Q review #2 (remediation)

Autonomic Dysreflexia S/S HH SE CB

-Severe Pounding Headache -Hypertension -Profuse Sweating (especially forehead) -Bradycardia -Nasal Congestion -piloerection -goose flesh

the majority of vaccines should be administered to a pediatric client by about what age

2 y/o

A client has been taught guided imagery as a method to relieve pain. How should the nurse first assess for pain relief after completion of guided imagery by the client? You answered this question Incorrectly 1. Assess vital signs 2. Use of pain intensity scale 3. Ask client to describe the pain 4. Observe ability to perform activities of daily living

2. Correct: The use of pain intensity scales is an easy and reliable method of determining the client's pain intensity. 1. Incorrect: Although respiratory and heart rate may decrease with guided imagery and pain reduction, the most objective measure is to ask the client to rate the pain.

what would make more sense: giving a client who is medically managed for an anti-inflammatory drug more anti - inflammatory drugs or avoiding adding additional anti - inflammatory drugs because of the potential side effects

obviously you want to prevent any risks by doubling up on meds that do the same thing

to prevent the eventual refusal of assignment, the RN should determine the client population prior to accepting a job offer

During your first interview. You need to ask the manager you speak with about the client population.

when you hear rheumatic fever, what two things come to mind

GBS status and pharyngitis

what is the worst case scenario for clients who take massive amounts of NSAIDS

GI bleed, liver disfunction or ulceration of the GI tract

a small school - aged child will be seeking to accomplish this developmental task of Ericksons stages

industry vs inferiority

conjunctivitis and itching subsequently results in

inflammation

you think TPN is considered a med? Think about who makes it....

yea, it is. it's made by pharmacy, idiot.

state the normal level of phenylalanine for the newborn

0.5 to 1

A client diagnosed with rheumatoid arthritis has been prescribed celecoxib. What should the nurse include in the client's education regarding this medication? You answered this question Incorrectly 1. Do not take celecoxib with ibuprofen. 2. GI complaints and headache are among the most common side effects. 3. Drink a lot of water to offset the dehydration that may occur. 4. Notify the healthcare provider immediately if black stools are noted. 5. This medication provides relief of pain and swelling so you can perform normal daily activities.

1, ., 2., 4., & 5. Correct: Concomitant use of celecoxib with aspirin or other NSAIDs (for example, ibuprofen, naproxen, etc.) may increase the occurrence of stomach and intestinal ulcers. This would increase the risk of GI bleeders. GI complaints and headache are two of the most common side effects. The client should stop taking celecoxib and get medical help right away if the client notices bloody or black/tarry stools. This would be an indication of GI bleeding. This medication is a nonsteroidal anti-inflammatory drug (NSAID), which relieves pain and swelling. It is used to treat arthritis. The pain and swelling relief provided by this medication should help the client perform normal daily activities.

Which statement made by a client post-thyroidectomy would require further investigation by the nurse? You answered this question Incorrectly 1. "I have a tingling feeling of my fingers." 2. "It hurts when I move my head." 3. "I feel pressure in my arm when you take my blood pressure." 4. "My legs are weak."

1. Correct. After this procedure the nurse should worry about the possibility of some of the parathyroids being accidentally removed with resulting hypoparathyroidism. Hypoparathyroidism results in hypocalcemia. Signs and symptoms include tingling, burning, or numbness of lips, fingers, and toes. The muscles may become tight and rigid, and seizures can result. 2. Incorrect. Pain is expected here. The incision is at the base of the neck, so movement of the head would increase the pain.

An 82 year old client tells the nurse at the clinic, "I have lived a good, successful life and married my best friend." Which of Erikson's developmental tasks does the nurse recognize that this client has probably accomplished? You answered this question Incorrectly 1. Ego Integrity versus Despair 2. Generativity versus Stagnation 3. Intimacy versus Isolation 4. Industry versus Inferiority

1. Correct: Ego Integrity versus Despair is the major task of those 65 and over: The developmental task for this age involves the individual reviewing one's life and deriving meaning from both positive and negative events, while achieving a positive sense of self. If the individual considers accomplishments and views self as leading a successful life, a sense of integrity is developed. On the contrary, if life is viewed as unsuccessful without accomplishing life's goals, a sense of despair and hopelessness develops. 3. Incorrect: Intimacy versus Isolation is the objective from 20-39 year olds to form an intense, lasting relationship or a commitment to another person. If the individual cannot form the intimate relationships (possibly due to personal needs) a sense of isolation may develop which can lead to feelings of depression.

Two hours after a gastrectomy, a client has pink tinged drainage from the nasogastric (NG) tube, and the tube appears occluded. What is the nurse's initial action at this time? You answered this question Incorrectly 1. Call the primary healthcare provider. 2. Reposition the client. 3. Increase the suction level. 4. Irrigate the tube.

1. Correct: Do not tamper with fresh surgery tubes. Call the primary healthcare provider for blood draining from the NG tube after gastrectomy. 4. Incorrect: Although the healthcare provider may prescribe for the tube to be irrigated later, the healthcare provider should be notified of the presence of blood initially. Irrigating the fresh NG tube in this situation could lead to increased bleeding.

A client suffers from migraine headaches. What assessment finding would the nurse expect to find during a migraine attack? You answered this question Incorrectly 1. Unilateral, pulsating pain quality. 2. Bilateral, pressing/tightening pain quality. 3. Ipsilateral nasal congestion and rhinorrhea. 4. Headache occurs after recovering from a headache treated with narcotics.

