disorder affecting the terminal bronchioles. Exacerbation of asthma or an "asthma attack" is an acute event. However, the effects of increased number of exacerbations and not using the medication is lung remodeling. This lung remodeling results in more narrow airways and increased mucous. By explaining the consequences of not using the medication, the nurse is reinforcing the need for daily management. Degeneration of alveoli causing increased expansion is a result of emphysema. Asthma does increase the risk of pneumonia, but this option does not address the permanent long-term issues associated with not taking the medication as prescribed. Chronic bronchoconstriction of the large airways is not associated with asthma. LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review BODY SYSTEM respiratory KEYWORDS asthmaconsequencelung

A nurse is caring for a client diagnosed with an obstructing renal calculus. Which focus of the health care provider's orders would the nurse prioritize? Push oral fluids Morphine sulfate for pain control Start intravenous antibiotics Apply warm compress over flank area

Morphine sulfate for pain control; The priority action for an obstructing renal calculus (kidney stone) is to provide prompt relief for the severe pain. Oral hydration or intravenous fluids will help move the stone though the urinary system, but would be prioritized after pain management. Applying a warm compress over the flank may help pain, but would be prioritized after narcotic analgesics for this diagnosis. A kidney stone is not an infection and does not indicate the need for intravenous antibiotics. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM urinary KEYWORDS renalcalculipainnarcotic

The nurse is caring for a client that is taking prednisone and aspirin for rheumatoid arthritis. Which action by the nurse is appropriate for this client? Test the client's stool for occult blood Apply a hot pack to a warm, acutely inflamed joint Assess the client's pain level once a shift Monitor the client's temperature every two hours

Test the client's stool for occult blood arthritis is a chronic, progressive immunologic disorder. This type of arthritis is associated with progressive inflammation of joints and pain. The client's pain level should be assessed more often than once a shift. However, the client's temperature does not need to be measured every two hours. The client is at risk for gastrointestinal bleeding with the use of these two medications. The nurse should anticipate checking the stool for occult blood and monitor the client for signs and symptoms of anemia. When joints are acutely inflamed and warm on palpitation, the nurse should apply an ice pack, not heat. ESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS prednisoneaspirinoccultstool

A 14-month infant is brought to the emergency department with irritability, lethargy for two days, dry skin and increased pulse rate. What additional questions should the nurse ask to assist the health care provider with determining the proper diagnosis? Change in eating habits The number of wet diapers in the past two days Use of daycare Reverse of sleep-wake cycles

The number of wet diapers in the past two days Based on these clinical findings, the nurse might suspect that the infant is dehydrated. Asking about the number of wet diapers would assess for decreased urine output, a key finding in dehydration. Asking about increased concentration of the urine would also be appropriate. The other questions, while appropriate, would not provide the most helpful diagnostic information. LESSON Physiological Adaptation Fluid and Electrolyte Imbalances COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS infantdehydrationassessment

The nurse is caring for a client who is scheduled for a right orchiectomy due to testicular cancer. The client asks what will be removed during this surgery. Which response is the best by the nurse? A partial surgical removal of the perineal area A surgical removal of the entire scrotum A dissection of related lymph nodes by the testes A surgical removal of one testicle

A surgical removal of one testicle The affected testicle is surgically removed along with its tunica and spermatic cord. The other genitals and the perineal area are not involved. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM reproductive KEYWORDS orchiectomycancertesticularsurgery

The nurse continually avoids answering the call light of clients with alternative lifestyles. The nurse's behavior is an example of which concept? Benevolence Nonmaleficence Discrimination Stereotyping

Discrimination Nurses are responsible for caring for individuals in a manner that demonstrates benevolence and nonmaleficence. This nurse is discriminating against these clients by continually not answering the call light. Stereotyping is defined as the thought that all members of an ethnic group, culture, or race all act alike. Correct! LESSON Management of Care or Coordinated Care Ethical Practice COURSE RN Review KEYWORDS alternate lifestylebehaviordiscrimination

The nurse who travels with an agency is uncertain about what tasks can be performed when working in a different state. It would be best for the nurse to check which resource? The American Nurses Association's Social Policy Statement The policies and procedures of the assigned agency in that state With a nurse colleague who has worked in that state two years ago The state nurse practice act in which the assignment is made

The state nurse practice act in which the assignment is made The state Nursing Practice Act is the governing document of the scope of practice in any given state. The assigned agency policy would not govern what the Registered Nurse can do in a state and while a nursing colleague may be knowledgeable, the nurse should review the primary legal document to ensure understanding. The American Nurses Association's Social Policy Statement provides information on the profession of nursing through the Social Contract theory. LESSON Management of Care or Coordinated Care Legal Rights and Responsibilites COURSE RN Review KEYWORDS Practice Act tasks

The client tells the nurse that they are fearful of the planned surgery because of evil thoughts from a close family member. What is the best response by the nurse? Ignore the superstitious feelings Explore the client's feelings Request a language translator Notify the health care provider

Therapeutic communications are based on attentive listening to expressed feelings. If the nurse is not familiar with the cultural beliefs of a client, the nurse's acceptance of feelings should be followed by further questions about the client's feelings to gain insight into the client's culturally-determined belief system. The other responses are not therapeutic or appropriate in this situation. Explore the client's feelings LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS fearsurgeryevil

The nurse is preparing a presentation focusing on the prevention of Lyme disease. Which statement by a participant would require further clarification by the nurse? "Lyme disease is caused by a virus similar to the flu." "Lyme disease can spread to my brain if I don't seek treatment." "I will call the doctor if I see a rash that looks like a bull's eye." "I should wear light-colored clothing and long pants when gardening."

While the symptoms of Lyme disease are similar to influenza, Lyme disease is not caused by a virus. Lyme disease is caused by the spirochete, Borrelia burgdorferi, which is transmitted to humans by deer ticks. Because the ticks are so small, it is easier to see them on light-colored clothing. Long pants and long-sleeved shirts help protect individuals from insect bites. After being outdoors, individuals should assess their body for any ticks or rashes. Parents should be instructed to check children for ticks and rashes. There may be a "bull's eye" rash at the site of the tick bite. Without antibiotics, the disease can spread to the brain, heart and joints of the body. "Lyme disease is caused by a virus similar to the flu."; LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review BODY SYSTEM nervous KEYWORDS Lyme disease disease prevention

A client with possible Hepatitis C discusses his health history with the nurse. The nurse should recognize which statement by the client as the most important in supporting this diagnosis? "I got back from Africa a few weeks ago." "I had a blood transfusion in 1990." "I have had unprotected sexual contact with at least one person." "I ate the best raw oysters last week."

a. The client who received a blood transfusion prior to screening for Hepatitis C (prior to July 1992) may show findings many years later due to Hepatitis C being asymptomatic in the early stages. Other risk factors for Hepatitis C include those who have been on long-term hemodialysis and have regular contact with blood at work. Contracting Hepatitis C from having unprotected sex with a person who has Hepatitis C is rare. However, unprotected sex with multiple partners does increase the risk. Eating raw oysters or drinking contaminated water would increase the risk of Hepatitis A. Travel to Africa would increase the risk of exposure to malaria from mosquitos carrying the disease as well as HIV if the person were exposed to blood carrying the infection or had unprotected sex with someone who was HIV positive. LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS hepatitistransfusionliver

The nurse is educating a community group about signs and symptoms of a stroke. Which symptom frequently seen with a stroke should the nurse include? Rapid heart rate Stress incontinence Slurred speech Difficulty breathing

c. A stroke is a medical emergency. The nurse should teach the group that immediate treatment is needed to minimize long-term or permanent damage to the brain. A helpful mnemonic for teaching is "F.A.S.T.: F- Facial Drooping, A- Arm weakness, S- Slurred Speech or Speech Difficulty, and T- Time to call 911. The other symptoms are not usually associated with a stroke. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS cerebral vascular accident CVA stroke geriatric

The nurse notes that a client's prescription was changed from captopril to losartan, even though the captopril provided effective blood pressure control. Which is the most likely reason for discontinuing the captopril? Sexual dysfunction Dry cough Blurred vision Rash and itching

b. ; Captopril is an ACE inhibitor that converts angiotensin I to the powerful vasoconstrictor angiotensin II in the renin-angiotensin-aldosterone system (RAAS). It is used in the management of hypertension and other cardiovascular diseases. A side effect of this medication is a dry cough, which many clients find intolerable. This is a common reason for a client's prescription to change from an ACEI to a similar medication such as an ARB (losartan). The other side effects are not typically seen with an ACEI drug. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS hypertension captopril capoten cough

The nurse is teaching a 10-year-old child prior to heart surgery. Which form of explanation is best for this client? Introduce the child to another child who had heart surgery three days ago Explain the surgery using a model of the heart Provide a verbal explanation just prior to the surgery Provide the child with a booklet to read about the surgery (1 attempt remaining)

b; LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS childheartsurgerydevelopmentalneedPiaget According to Piaget, the school-age child is in the concrete operations stage of cognitive development. The use of something concrete, such as a model, will help the child understand the explanation of the heart surgery. The other options are not appropriate for the developmental age or they are not therapeutic methods of teaching children.

The nurse is caring for a child who is receiving treatment for lead poisoning. The nurse understands that the most serious effect of lead exposure is related to which of the following? Impaired kidney function Lead colic and constipation Damage to the central nervous system Anemia and fatigue

c; Lead toxicity can affect every organ system but it is especially dangerous for the brain. Lead can even alter the structure of the blood vessels in the brain and can lead to bleeding and brain swelling. In children, lead exposure is associated with lower IQ scores, learning disabilities, hyperactive behavior and impaired hearing; higher levels of exposure can cause seizures and death. Neurological effects may persist into adulthood, despite treatment. Anemia (and fatigue), damage to the kidneys and abdominal pain (also called lead colic) are potentially reversible with treatment. LESSON Physiological Adaptation Alternations in Body Systems COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS childleadpoisoningbrain

While assessing a client's blood pressure (BP), the nurse cannot hear the sounds through the stethoscope. However, the nurse is able to palpate the systolic pressure reading. Which action should the nurse take first? Use an electronic BP cuff in another location to verify the systolic pressure Take the BP in the same location after waiting two minutes Check to ensure the diaphragm of the stethoscope is being used Review the medical record to find the client's baseline BP

c; If a BP can be palpated for the systolic reading but nothing is heard on auscultation, the first action is to check to see if the stethoscope is turned to the bell side (a peripheral BP is taken using the diaphragm side of the stethoscope.) Then the nurse would wait two minutes between readings of a BP in the same arm to allow the vessels to recover from being squeezed. The electronic cuff would also require a two minute wait. The nurse should also be aware that the electronic cuff may not read pressures below 80 mm Hg. LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS BP blood pressure stethoscope systolic CONFIDENCE

The home health aide calls the nurse to report information about a client. Which information should be the highest priority for the nurse? "The client reports not sleeping well for the past week." "The partner says the client has gotten slower when doing things every other day." "The family wants to discontinue the home meal service called Meals on Wheels." "The urine in the urinary catheter bag is of a deeper amber, almost brown color."

d; Home health aides often report diverse client information to nurses through phone calls and electronic documentation. The nurse who develops the plan of care for a specific client, and supervises the aide, must identify potential danger signs that require immediate action and follow-up. The information of highest priority is the abnormal color of the urine from the client's urinary catheter which can be indicative of a urinary tract infection or other renal-urinary problem. The other options may need further assessment but are not the priority. LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS aideUAPsupervision

The nurse is providing discharge education to a client diagnosed with coronary artery disease. The client is prescribed to use a nitroglycerin transdermal patch at home. Which statement by the client indicates a correct understanding of safe medication administration? "I will remove the old patch and cleanse the area before applying a new patch." "I can place this patch on broken skin. It will absorb better." "This drug can lead to hypertension. So, I will monitor my blood pressure at home." "I will keep a record of chest pain occurrences now that I have this patch."