1. Correct: Migraine headaches have a pulsating pain quality, unilateral location, moderate or severe pain intensity, aggravated by or causing avoidance of routine physical activity (walking, climbing stairs). During headache at least one of the following accompanies the headache: nausea and/or vomiting; photophobia and phonophobia. Nausea/vomiting, photophobia and phonophobia are not common manifestations with tension headaches. 2. Incorrect: This is seen in tension headaches. Headaches last 30 minutes to 7 days. Pain is mild or moderate in intensity. It is not aggravated by routine physical activity. These usually start gradually, often in the middle of the day.

The nurse is planning care for a pediatric client reporting acute pain with sickle cell crisis? What should the nurse identify as an appropriate goal for this client? You answered this question Incorrectly 1. Client will report a pain level of less than 2 on a Faces scale. 2. The nurse will administer prescribed pain meds around the clock. 3. Client will only take breakthrough pain medication. 4. Client will use distraction instead of pain medication.

1. Correct: Yes, having a pain level of less than 2 is the best goal for pain and the use of a Faces scale, instead of a numerical scale is age appropriate. Sickle cell crisis is extremely painful, and often times, the pain is not completely relieved during the acute stage. 2. Incorrect: The goal should be client centered. This option is a nursing intervention, not a client goal.

An RN on the general pediatric unit has been reassigned to the spinal/neurology unit. What assignment by the charge nurse would be appropriate for this RN? You answered this question Incorrectly 1. Child with spina bifida with a previous shunt revision 2. Adolescent who is 4 days post op from a spinal fusion 3. Child with a ventriculoperitoneal shunt one day post-op 4. Child with spinal muscle atrophy who is ventilator assisted 5. Child with cerebral palsy who had a tracheostomy performed this AM

1., & 2. Correct: The child who had a previous shunt revision and the adolescent who is 4 days post spinal fusion will be the most stable and will require the least skill level when compared with the other choices. On a general pediatric unit, the nurse would be familiar with checking for increased ICP, which would be necessary for caring for any client with a previous shunt revision. Immediately postop, the adolescent with spinal fusion would require special turning and lung assessment to prevent and observe for congestion/pneumonia, skills not acquired on a general floor. However, at 4 days postop this client should be ambulating and will not need specialized turning, so the nurse from the general pediatric unit could care for this client. 3. Incorrect: This client is more acute and requires a higher skill level. Nursing care for this child would involve frequent neurologic assessments and monitoring for infection. The child should also be monitored for signs of possible complications including bowel perforation.

An adult client has just returned to the nursing care unit following a gastroscopy. Which intervention should the nurse include on the plan of care? You answered this question Incorrectly 1. Vital sign checks every 15 min x 4 2. Supine position for 6 hours 3. NPO until return of gag reflex 4. Irrigate NG tube every 2 hours 5. Raise four siderails

1., & 3. Correct: Vital signs post procedure are important to monitor for any post-procedure complications such as bleeding or any signs of respiratory compromise. VS are checked frequently for the first hour post procedure. Any client who has a scope inserted down the throat and has received numbing medication in the back of the throat to depress the gag reflex should be kept NPO until the gag reflex returns. 2. Incorrect: Supine position for 6 hours is contraindicated. The HOB should be elevated. In the event the client vomits, he/she is less likely to aspirate with the HOB elevated. Supine position for 6 hours is used after a heart catheterization. 5. Incorrect: Raising all side rails is a form of restraint. Have the bed in low locked position. Raise three side rails, and have call light within reach.

Which prescriptions would the nurse recognize as being appropriate for the client with shingles? You answered this question Incorrectly 1. Private room 2. Negative pressure airflow 3. Respirator mask (N95) 4. Face Shield 5. Positive pressure room

1., 2. & 3. Correct: According to the current standards of Standard Precautions per the CDC, the client with shingles should be placed on airborne precautions which require the use of a private room with negative pressure airflow and a N-95 respirator mask. 5. Incorrect: Negative pressure is required in order to prevent the airborne infection from spreading outside of the room. Positive pressure is used only in protective environments such as when immunocompromised. This keeps the contents of the rooms undisturbed by outside agents. Clients require protection from potential infectious agents outside of the room.

A client with a history of command hallucinations was admitted to the hospital yesterday. What questions are most important for the nurse to ask? You answered this question Incorrectly 1. "Are you hearing voices today?" 2. "What are the voices saying?" 3. "How are you feeling today?" 4. "Did you have difficulty sleeping last night?" 5. "Are the voices telling you to harm yourself or anyone else?"

1., 2. & 5. Correct: The nurse must assess for hallucinations. The nurse needs to know what the voices are saying to determine the level of threat. The nurse needs to know if the command hallucination exists and whether it involves harming self or others which must be reported. These answers are important to know, as the client has a history of command hallucinations. 3. Incorrect: The priority is safety of the client and others on the unit. This question does not get the most essential information related to command hallucinations that may cause the client to engage in behavior that is harmful to self or others. 4. Incorrect: This question does not focus on the problem: command hallucinations. If you assume the worse, you want to know if the voices from the command hallucinations are telling the client to harm self or others.

The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which clients would be appropriate for the nurse to assign to the LPN/VN? You answered this question Incorrectly 1. In Bucks traction requiring frequent pain medication. 2. 24 hours post appendectomy. 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM. 4. Admitted 6 hours ago in adrenal insufficiency. 5. Client newly diagnosed with Type 2 diabetes.

1., 2., & 3. Correct These clients are stable and require predictable care that can be done appropriately by the LPN/VN.