"I will remove the old patch and cleanse the area before applying a new patch."; Numerous administration errors have been reported with nitroglycerin paste and patches. The errors include improper storage and basic administration. The client should be taught to remove the previous patch before applying the new patch and to properly label the tube of nitroglycerin paste and keep it out of the reach of children. When selecting an area to place the patch, the skin should be intact and show no signs of irritation. Nitroglycerin paste has been used erroneously as lotion and caused toxic effects. Nitroglycerin causes vasodilation, which increases the blood supply through the coronary arteries. This may cause hypotension in clients. Some other common side effects include lightheadedness, nausea, dizziness, headache and redness or irritation of the skin covered by the patch. LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN & PN Review BODY SYSTEM cardiovascular KEYWORDS angina nitroglycerin patch

At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. The client asks about preconception diet changes. Which nutritional recommendation is the priority for this client? "Eat at least one serving of fish weekly." "Increase your intake of green leafy vegetables." "Include fiber in your daily diet." "Drink a glass of milk with each meal."

"Increase your intake of green leafy vegetables." Folic acid sources should be included in the diet daily for 3 months before and 3 months after conception. Folic acid is critical in the preconceptual and early gestational periods to foster neural tube development and prevent birth defects such as spina bifida. The recommended amount of folic acid is 0.4 mg daily. The increased levels could be provided by natural sources of food high in folate, fortified foods, or supplements. Folate is widely available in foods, particularly in leafy green vegetables, legumes, ready-to-eat cereals, and some fruits and juices; thus, recommending to increase intake of green leafy vegetables is the priority for this client. While the other recommendations are also appropriate, they are not a priority for the preconceptual and early gestational periods. LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS assess health pregnancy diet

The nurse is caring for a client who was admitted with complications related to diabetes mellitus. The client asks the nurse about the purpose for a glycosylated hemoglobin (HbA1c) test. How should the nurse respond? "The test provides a more precise blood glucose value than self-monitoring." "The test reflects an average blood glucose level for the prior 2 to 3 months." "The test measures the amount of circulating insulin in the blood." "The test is performed to detect any renal complications related to diabetes mellitus."

"The test reflects an average blood glucose level for the prior 2 to 3 months." Main Menu 23of171 Main ContentRef # 2280The nurse is caring for a client who was admitted with complications related to diabetes mellitus. The client asks the nurse about the purpose for a glycosylated hemoglobin (HbA1c) test. How should the nurse respond?"The test provides a more precise blood glucose value than self-monitoring." "The test reflects an average blood glucose level for the prior 2 to 3 months." Correct! "The test measures the amount of circulating insulin in the blood." "The test is performed to detect any renal complications related to diabetes mellitus." The HbA1c test is used to determine the average blood sugar level for the past 2 to 3 months. For most diabetic clients, the goal is to keep the HbA1c at or below 7%. A HbA1c does not measure kidney function or renal damage. A HbA1c also does not measure circulating insulin and the value attained is not the same type of glucose level that a client would check at home. LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM endocrine KEYWORDS diabetic HgbA1c glucose CONFIDENCE

The nurse is speaking with the parents of a 5-year-old boy who is diagnosed with hemophilia A. The parents recently underwent genetic counseling that showed that the mother is a carrier and the father is unaffected. The parents are asking the nurse what the chances are of having another child with this genetic disorder. How should the nurse respond? "There is a 25% probability that daughters will be a carrier of this disease." "All of your male children will have this disease." "There is a 50% probability that another male child would have this disease." "All daughters will be carriers of this disease."

"There is a 25% probability that daughters will be a carrier of this disease." Hemophilia A is a sex-linked recessive trait seen almost exclusively in males. When the carrier mother and the unaffected father are pregnant, there are four possible outcomes: a 25% (one in four) chance of having a son without hemophilia a 25% (one in four) chance of having a son with hemophilia a 25% (one in four) chance of having a daughter who is a carrier a 25% (one in four) chance of having a daughter who is not a carrier LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN & PN Review BODY SYSTEM cardiovascular KEYWORDS hemophiliaprobabilitycarrier

The nurse is admitting a client diagnosed with uncontrolled hypertension. Which of the following questions is a priority for the nurse to ask? "Describe your family's cardiovascular history." "Tell me about your usual diet for one day." "What over-the-counter medications do you take?" "Describe your usual exercise and activity patterns."

"What over-the-counter medications do you take?" Over-the-counter (OTC) medications, especially those that treat cold symptoms, can increase blood pressure. Clients diagnosed with hypertension should be educated to avoid OTC medications that contain phenylephrine and look for OTC cold medication specifically design for people with hypertension. The other options are essential parts of this client's medical history. However, they do not pose the greatest risk to the client. ESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS assesshypertensionOTC

During the 1-month well-baby checkup, the parents respond to questions about their newborn. Which of the parents' comments is of greatest concern to the nurse? "We notice the baby is fussy and cries a lot." "The baby does not sleep for longer than two hours at a time." "The baby seems to want to eat every couple of hours." "When the baby spits up, it shoots across the room."

"When the baby spits up, it shoots across the room." Spit up that shoots across the room is indicative of projectile vomiting. Projectile vomiting, chronic hunger, poor weight gain, distended upper abdomen are clinical manifestation of pyloric stenosis. Hypertrophic pyloric stenosis (HPS) occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric canal. This produces an outlet obstruction and compensatory dilation, hypertrophy and hyperperistalsis of the stomach.This condition usually develops in the first few weeks of life, causing nonbilious vomiting, which occurs after a feeding. Projectile vomiting may develop and the infant is fussy and hungry after vomiting. Infants with HPS have nonbilious vomiting in the early stages. Vomiting usually begins at 3 weeks of age but can start as early as 1 week and as late as 5 months. Vomiting usually occurs 30-60 minutes after feeding and becomes projectile as the obstruction progresses. Initially the infant is hungry and irritable, but prolonged vomiting may lead to dehydration, weight loss and failure to thrive.The other comments indicate normal behavior for a 1-month-old infant. LESSON Reduction of Risk Potential Potential for Alternations in Body Systems COURSE RN & PN Review BODY SYSTEM gastroinstestinal KEYWORDS pyloric stenosisassessmentprojectilevomitnewborn