What should the nurse tell the parents of a newborn about a Guthrie test? You answered this question Incorrectly 1. The purpose of this test is to determine the presence of phenylalanine in the blood. 2. A positive test indicates a metabolic disorder. 3. To conduct this test, a sample of blood is taken from the baby's heel. 4. An increase in protein intake can interfere with the test. 5. This test will be done when your baby is 6 weeks old.

1., 2., 3. Correct: These are true statements. A positive test indicates decreased metabolism of phenylalanine, leading to phenylketonuria. The normal level of phenylalanine in newborns is 0.5 to 1 mg/dl. The Guthrie test detects levels greater than 4 mg/dl. Only fresh heel blood, not cord blood, can be used for the test. The main objective for diagnosing and treating this disorder is to prevent cognitive impairment. 4. Incorrect: A lack of protein intake can interfere with the test. The screening test is most reliable when the blood sample is obtained after the baby has ingested a source of protein.

The charge nurse is making assignments for one RN and one LPN/VN on a pediatric unit. Which clients would be most appropriate for the charge nurse to assign to the RN? You answered this question Incorrectly 1. 2 year old with asthma receiving IV medication. 2. 6 year old with new onset seizures. 3. 12 year old with colitis receiving TPN. 4. 2 month old with urinary tract infection. 5. 10 year old paraplegic needing assistance with bowel training.

1., 2., 3. Correct: These clients should be assigned to the RN as they will require more frequent assessment due to the nature of each diagnosis and have a potential for more rapid change in condition. Also, these clients may require skills by the RN that the LPN/VN could not do; for example, giving IV medications that asthma clients take; teaching the family about seizures, meds, and management; and administering TPN intravenously. 5. Incorrect: This assignment is appropriate as the LPN/VN can provide care related to elimination needs.

The nurse is caring for a client admitted to the psychiatric unit with a diagnosis of major depression. What behaviors could the nurse expect upon assessment of this client? You answered this question Incorrectly 1. Withdrawn behavior 2. Sitting in room, lights out, drapes closed 3. Unkempt appearance 4. Overeating 5. Severe insomnia

1., 2., 3., & 5. Correct: The client with severe depression has extremely low self-esteem and low energy levels and may just sit for hours. Depressed clients prefer to be alone and avoid social interactions. The room environment mimics the mood of the client (dark and gloomy). The client may not have the energy to bathe, change clothes, or even comb hair. The severely depressed person may have severe insomnia. However, sleeping too much is also a symptom of mild depression. 4. Incorrect: The client who is severely depressed, as in the depressive disorder, usually has no appetite and loses weight. A mildly depressed client is more likely to overeat as a coping mechanism.

What should a nurse teach family members prior to them entering the room of a client who has agranulocytosis? You answered this question Incorrectly 1. Meticulous hand washing is needed. 2. Do not visit if you have any infection. 3. The client must wear a mask. 4. Children under 12 may not visit. 5. Flowers are not allowed in the room.

1., 2., 4., & 5. Correct: Protective isolation is needed for this client because of the presence of a low white blood cell count. We are protecting the client from acquiring an infection. So any visitors will need to have meticulous hand washing prior to entering. The visitor should not enter if he or she has any type of infection. To decrease the risk of infection, small children should not visit. Even the mildest symptom of infection could be detrimental to the client. Flowers have bacteria and should not be brought into the room. 3. Incorrect: A mask must be worn by the visitor, not the client. The mask is worn by visitors to prevent a possible spread of an airborne infection to the immunocompromised client.

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client? You answered this question Incorrectly 1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen

1., 2., 4., & 5. Correct: An alternating pressure mattress will help to prevent pressure ulcers. The risk of respiratory compromise increases as the neurologic status deteriorates. A hospital bed is needed so that the head of the client's bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. The client with hepatic encephalopathy is unresponsive due to accumulation of toxins and may need suctioning if unable to clear secretions from the oropharynx. Hepatic encephalopathy frequently has associated bleeding varices. The increasing ascites leads to hypovolemia. Both of these conditions can result in hypoxemia for the client at the end stages of liver disease; therefore, oxygen therapy is provided. 3. Incorrect: As hepatic encephalopathy progresses and toxins accumulate, the client lapses into a coma. Therefore, the unresponsive client will not be ambulatory and would not need a walker.

Which immunizations obtained by the age of two would indicate to the pediatric nurse that the child is up-to-date on immunizations? You answered this question Incorrectly 1. Diptheria-tetanus-pertussis (DTaP). 2. Inactivated polio (IPV). 3. Herpes zoster. 4. Hep A & B 5. Meningococcal 6. Haemophilus influenza type B (Hib). 7. PCV 8. RV

1., 2., 5, 6, 7 & 8. Correct: By the age of two, the DTaP, IPV, MMR, Hib, varicella, pneumococcal, and rotovirus vaccines should have been received. The nurse should clarify this with the parent.

The nurse is advising the family of a client receiving palliative care on alternative methods for pain control to be used in conjunction with pain medications. Which method should the nurse include? You answered this question Incorrectly 1. Providing a back massage 2. Administering pain medication when pain is rated at 5 out of 10 3. Distracting with music 4. Exercise 5. Prayer

1., 3., & 5. Correct: These are types of alternative pain control that could be used in conjunction with traditional pain management. They can be used to provide relaxation and comfort; mind-body therapies such as meditation, guided imagery and hypnosis may be effective. Other measures may include: acupuncture, therapeutic touch, music therapy and spiritual practices such as prayer. These have been found to be effective in helping to reduce pain.

To reduce the risk of developing a complication following balloon angioplasty, the nurse should implement which measure? You answered this question Incorrectly 1. Monitor cardiac rhythm 2. Assess the puncture site every 8 hours 3. Measure urinary output hourly 4. Prevent flexion of the affected leg 5. Avoid lifting buttocks off the bed

1., 3., 4., & 5. Correct: The primary healthcare provider should be notified of any rhythm changes or report chest pain/discomfort. These could be signs of re-occlusion. Decreased urinary output (UOP) could be due to poor renal perfusion, which can result from decreased cardiac output and shock. Frequent VS and UOP measurements are needed. Flexion should be avoided at the catheter access site to allow time for the clot to stabilize and reduce the risk of bleeding and hematoma formation. The client should avoid lifting the buttocks off the bed because this increases pressure at the insertion site which increases the risk of hematoma formation/bleeding. 2. Incorrect: Assessments are needed more frequently than every 8 hours. Although policies may differ, assessment of the insertion site is usually every 15 minutes for 1 hour, every 30 minutes for 1 hour, and then hourly for 4 hours. More frequent monitoring may be required. During the assessment, the nurse should observe the catheter access site for bleeding or hematoma formation and should assess the peripheral pulses in the affected extremity.

The parents of a 4 year old child are concerned about whether the child will adapt to the newborn baby they are expecting in two weeks. What suggestions should the nurse make to assist with sibling adaptation? You answered this question Incorrectly 1. Allow child to be one of the first to see the newborn. 2. Have child stay with parents during labor and delivery. 3. Arrange for one parent to spend time with the child while the other parent cares for the newborn. 4. Provide a gift from the newborn to give to the child. 5. Have child care for a doll.

1., 3., 4., & 5: These are good recommendations for the nurse to make to the parents in an effort to promote sibling adaptation. Make the 4 year old part of the process as much as possible. Demonstrate the importance of the child by allowing the child to see the baby first. Provide personal time with the 4 year old. This shows that the 4 year old is important to the family. The baby is providing a gift to the child which promotes a bond between the two and demonstrates to the child that he or she is important. Having a 4 year old care for a doll gets the child involved in caring for another. The child can learn what a newborn needs both physically and emotionally by imitating the parents.

The RN is caring for a client diagnosed with an abdominal aortic aneurysm. Which prescription can the RN delegate to the LPN? You answered this question Incorrectly 1. Obtain vital signs every 15 minutes. 2. Insert a urinary catheter for hourly urinary outputs. 3. Place a PICC line for fluid management. 4. Provide morphine 1 mg per PCA pump at a 10 minute lockout.

2. Correct. Inserting a urinary catheter is within the scope of practice for the LPN. This task does not include further assessment of the urinary output, which the RN will perform. 1. Incorrect. The UAP can do this task as well as the LPN. In order to be most effective with the nurse's time, this task can be delegated to the UAP.

A nurse, assigned to take care of a client who is HIV positive, refuses the assignment, stating fear of personal injury. What action should the charge nurse take first? You answered this question Incorrectly 1. Re-assign the client to a nurse who does not mind caring for HIV positive clients. 2. Inform the nurse that refusing client care is not acceptable nursing practice. 3. Have the nurse document rationale and support for refusing the client assignment. 4. Transfer the nurse to a unit where there are no HIV positive clients.

2. Correct. This action by the charge nurse demonstrates an understanding of the code of ethics for nurses. Any nurse who feels compelled to refuse to provide care for a particular type of client faces an ethical dilemma. The reasons given for refusal range from a conflict of personal values to fear of personal risk of injury. Such instances have increased since the advent of acquired immunodeficiency syndrome (AIDS) as a major health problem. The ethical obligation to care for all clients is clearly identified in the first statement of the Code of Ethics for Nurses. To avoid facing these moral and ethical situations, a nurse can follow certain strategies. For example, when applying for a job, one should ask questions regarding the client population. If one is uncomfortable with a particular situation, then not accepting the position would be an option. Denial of care, or providing substandard nursing care to some members of our society, is not acceptable nursing practice. As a professional, the nurse should provide the same level of care to every client, regardless of diagnosis, skin color, ethnicity or economic status. 1. Incorrect: This is not the best action for the charge nurse to take.The charge nurse should remind the nurse of the responsibility for the agency to provide nondiscriminatory care to all clients. The re-assignment of the client to another nurse does not resolve the ethical dilemma by the nurse refusing to provide care.

The nurse is teaching a newly diagnosed diabetic about the action of regular insulin. The nurse verifies that teaching has been successful when the client verbalizes being at greatest risk for developing hypoglycemia at what time following the 8:00 a.m. dose of regular insulin? You answered this question Incorrectly 1. 8:30 AM 2. 11:00 AM 3. 1:30 PM 4. 4:00 PM

2. Correct: 11:00 AM: Regular insulin peaks 2-3 hours after administration. Clients are at greatest risk for hypoglycemia when insulin is at its peak. 1. Incorrect: 8:30 AM: Rapid acting insulin will begin peaking in 30 minutes. 3. Incorrect: 1:30 PM: Intermediate acting insulin begins peaking at 4 hours. So at 1:30 PM this would be a time of worry. 4. Incorrect: 4:00 PM: At 4 PM you would still be worried about intermediate acting insulin. But you would also be worried about long acting insulin as well. Which starts to peak at 6 hours.

The family member of a schizophrenic client asks the nurse why the client is receiving chlorpromazine and benztropine. What is the best response by the nurse? You answered this question Incorrectly 1. The chlorpromazine makes the benztropine more effective so a smaller dose of both drugs can be used. 2. Benztropine is given to treat the side effects produced by the chlorpromazine. 3. Chlorpromazine is used for severe hiccups that can occur with the use of benztropine. 4. Chlorpromazine is used for psychosis and benztropine is used for preventing agranulocytosis.