The nurse is caring for a client who has end-stage renal disease and is scheduled for hemodialysis later today. The client has an arteriovenous fistula. Which interventions should the nurse implement to help prepare the client for dialysis? Select all that apply. Assess the patency of the fistula Administer Vitamin D, as prescribed Ensure the client eats a high fiber, high protein breakfast Administer the phosphate binder, as prescribed Hold all oral medications Weigh the client

ABDF; The nurse should administer medications as prescribed, such as vitamin D and sevelamer (a phosphate binder). These medications may be prescribed to help control both serum calcium and phosphate levels. Some medications that are dialyzable or could lower blood pressure are held until after the procedure. The client should eat a meal that is easily digestible at least 2 hours before the procedure begins. A meal high in fiber and protein is not easily digested. The nurse should assess the client's weight as a baseline prior to the procedure and measure vital signs. The access site should be assessed including palpating a thrill, auscultating a bruit and palpating pulses and circulation distal to the site. Incorrect LESSON Physiological Adaptation Hemodynamics - RN COURSE RN Review BODY SYSTEM urinary KEYWORDS kidney diseasehemodialysisphosphate bindervitamin

The nurse is caring for a client who was diagnosed with a deep vein thrombosis (DVT). The client reports sudden shortness of breath and the oxygen saturation decreases to 87% on room air. Which intervention is a priority action by the nurse? Begin continuous cardiac monitoring Call the health care provider (HCP) Administer oxygen to maintain a saturation of 92% Administer the PRN albuterol nebulizer

Administer oxygen to maintain a saturation of 92% An acute onset of dyspnea and hypoxia is a classic finding of pulmonary embolism (PE). A client with a DVT has a risk for part of the clot breaking off and traveling to the lungs. The administration of oxygen to correct hypoxia is the highest priority. After administering oxygen, the HCP would need to be notified and the nurse should anticipate orders for diagnostic tests (Pulmonary Angiogram, d-dimer, CT scan). Albuterol nebulization is a standard treatment for respiratory distress related to asthma, COPD and anaphylaxis. However, it is not used for dyspnea due to a PE. LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS DVTshortness of breathoxygen

The nurse is performing a routine assessment on a six-month-old infant. The child's mother states that the child weighed 7 pounds 8 ounces at birth. Which would be an appropriate finding for the weight of the child at this visit? Add two pounds each month Double the birth weight Gain six ounces each week Triple the birth weight

Appropriate growth and development of a child is an indicator of adequate nutrition, good health and absence of chronic illness. Although growth rates vary, infants normally double their birth weight by six months. At 12 months, the weight should be triple the birth weight. Important anthropometric measurements for the pediatric population include: height or length, weight, body mass index (BMI) and head circumference. The head circumference will generally be measured at every routine health care provider visit until the child is 2-years-old. The measurements will be recorded on a graph and compared to previous measurements and to percentiles of their peers. Children falling between the 5th and 95th percentile are considered to have a normal growth range. LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS infantgrowthnormalweight

The nurse is caring for a client who is receiving isoniazid for tuberculosis (TB). Which assessment finding would indicate the client is having a possible adverse response to this medication? Tinnitus and decreased hearing Yellowing of the sclera Correct Response Headache and nausea Tingling in extremities

Isoniazid is a first-line anti-tuberculosis drug that is used as part of the combination therapy for treatment of tuberculosis. These first-line medications may be used up to 2 years in clients who are being treated for tuberculosis. The use of long-term combination treatment increases the effectiveness and decreases the occurrence of resistant strands. Clients receiving this medication are at risk for drug-induced hepatitis. The appearance of jaundice may indicate an elevation of the client's serum bilirubin levels and liver enzymes (AST and ALT). A small number of clients taking isoniazid develop severe hepatitis that may progress to liver failure and death unless the medication is stopped immediately. Other common side effects include nausea and tingling in extremities. This medication is not ototoxic and does not affect hearing. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM respiratory KEYWORDS tuberculosisTBisoniazidINHadverse

The nurse is caring for a 14-year-old adolescent who attempted suicide. Which stressor is most likely to occur during adolescence and contribute to the risk of suicide? The ending of a long-term romantic relationship Peer pressure and social isolation Financial strain and increased financial responsibilities A challenging academic environment

Peer pressure and social isolation; During adolescence, an important benchmark is to achieve a sense of identity and peer acceptance. Peer pressure is a common occurrence during adolescence. Social isolation can be self-imposed or can occur as the result of the inability to express feelings to peers or family members. A challenging academic environment, financial responsibilities, or the end of a romantic relationship are not stressors commonly associated with an adolescent attempting suicide. LESSON Psychosocial Integrity Mental Health Concepts COURSE RN Review KEYWORDS suicide adolescent isolation

The nurse is caring for a client who was prescribed alprazolam. When educating the client about the new medication, which intended effect should the nurse include? Reduce symptoms of depression Alleviate signs and symptoms of spasticity Increase coordination and the ability to concentrate Reduce anxiety and provide a calming effect

Reduce anxiety and provide a calming effect Correct! Alprazolam is a benzodiazepine which is as an anxiolytic. The medication will not increase coordination and the ability to concentrate or alleviate symptoms associated with nerve damage, such as spasticity. Alprazolam will not reduce symptoms of depression. LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM nervous KEYWORDS xanax alprazolam anxiety calm

A client is transported to the emergency department following a boating accident and submersion in cold water. The client is conscious, shivering and confused. What interventions should the nurse implement? Select all that apply. Massage extremities Remove wet clothing Monitor vital signs Provide warmed blankets Monitor level of consciousness Give the client warm tea Administer warmed IV fluids as ordered

Remove wet clothing Correct! Monitor vital signs Correct! Provide warmed blankets Correct! Monitor level of consciousness Correct! Administer warmed IV fluids as ordered Correct! The client is at risk for hypothermia. The nurse should remove wet clothing carefully. External rewarming, such as warmed blankets or heat packs, which are placed under the arms and on the neck, chest and groin. The client may also be ordered to receive warmed IV fluids and humidified oxygen to help stabilize the core temperature. Monitoring should include vital signs, level of consciousness, cardiac rhythm and core body temperature. The client should not receive any oral fluids until their condition is stabilized and extremities should not be massaged. LESSON Physiological Adaptation Medical Emergencies COURSE RN Review KEYWORDS accident hypothermia

The interdisciplinary team is meeting to discuss the discharge plan for a client following total hip replacement surgery. Which assessment finding is most important for the team to address? The adult daughter will be responsible for shopping and driving the client after discharge The home is a two-story and all bedrooms and bathrooms are located upstairs. The client does not like the taste of the oral potassium supplement medication. The partner expresses some discomfort with the dressing change.