2. Correct: Benztropine is used to treat parkinsonism of various causes and drug-induced extrapyramidal reactions seen with chlorpromazine, which is an antipsychotic agent. EPS' are neurologic disturbances in the area of the brain that controls motor coordination. This disruption can cause symptoms that mimic Parkinson's disease, including stiffness, rigidity, tremor, drooling and the classic "mask like" facial expression. These symptoms can be treated and are reversible using such medications as benztropine. 4. Incorrect: Benztropine is not used to prevent agranulocytosis.

The nurse in the emergency department suspects that a client's lesion is caused by anthrax. What assessment question is most important? You answered this question Incorrectly 1. Have you traveled out of the United States recently? 2. Have you recently worked with any farm animals or any animal-skin products? 3. Have you experienced any gastrointestinal upset recently? 4. Have you eaten any home-canned foods recently?

2. Correct: Cutaneous anthrax may be contracted by working with contaminated animal-skin products. Anthrax is found in nature and commonly infects wild and domestic hoofed animals. 1. Incorrect: Cutaneous anthrax is also found in the United States, so asking about travel abroad would not be necessary.

A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R 36. The client is extremely anxious and crying uncontrollably. Based on this assessment, the nurse should anticipate that this client is likely in which acid base imbalance? You answered this question Incorrectly 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

2. Correct: Hyperventilation due to anxiety, pain, shock, severe infection, fever, liver failure can lead to respiratory alkalosis. With each of these, the client loses too much CO2. The reduction of CO2 creates an excessive loss of acid, resulting in an alkalotic state. Since the problem is respiratory, it is respiratory alkalosis. 1. Incorrect: This problem is respiratory, but there is excessive CO2 loss. CO2 combines with water to form an acid. If too much of the CO2 is lost, the result of the acid forming substance loss would be alkalosis-Not acidosis.

A client, hospitalized with possible acute pancreatitis secondary to chronic cholecystitis, has severe abdominal pain and nausea. The client is kept NPO, an NG tube is inserted, and IV fluids are being administered. What is the rationale for the client being NPO with an NG tube to low suction? You answered this question Incorrectly 1. Relieve nausea 2. Reduce pancreatic secretions 3. Control fluid and electrolyte imbalance 4. Remove the precipitating irritants

2. Correct: In clients with pancreatitis, the pancreatic enzymes cannot exit the pancreas. These enzymes, when activated, begin to digest the pancreas itself. The enzymes become activated in the pancreas when fluid or food accumulates in the stomach. The goal in treating this client is to stop the activation of the pancreatic enzymes. Treatment is focused on keeping the stomach empty and dry. This allows the pancreas time to rest and heal. Note: Autodigestion (pancreas digesting itself) is painful for the client and can lead to other problems such as bleeding. 1. Incorrect: The primary purpose of the NG tube to suction is to keep the stomach empty and dry to decrease pancreatic enzyme production, not to relieve nausea. 3. Incorrect: Because gastric contents are removed, the NG tube to suction may lead to fluid and electrolyte disturbances rather than helping to control them.

During the insertion of a urinary catheter, the tip of the catheter touches the client's thigh. What action should the nurse take? You answered this question Incorrectly 1. Wipe the tip of the catheter with alcohol. 2. Call for another urinary catheter and a pair of sterile gloves. 3. Insert the catheter and obtain a prescription for antibiotics. 4. Leave the room to obtain another sterile urinary catheter kit.

2. Correct: Indwelling catheter insertion is a sterile procedure. If contamination occurs, do not turn back on sterile field. Get on the call light to request another urinary catheter and sterile gloves to continue the procedure. Continuing the procedure with contaminated equipment would jeopardize the client's safety. 4. Incorrect: The catheter is contaminated, but the sterile field is still okay. It is more cost efficient to have someone bring the nurse another catheter and pair of sterile gloves rather than getting an entire sterile kit.

A client diagnosed with major depression has been taking an SSRI x 6 weeks. When visiting the mental health center, the nurse discusses the medication and response with the client. The nurse's assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation? You answered this question Incorrectly 1. Are you having trouble sleeping at night? 2. Do you have periods of muscle jerking? 3. Are you having any sexual dysfunction? 4. Is your mood improving?

2. Correct: Myoclonus, high body temperature, shaking, chills, and mental confusion are some of the symptoms of serotonin syndrome. This client may be having symptoms of this adverse reaction which, if severe, can be fatal. 4. Incorrect: The response to the SSRI medications is important; however, there is a more significant issue in this case. The possible serotonin syndrome is a serious situation that would be the priority for the nurse to address.

The nurse is giving discharge instructions to an Asian client following a colonoscopy. During the instructions, the client stares directly at the floor, despite being able to speak English. Based on the client's body language, how would the nurse classify this behavior? You answered this question Incorrectly 1. Embarrassment. 2. Attentiveness. 3. Disinterest. 4. Confusion.

2. Correct: Nurses must be aware of clients' specific cultural or religious beliefs in order to provide appropriate care and discharge planning. Asian societies have a deep respect for others and making eye contact with the nurse would be considered rude and offensive. The nurse is considered superior to the client, so direct eye contact with a superior shows a lack of respect. This client is displaying attentiveness while also showing respect for the nurse. 3. Incorrect: The client's body language does not suggest disinterest. Although staring downward, this client does not display other signs of disinterest. A culturally aware nurse understands that the client's Asian background impacts this behavior and conveys the meaning of respect for the nurses' position.