Two pairs of cotton socks; Clients with peripheral artery disease (PAD) are at risk for frostbite or hypothermia. It is therefore important for the nurse to ensure that the client understands how to prevent injury by dressing appropriately for cold weather. When cotton becomes damp or wet, it doesn't insulate well. Non-cotton materials are preferred. Additionally, a double layer of socks may become constricting and further decrease circulation. Instead, the client should carry an extra pair of socks if needed. The other clothing choices are appropriate. LESSON Physiological Adaptation Alternations in Body Systems COURSE RN & PN Review BODY SYSTEM integumentary KEYWORDS peripheral arterial disease hypothermia frostbite

The nurse is planning care for a client following a stroke. Which approach would be most effective in the prevention of skin breakdown? Reposition every two hours when in bed Massage reddened bony prominence Pad the bony prominences Place client in the wheelchair for four hours daily

a; Following a stroke, clients often experience some degree of immobility, leading to an increased risk for impaired skin integrity. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained. Repositioning the client every two hours while in bed would be most effective in preventing skin breakdown such as a pressure ulcer. If the client is in a wheelchair, a shift of the weight should be done every hour. Massage of reddened bony prominences is no longer recommended to prevent pressure ulcers or injuries. LESSON Reduction of Risk Potential Potential for Alterations in Body Systems COURSE RN Review BODY SYSTEM integumentary KEYWORDS skin breakdown CVA

The nurse is caring for a client who is prescribed warfarin. Which lab test would the nurse monitor to determine a therapeutic response to the drug? International Normalized Ratio (INR) Partial thromboplastin time (PTT) D-dimer Bleeding time

a; The warfarin dosage is based on the result of a client's daily INR (or prothrombin time [PT]). Warfarin affects the function of the coagulation cascade and inhibits the formation of blood clots. The goal of warfarin therapy is to maintain a balance between preventing clots and causing excessive bleeding, which is why careful monitoring is needed. A Partial thromboplastin time (PTT) is associated with monitoring heparin. A bleeding time test is performed to monitor basic platelet function. The d-dimer test is a test used to diagnose a blood clot. Correct! LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS warfarinCoumadinlabtherapeutic

The nurse in the emergency department is assessing a client diagnosed with an acute asthma attack. Which assessment finding would support this diagnosis? Diffuse expiratory wheezes Sharp pain during inspiration Loose, productive cough Fever and chills

a; sthma is characterized as a hyper-responsive inflammatory disorder of the terminal bronchioles. The inflammation causes constriction of the smooth muscle around the bronchioles (bronchoconstriction). These changes make it difficult for air to enter the lungs, resulting in wheezes. The other findings are not typically seen with an acute asthma attack. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM respiratory KEYWORDS asthmaassesswheezing

A nurse is caring for a trauma victim who experienced significant blood loss. The client has received multiple transfusions. Which test would be the most accurate indicator of oxygenation? Arterial blood gases (ABGs) Complete blood count (CBC) Pulse oximetry Hemoglobin and hematocrit (H and H)

a; During hypovolemic shock, priority interventions focus on perfusion of tissue. ABGs are the most accurate measure of oxygenation at this time. An ABG test measures PaO2, PaCO2, pH, HCO3 and oxygen saturation. During hypovolemic shock, the extremities will be vasoconstricted. Pulse oximetry, a peripheral test, would not be as accurate. A CBC examines all components of blood, including hemoglobin and hematocrit. While these may be helpful, the ABG will provide the most accurate data concerning oxygenation. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS blood gasestransfusionoxygenABG

The nurse is inserting a urinary catheter in an adult female client. The nurse advances the catheter 2 to 3 inches (5 to 7 cm), but no urine return is seen. Which intervention is appropriate for the nurse to do next? Advance the catheter a few more inches. Inflate the catheter balloon. Withdraw the catheter and try again. Notify the health care provider (HCP).

a; For an adult female, a urinary catheter should be inserted about 2 to 3 inches (5 to 7 cm) in the urinary meatus until the urine begins to flow. If the urine does not flow, the catheter can be carefully inserted a bit further. If no urine flows after the further advancement, the catheter is probably in the vaginal canal. Once the inappropriately placed catheter is removed, a new sterile catheter should be used. The nurse should not inflate the balloon until proper placement is confirmed by flowing urine. If the balloon is inflated too soon, the urethra could be damaged. The nurse should never use the same catheter because the risk of contamination with withdrawal is too great. The health care provider should be notified after troubleshooting and a second unsuccessful attempt. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN & PN Review BODY SYSTEM urinary KEYWORDS urinary catheter insertion

The nurse is caring for a client who reports the onset of symptoms associated with tardive dyskinesia. Which finding would the nurse expect to observe? Rapid, repetitive tongue movements Fine motor tremors of the hands while eating Behavior changes related to judgment Involuntary yelling of random words

a; Tardive dyskinesia (TD) is a syndrome of involuntary movements that usually affects the face, mouth, tongue, trunk and limbs. TD may occur years after treatment with a neuroleptic agent and may be irreversible. Predisposing factors include older age, phenothiazine treatment, history of smoking and history of diabetes mellitus. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS tardive dyskinesiatongue

While caring for a newborn, the nurse notes a high-pitched cry, irritability and lack of interest in feeding. The nurse suspects the newborn is experiencing neonatal abstinence syndrome. Which intervention is most appropriate for this newborn? Dim the lights and reduce the noise in the room. Remove the swaddling blanket from the newborn. Do not allow the newborn to use a pacifier. Offer the newborn formula every four hours.

a; A high-pitched cry, irritability, poor feeding, increased respiratory rate, fever, vomiting and diarrhea are all clinical manifestations of neonatal abstinence syndrome (NAS). NAS is a term used to describe the behaviors exhibited by the infant exposed to drugs in utero.Appropriate treatment of NAS includes reducing environmental stimuli (dimming the lights in the room, reducing noise in the room, speaking in a soft voice), swaddling, oscillating (vibrating) cribs and pacifiers. LESSON Reduction of Risk Potential System Specific Assessments - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS newborn withdrawal stimuli

The nurse is caring for child diagnosed with celiac disease. Which of the following foods would be an appropriate snack choice for this child? A cup of yogurt A cup of cereal An oatmeal cookie A slice of wheat bread

a; Celiac disease is an autoimmune disease that occurs in genetically predisposed people, where the ingestion of gluten leads to damage in the small intestine. Gluten is a general name for the proteins found in wheat, rye, barley and triticale (a cross between wheat and rye). Gluten helps foods maintain their shape, acting as a glue that holds food together. Gluten can be found in many types of foods, even ones that would not be expected. Children or adults with celiac disease should eat a gluten-free diet. An oatmeal cookie, wheat bread and cereal contain gluten and should be avoided. Dairy products are generally considered gluten-free and are an appropriate snack choice for the child. LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN & PN Review BODY SYSTEM gastroinstestinal KEYWORDS celiac diseaseglutengluten-free

The nurse is performing the initial assessment of a client in the emergency department. Which statement by the client most strongly suggests domestic or partner violence? "I have tried leaving home but have always gone back." "I am determined to make things work out." "No one else in the family is as accident prone as I am." "I have only been married for two months."

a; Intimate partner violence may occur as a pattern or frequently. The violence is part of a cycle of abuse. After the incident, the honeymoon phase occurs, and the abuser demonstrates love and vows to change. The victim may feel responsible for the violent attack and may consider reconciliation. The victim may leave the abuser and return frequently before a decision to leave permanently may occur. Correct! LESSON Psychosocial Integrity Abuse, Neglect COURSE RN Review KEYWORDS domestic violencepartner violence

The nurse is caring for a client who received tenecteplase to open an occluded coronary artery. Which finding should be of highest concern for the nurse? Hematemesis Epistaxis Bleeding gums Urinary retention

a; Tenecteplase, a thrombolytic agent, breaks down a thrombus by stimulating the plasmin system. The plasmin system is a natural anticlotting system, which breaks down fibrin and dissolves any clots. Since this medication is not specific to a certain type of clot, the client should be expected to have an increased bleeding risk after administration. The most common adverse effect of thrombolytic medications is bleeding and hemorrhage. The nurse should monitor the client for signs and symptoms of abnormal bleeding. Hematemesis means vomiting blood. This is usually related to a bleeding gastric ulcer and should be of highest concern. Epistaxis (nose bleed) and bleeding gums are usually minor bleeding and can be easily monitored by the nurse. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS thrombolytic clot myocardial infarction bleeding

The oncology nurse is caring for a female client who is being treated for metastatic breast cancer. The client is scheduled to receive their first dose of trastuzumab. Which assessment finding is most important to notify the health care provider of? Irregular apical pulse Absolute neutrophil count 2.5 (2,500 mm3) Blood glucose 130 mg/dL Intermittent nausea and vomiting

a; Trastuzumab is a monoclonal antibody used as anticancer therapy for women with HER2-positive breast cancer. The main concern in administering trastuzumab is cardiotoxicity, manifesting as ventricular dysfunction and congestive heart failure. Therefore, the irregular apical pulse is the most important assessment findings. An ejection fraction is obtained as a baseline before treatment and may be monitored every few months while the client is receiving this medication. The other findings are to be expected, normal or near normal and not as important as the irregular apical pulse. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS cancer trastuzumab pulse

The nurse is teaching a parent about the prevention of diaper dermatitis. Which of the statements by the parent indicates understanding? "I will use rubber pants to assist with toilet training." "I will change the diaper every 2-3 hours during the day." "Diaper dermatitis is associated with chronic itching." "If a rash occurs, I will put oil on the skin before putting the diaper on."

b, Diaper dermatitis is an inflammatory reaction of the skin that is covered by a diaper. This inflammatory response is related to exposure to urine and feces. Prevention is the best management of diaper dermatitis and includes frequent diaper changes and changing feces soiled diapers as soon as possible. Atopic dermatitis is associated with chronic itching. Rubber pants should not be used as they increase the risk of diaper dermatitis. If a rash does occur, the parents should be instructed to allow the child to go diaper-less for a period of time during the day. Creams are available but oils will increase the moisture on the skin. LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM integumentary KEYWORDS dermatitisinfantteachdiaperfood

A nurse is teaching a client with asthma about the correct use of the fluticasone inhaler. Which statement, if made by the client, would indicate that the teaching was effective? "The inhaler can be used when I feel short of breath." "I should rinse my mouth after using the inhaler." "I should not use a spacer with my inhaler." "If I forget a dose, I will double the next dose."

b. Fluticasone is an inhaled corticosteroid used to prevent asthma attacks. After using the inhaler, the client should rinse away any residue in the mouth to reduce the risk of an oral fungal infection. Fluticasone is not a bronchodilator and should not be used as needed for shortness of breath. The client should not double the dose of this medication and should use a spacer with this inhaler. LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM respiratory KEYWORDS asthma Azmacort triamcinolone inhaler steroid

The nurse is obtaining the health history for a client with the help of an interpreter. To promote clear communication with the client, which of these actions is appropriate for the nurse to use? Provide the interpreter with a list of questions to address and stay with the client Arrange the setting so the interpreter and client can be easily seen by the nurse Look at the interpreter when communicating the needed questions Ask the client to speak slowly and clearly with pauses after every statement

b; LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS interpretercommunication