A child is being admitted with possible rheumatic fever. What assessment data would be most important for the nurse to obtain from the parent? You answered this question Incorrectly 1. 102° F (38.89° C) temperature that started 2 days previously. 2. History of pharyngitis approximately 4 weeks ago. 3. Vomiting for 3 days. 4. A cough that started about 1 week earlier.

2. Correct: Rheumatic fever is often the result of untreated or improperly treated group A β-hemolytic streptococcal infections (GABHS), such as pharyngitis. Therefore, the history of pharyngitis or upper respiratory infection is a key assessment finding for establishing a diagnosis of rheumatic fever. Subsequent development of rheumatic fever usually occurs 2 to 6 weeks following the GABHS, so the assessment should include a remote history of pharyngitis. 1. Incorrect: The fever with rheumatic fever is usually low grade and is considered a minor manifestation of rheumatic fever.

A newly admitted client with schizophrenia has an unkempt appearance and needs to attend to personal hygiene. Which statement by the nurse is most therapeutic? You answered this question Incorrectly 1. A shower will make you feel better. 2. It is time to take a shower. 3. Have you thought about taking a shower? 4. I need you to take a shower.

2. Correct: Schizophrenia is a thought disorder. Many clients with schizophrenia are not abstract thinkers and have difficulty making decisions. The nurse needs to be direct, clear and concise in communicating with the client. This is a direct, clear and concise statement that guides the client to perform the needed activity. 1. Incorrect: Many clients with schizophrenia are concrete thinkers. The nurse needs to be direct, clear and concise in communicating with the client. The client may not comprehend how the shower improves the overall sense of well-being and would remain reluctant to take the shower. 3. Incorrect: Clients diagnosed with schizophrenia often have trouble making decisions. The client needs to be guided with simple, direct instructions.

The nurse is caring for a client admitted to the skilled nursing unit approximately 3 months ago. Since admission, the client has lost 8 pounds. There have been no documented changes in the client's physical health. Which strategy may help to improve caloric intake for this client? You answered this question Incorrectly 1. Encourage the client to eat meals in the room. 2. Take the client to the dining room for all meals. 3. Provide a high protein supplement 30 minutes before meals. 4. Ask the unlicensed assistive personnel to feed the client at each meal.

2. Correct: The client may be lonely and miss the interaction with others, but reluctant to go to the dining room. Eating with others may help to improve appetite and intake of food. The nurse can actively seek out the client and take this client to the dining room. Simply encouraging the client to go to the dining room may not be sufficient to get the client to go. 3. Incorrect: A high protein supplement may increase caloric intake; however, to give that to the client 30 minutes before a meal will interfere with food intake at mealtime.

The client at the mental health center has voiced suicidal thoughts and has access to firearms at home. Which action by the nurse is priority? You answered this question Incorrectly 1. Empathize with the client and listen to feelings. 2. Inform the family and ask them to remove the guns. 3. Chart the thinking pattern and make a follow up appointment. 4. Ask the client to return to the clinic tomorrow for further evaluation.

2. Correct: The family should be notified. Suicidal thinking is one condition that necessitates breach of confidentiality. The client has identified a plan and has access to firearms; therefore, the family should remove them from the house. Client safety is a priority. This client will likely be directly admitted to the hospital. 1. Incorrect: This is appropriate; however, client safety is priority at this time. Suicide risk is higher when a plan is expressed and lethal means are available.

Which assessment finding would indicate to a nurse that a client receiving chemotherapy may have difficulty maintaining proper nutrition? You answered this question Incorrectly 1. Fatigue 2. Mucositis 3. Neutropenia 4. Diarrhea

2. Correct: Ulcerations in the oral cavity can make it difficult to chew food or be intolerant to certain foods due to discomfort and pain. Intake may be inadequate as a result of this. 4. Incorrect: Diarrhea may need to be treated by making diet changes. However, the maintenance of nutrition should be focused on intake. The impact of the mucositis should be considered first for maintaining proper nutrition.

The nurse is caring for a client in the emergency department after a violent altercation with her husband. She describes increasingly violent episodes over the past 10 years. She says, "This is the last time he will hit me." Which response by the nurse demonstrates understanding of the violence cycle? You answered this question Incorrectly 1. When you leave, you don't have to worry anymore. 2. You are at greatest risk when you leave. 3. That is the best decision you can make. 4. I am glad that you won't be hurt ever again.

2. Correct: Violence is likely to escalate and may become lethal when the spouse leaves the abusive partner. The risk of death or injury is highest at the time the abused person decides to leave the abusive relationship or shortly after leaving. 3. Incorrect: The client should be praised; however, there are risks with both leaving and staying. The client should be informed. The nurse should acknowledge the fear of staying in the relationship and guide the client to resources that can be used to help make informed decisions.

Which statements should a nurse make when educating a client about advance directives? You answered this question Incorrectly 1. Used as guidelines for client treatment should the client's family deem them necessary. 2. Legally binding document. 3. Should be documented in the client's medical record as to whether or not the client has an advance directive. 4. Specifies a client's wishes for healthcare treatment should the client become incapacitated. 5. Allows the client's spouse to make end-of-life decisions.

2., 3. & 4. Correct: Advance directives are legally binding documents. Documentation is required in the medical record as to whether an advance directive exists. If one exists, a copy should be placed in the medical record. The document is prepared by the client detailing wishes for treatment should the client become unable to make informed healthcare decisions. 1. Incorrect: The family's wishes for treatment of the client do not take the place of or negate the client's advance directive.

The nurse wants to provide anticipatory guidance for a group of young parents who have children between the ages of 18 months to 3 years. What points about the next year should the nurse be sure to provide these parents? You answered this question Incorrectly 1. Be strict and rigid with toilet training, rather than being accepting and letting the child lead the training. 2. Tell the parents about the importance of letting the child do tasks alone. 3. Provide finger foods for the child to eat. 4. Your child will want you to provide emotional support when needed. 5. Assist your child with all tasks to promote independence.

2., 3. & 4. Correct: Letting the child do things on their own will promote a sense of self control and independence during this stage of autonomy vs shame and doubt. Finger foods allow for independence with eating and builds a sense of autonomy. At this age, the child becomes increasingly aware of separateness from the parent. The need is for the parent to be available for emotional support when needed. However, if emotional needs are inconsistently met or if the parent rewards clinging, dependent behaviors and withholds nurturing when the child demonstrates independence, feelings of rage and fear of abandonment may develop in adulthood. The support provided by the parent can lessen feelings of anxiety for the child when the emotional presence is needed. 5. Incorrect: Assisting with all tasks will promote dependence. This does not give the child opportunities to perform age-appropriate tasks independently and gain a sense of autonomy. Notice the word "all"? This conveys a thought or concept that has no exceptions. Words such as just, always, never, all, every, none, and only are absolute and place limits on the statement that generally is considered correct. Statements including these words generally make the statement false as the statement is general and broad and does not allow for exceptions.

A nurse is caring for a client who delivered a baby vaginally two hours ago. What signs and symptoms of postpartum hemorrhage should the nurse report to the primary healthcare provider? You answered this question Incorrectly 1. Two blood clots the size of a dime. 2. Perineal pad saturation in 10 minutes. 3. Constant trickling of bright red blood from vagina. 4. Oliguria 5. Firm fundus

2., 3., & 4. Correct: Lochia should not exceed an amount that is needed to partially saturate four to eight peripads daily, which is considered a moderate amount. Perineal pad saturation in 15 minutes or less is considered excessive and is reason for immediate concern. Saturation of a peripad in one hour is considered heavy. Also, trickling of bright red blood from the vagina can indicate hemorrhage and is often a result of cervical or vaginal lacerations. Bright red blood indicates active bleeding. Oliguria is a sign of fluid volume deficit. As blood volume goes down, renal perfusion decreases and urinary output (UOP) decreases. The kidneys are also attempting to hold on to what little fluid volume is left.

The school nurse has identified a large outbreak of viral conjunctivitis among one middle school class and plans to educate these students on this illness. Which data should the nurse be sure to include? You answered this question Incorrectly 1. Use personal handkerchief to wipe the eye of discharge. 2. Light cold compresses over the eyes several times a day will ease discomfort. 3. Do not share towels or linens. 4. Discard all makeup and use new makeup after infection resolves. 5. Wash hands frequently with soap and water.

2., 3., 4. & 5. Correct: All of these measures will promote comfort and decrease risk of transmitting infection. Clients should also avoid touching the eyes and shaking hands/touching other. Cool compresses provide symptomatic relief.

The nurse on a neuro rehabilitation unit is caring for a client with a T4 injury. The client suddenly reports a severe, pounding headache. Profuse diaphoresis is noted on the forehead. The blood pressure is 180/112 and the heart rate is 56. What interventions should the nurse initiate? You answered this question Incorrectly 1. Place client supine with legs elevated. 2. Assess bladder and bowel for distention. 3. Examine skin for pressure areas. 4. Eliminate drafts. 5. Remove triggering stimulus. 6. Administer hydralazine if BP does not return to normal.

2., 3., 4., 5. & 6. Correct: The client is experiencing autonomic dysreflexia, which is a potentially dangerous syndrome that can develop in clients with spinal cord injuries. The cause of autonomic dysreflexia with these associated symptoms is a strong sensory or noxious stimulus. The most common stimulus is bowel, bladder distention, or irritation. Any painful, irritating or strong stimulus including environmental temperature changes, drafts, etc. can trigger autonomic dysreflexia. It is considered a medical emergency and must be promptly treated. 1. Incorrect: The client should be placed immediately in a sitting position to lower blood pressure. The supine position with the legs elevated could increase the BP to higher and more dangerous levels.

Question: What interventions should the nurse initiate to keep the airway free of secretions in a client with pneumonia? You answered this question Incorrectly 1. Evaluate results of ABG's and report abnormal findings. 2. Increase oral intake to at least 2000 mL/day. 3. Administer a cough suppressant medication. 4. Educate client on incentive spirometry. 5. Perform percussion to affected area.

2., 4., & 5. Correct: Liquefy secretions by increasing oral intake to at least eight, 8 ounce glasses of liquid/day unless fluid restrictions are required. Incentive spirometry helps keep alveoli open and prevents further pneumonia and atelectasis. Prescribed percussion can assist with loosening secretions for expectoration. 1. Incorrect: This does not get rid of secretions. This monitors respiratory effectiveness.

The nurse is working in a long term care facility. What actions by the nurse are appropriate when taking a telephone prescription from a primary healthcare provider? You answered this question Incorrectly 1. Document the prescription prior to the end of the shift. 2. Explain to the pimary healthcare provider that nurses cannot take telephone prescriptions. 3. Repeat the prescription back to the primary healthcare provider prior to hanging up. 4. Transcribe the prescription in the client's record. 5. Ask the primary healthcare provider to wait and write the prescription during rounds.