The nurse is caring for a 14-month-old client who had a surgical repair of a cleft palate several days ago. The parents ask the nurse about meals after discharge. Which lunch is the best example of an appropriate meal for this client? Hot dog, carrot sticks and juice Soup, ice cream and milk Peanut butter and jelly sandwich, chips and milk Baked chicken, apple sauce, cookie and juice

b; After cleft palate surgery, the parents should prepare soft foods. Any foods with sharp edges or particles may traumatize the surgical site. The other options include foods with rough edges such as carrots, chips and cookies. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS cleft palatesurgeryfeed

The nurse is caring for an 83-year-old client who is experiencing a sudden onset of confusion. Which medication most likely contributed to this change? Anticoagulant Antihistamine Liquid antacid Cardiac glycoside

b; Older adults are more susceptible to the side effects of anticholinergic medications, such as antihistamines. Antihistamines often cause confusion in the older adult, especially at high doses. Cardiac glycosides, anticoagulants and antacids are not associated with confusion or mental status changes in the older adult. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review KEYWORDS confusion sudden anticholinergic

The interdisciplinary team is meeting to discuss the discharge plan for a client following total hip replacement surgery. Which assessment finding is most important for the team to address? The adult daughter will be responsible for shopping and driving the client after discharge The home is a two-story and all bedrooms and bathrooms are located upstairs. The client does not like the taste of the oral potassium supplement medication. The partner expresses some discomfort with the dressing change.

b; Nurses are charged with the responsibility to advocate for clients. Because of the intimate work with clients, nurses often discover critical information that will impact discharge planning. It is important to share these insights with the health care team to ensure the client's needs are met after discharge. A client who has undergone major orthopedic surgery can expect some mobility impairment after discharge. The nurse should ask questions regarding the physical characteristics of the home including stairs, location of essential rooms, bathroom set up, pets and carpeting. Therefore, it is most important to identify and address any potential safety issues in the client's home. LESSON Management of Care or Coordinated Care Collaboration with Interdisciplinary Team COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS dischargeplanassessmentsafety

A nurse is caring for a client who is being evaluated for a possible myocardial infarction. The nurse notes what appears to be ventricular tachycardia on the cardiac monitor. Which action is a priority for the nurse? Begin cardiopulmonary resuscitation Assess airway, breathing and circulation Prepare for immediate defibrillation Notify the rapid response team and the health care provider

b; The nurse must treat the client, not the cardiac monitor. Always assess the client to determine the next step. This focused assessment includes checking the client's airway, breathing, and circulation (ABCs) and for signs of low cardiac output. Signs of low cardiac output include chest pain, dyspnea, hypotension and an altered level of consciousness. These clinical manifestations would indicate a need for cardioversion and other emergency interventions. The other options would be appropriate after the nurse has assessed the client. LESSON Physiological Adaptation Hemodynamics - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS tachycardia ventricular myocardial infarction

The nurse is caring for a client who is diagnosed with autism. The client begins eating his meal with his utensils, but places them on the table and begins to use his hands. Which response by the nurse would be best? Remove the food and state: "You can't have any more food until you use the spoon." Jokingly state: "Well I guess fingers sometimes work better than spoons." Place the spoon in the client's hand and state, "Use the spoon to eat your food." Make the comment: "I believe you know better than to eat with your hands."

c; This response identifies an expectation and instruction for the client. Since the client has demonstrated that he can use his utensils, he should be expected to maintain this level of independence. The other options are not therapeutic approaches for this client. LESSON Psychosocial Integrity Behavioral Interventions or Behavioral Management COURSE RN Review KEYWORDS autismeatbehavior

The nurse is caring for a 12-year-old client with thalassemia. What lab value is most important to monitor for this client? Platelet count Serum creatinine level Hemoglobin level Prothrombin time

c; Thalassemia is a hereditary blood disorder in which the body makes an abnormal form or inadequate amount of hemoglobin. Hemoglobin is the protein in red blood cells that carries oxygen. The disorder results in large numbers of red blood cells being destroyed, which leads to anemia. Therefore, it is most important to monitor the hemoglobin level for this client. The other lab values do not pertain to thalassemia. LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS thalassemia blood transfusion hemoglobin

The nurse is taking a health history from the parents of a child who is admitted for Reye's syndrome. Which recent illness would the nurse identify as a significant risk of developing Reye's syndrome? Rubeola Hepatitis Influenza Meningitis (1 attempt remaining)

c; Varicella (chickenpox) and influenza are viral illnesses that have been identified as risks for the development of Reye's syndrome. It is important for nurses to educate parents to not use aspirin in children (birth to 19 years of age). The use of aspirin in the presence of viral infections can increase the risk of Reye's syndrome for children. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM lymphatic KEYWORDS Reye'schildinfluenzaaspirin

The nurse is evaluating comprehension of a client newly diagnosed with testicular cancer. Which statement by the client indicate an understanding of this type of cancer? "I will probably never be able to have children after receiving chemotherapy." "If they find lymph node involvement, I am pretty much dead, aren't I?" "After surgery, I can have a prosthesis placed inside my scrotum." "I should have been better about using a condom during sexual intercourse."

c;Testicular cancer is a rare cancer that most often affects men between 20 and 35 years of age. With early detection and treatment, testicular cancer has a 95% cure rate. It can occur in one testicle or both. Surgery is the main treatment for testicular cancer. For stage 0 or 1 (localized disease), a unilateral orchiectomy is usually performed. A gel-filled silicone prosthesis may be surgically implanted into the scrotum at the time of the orchiectomy or later if the client desires. If there are concerns about sterility, the client has the option of sperm storage. Sexual intercourse, with or without a condom, does not cause testicular cancer. Correct! LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM reproductive KEYWORDS testicular cancerstage

The nurse is performing a surgical dressing change on a client who had a laparotomy five days ago. The nurse notices the incision edges are separated and there is a visible bulge of organ tissue protruding from the wound opening. Which is the best way for the nurse to dress the incision before leaving the room to call the surgeon? Place iodine-soaked gauze over the wound and then cover it with an abdominal pad. Approximate the wound edges as much as possible with wound-closure strips. Apply antibiotic ointment to the wound and cover it with a non-adherent dressing. Cover the wound with sterile gauze moistened with sterile 0.9% saline.

d; This client likely has a wound evisceration, a complication of surgery. An evisceration is when a surgical wound opens and has protrusion of internal organs. This is considered a surgical emergency. The nurse should notify the surgeon of this finding immediately. When evisceration occurs, the best way to dress the wound is to cover it with sterile gauze dampened with sterile 0.9% saline using sterile technique. Correct! LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM integumentary KEYWORDS surgerycomplicationseviscerationemergency

The school nurse is educating teachers that the number of children diagnosed with fifth disease has increased. Which clinical manifestation of fifth disease should the nurse emphasize to the teachers? Macule that rapidly progresses to papule and then vesicles Koplik spots appear first followed by a rash that appears first on the face and spreads downward Discrete rose pink macules will appear first on the trunk and fade when pressure is applied Bright red cheeks, with a "slapped face" appearance

d; Fifth disease is also referred to as parvovirus infection or erythema infectiosum. Some people may call it slapped-cheek disease because of the face rash that develops resembling slap marks. It is also commonly called fifth disease because it was fifth of a group of once-common childhood diseases that all have similar rashes. The other four diseases are measles, rubella, scarlet fever and Dukes' disease. People will not know that a child has parvovirus infection until the rash appears, and by that time the child is no longer contagious. LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM integumentary KEYWORDS childschoolskinrashfifth disease

The nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). What is the priority goal for the client during the procedure? Prevent memory loss and confusion Eliminate suicide ideations Reduce the client's depressive symptoms Maintain an open airway

d; With ECT, a seizure is induced by administering a dose of electrical current through electrodes placed either bilaterally or unilaterally on the right side of the frontotemporal area of the client's head. The procedure is typically performed in a special setting with an anesthesiologist and critical care nurses present. Due to the anesthetic agents administered for the procedure, maintaining an open/patent airway is the priority goal during the ECT procedure. The most common side effects of ECT are temporary memory loss and confusion. LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM nervous KEYWORDS depression ECT electroconvulsive succinylcholine

The nurse is caring for clients in an assisted living facility. A client enters the day room wearing a sheer night gown. Which nursing action is the most therapeutic in response to the client's attire? Quietly point out how the other clients are dressed on the unit Tactfully explain appropriate clothing for the unit Ask the client's daughter to address the client's attire on her next visit Assist the client to her room and help her select appropriate attire

d; This action assists the client to maintain self-esteem while modifying her behavior. By pointing out the other clients' attire, the client could feel ashamed and self-conscious. Explaining appropriate attire does not directly address the situation as effectively as assisting the client. The action needed should be direct and timely, but avoid embarrassment for the client. Correct! LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS therapeuticbehaviorself-esteem

A client has undergone electroconvulsive therapy (ECT). What is an appropriate postprocedure nursing intervention? Remain with client until oriented to time, place and person Permit the client to sleep for four to six hours Expect long-term memory loss for a few hours Offer frequent sips of clear liquids

d; During alcohol withdrawal, the client may experience many clinical manifestations. Six to eight hours after alcohol cessation, the client may experience tremors, nausea and agitation. After eight to ten hours, the client may experience increasing perceptual changes such as hallucinations, unconsciousness, seizures, or delirium. This is a medical emergency and the nurse should anticipate administration of lorazepam or chlordiazepoxide. After twelve to twenty-four hours, the client may experience tonic-clonic seizures and diazepam may be administered. Monitoring the client for Delirium tremens (DTs) is a nursing priority. DTs are a medical emergency and if left untreated have a significant risk of death. Vital signs and monitoring for clinical manifestations of DTs should be done more often than every 6 hours. During this time, regularly updating the client on their progress may cause frustration with the client. Additionally, if the client wants the family at the bedside, privacy is not needed. Correct! LESSON Psychosocial Integrity Chemical and Other Dependencies, Substance Use Disorder COURSE RN & PN Review KEYWORDS alcoholdetoxificationnaltrexonesubstance abuse

The nurse is caring for a newborn with tracheoesophageal fistula (TEF). Which assessment is the highest priority? Monitor intake and output Monitor for fever over 101°F (38.3 °C) Observe the newborn for tachycardia with activity Observe the newborn for cyanosis

d; With TEF, there is an abnormal opening between the trachea and esophagus. Fluids can easily be aspirated into the trachea and lungs. The 3 Cs of TEF are choking, coughing and cyanosis. The priority is to prevent aspiration and maintain an open airway. The other options are appropriate when monitoring any newborn. However, they are not specific to TEF. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS newbornTEFaspirationpriority

Several hours after a total gastrectomy, the client's nasogastric tube (NGT) stops draining. After referring to the postoperative orders, which order will the nurse implement first? Reposition the tube until it begins to drain Notify the surgeon Increase the amount of suction by 5 mmHg Irrigate the nasogastric tube

d; After surgery, the nurse should closely monitor the nasogastric tube (NGT) to ensure it is suctioning appropriately. Irrigating the NGT is appropriate because these tubes may become clogged. A clogged NGT could lead to acute gastric dilation after surgery. This intervention should be performed first. LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS gastrectomy nasogastric irrigate

The nurse is educating a pregnant woman who was advised to increase the intake of protein and vitamin C to meet the needs of the growing fetus. Which food choice best satisfies these dietary recommendations? Hamburger and a salad Spaghetti and an orange Cheese pizza with sausage topping Baked chicken and fresh strawberries

d; The food choice that best satisfies an increased protein and Vitamin C intake is baked chicken (protein) and fresh strawberries (vitamin C). The other choices might contain some protein and vitamin C as well but are also high in carbohydrates or fats, making them a less nutritious choice. LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care Health Promotion, Disease Prevention COURSE RN Review KEYWORDS vitamin C diet pregnancy protein