3. & 4. Correct: Whenever a verbal or telephone prescription is given, the nurse is to transcribe the prescription, and then read it back to the prescribing primary healthcare provider at the time the prescription is given for validation of accuracy of the prescription received. Otherwise an error may occur. 2. Incorrect: Nurses can take telephone prescriptions; however, safety measures include writing down the prescriptions immediately and repeating the prescriptions to the primary healthcare provider. 5. Incorrect: Asking the primary healthcare provider to wait until rounds is not appropriate, as nurses can take telephone prescriptions with appropriate safety measures to ensure accuracy.

On the third postoperative day, a client develops a fever of 103.3ºF (39.6ºC) shivering and nausea. The primary healthcare provider writes these prescriptions. Which should the nurse do first? You answered this question Incorrectly 1. Apply cooling blanket for fever. 2. Give ceftriaxone 1 gram IVPB stat. 3. Draw blood cultures. 4. Give promazine 50 mg po PRN for nausea.

3. Correct: Blood cultures MUST be drawn immediately to identify the causative bacteria. Once the organism is identified, the primary healthcare provider will order organism specific antibiotics. Always draw blood cultures before administering the antibiotic. If antibiotics are given before the blood cultures are drawn, the culture will be inaccurate, and the client cannot be treated appropriately. 1. Incorrect: Application of a cooling blanket is appropriate, but the key in this question is to "fix the problem" ASAP. To treat the infection, the blood cultures must be drawn ASAP and be done before starting the antibiotics. 2. Incorrect: Antibiotics are not given until the cultures have been drawn. Administering the antibiotic first would cause the culture to be inaccurate.

A client is admitted to the emergency department reporting abdominal discomfort and constipation lasting 3 days. Which abdominal assessment data would the nurse report to the primary healthcare provider? You answered this question Incorrectly 1. Striae. 2. Borborygmi. 3. High-pitched bowel sounds. 4. Tympany noted on percussion.

3. Correct: High-pitched bowel sounds are indicative of an early bowel obstruction and hypoactive bowel sounds develop as obstruction worsens. The additional signs presented are also clues of a possible obstruction. 1. Incorrect: Striae on the abdomen may be a sign of past weight changes such as those seen with weight gain from pregnancy. These do not create abdominal discomfort nor constipation. 2. Incorrect: Borborygmi are normal, loud, rumbling sounds from gas movement through the intestines or from hunger. These are easily audible bowel sounds. These are not typically associated with constipation but may be present with diarrhea. 4. Incorrect: This is a normal finding in the abdomen. Tympany is usually present in most of the abdomen caused by air in the gut (a higher pitch than the lungs). Tympany would be minimal in this case, dependent upon the degree of constipation, which would lead to a dull sound upon percussion.

What assignment would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? You answered this question Incorrectly 1. Teaching the client perineal care. 2. Changing a colostomy bag on a client. 3. Serving the diet tray for a diabetic client. 4. Taking the initial vital signs on a client who is to receive blood.

3. Correct: The most appropriate task for a non-licensed person would be serving the diet tray for a client. This does not require experience for a particular skill nor does it require higher level skills that would require a licensed person to perform. 2. Incorrect: Changing the colostomy bag on a client will need someone with the experience/skill of performing this task. Although some agencies allow UAP's to change colostomy bags, there may be further assessment needed associated with the ostomy, such as skin condition around the ostomy. This would not be the best option to assign to the UAP.

A 70 year old client was admitted to the vascular surgery unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's BP is 198/94. What would be the best action for the charge nurse to delegate at this time? You answered this question Incorrectly. 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm in 15 minutes. 3. Have the LPN/LVN administer the 0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for pain.

3. Correct: The nurse should recognize the need for measures to reduce the blood pressure. Administering the client's blood pressure medicine is aimed at correcting the problem. It is appropriate to administer the medications at this time in relation to the time that the next dose is due. 1. Incorrect: This is an appropriate action, but does not address the problem of lowering the client's blood pressure.

The triage nurse in the emergency department (ED) assesses 4 clients. Which client is in need of emergent care the most? You answered this question Incorrectly 1. A 52 year old who has a partially amputated finger. 2. A 9 month old with temperature of 103°F (39.4°C). 3. A two year old with excessive drooling and a weak cough. 4. A 28 year old experiencing a migraine headache for three days.

3. Correct: The two year old is exhibiting signs of respiratory difficulty with excessive drooling and a weak cough. Partial airway obstruction is likely and maybe the result of acute epiglottitis in which rapid progression to severe respiratory distress can occur . Airway takes priority over the other clients. 2. Incorrect: Most fevers in children do not last for long periods and do not have much consequence. Elevated temperature would not take priority over airway. Antipyretics can be given in triage.

The RN is teaching a client about foods containing tyramine which should be avoided while taking a monoamine oxidase inhibitor (MAOI). Which meal selection, if chosen by the client, indicates successful teaching? You answered this question Incorrectly 1. Smoked turkey and dressing, sweet peas and carrots and milk. 2. Baked chicken over pasta with parmesan sauce, baked potato and tea. 3. Fried catfish, French fries, coleslaw and apple juice. 4. Liver smothered in gravy and onions, rice, squash and water.

3. Correct: These foods are not high in tyramine. Tyramine is an amino acid that helps in the regulation of blood pressure. MAOIs block the enzyme monoamine oxidase which is responsible for breaking down excess tyramine in the body. Eating foods high in tyramine while on MAOIs can result in dangerously high levels of tyramine in the body. This can lead to a serious rise in blood pressure, creating an emergency situation. Tyramine is found in protein-containing foods and the levels increase as these foods age. Food such as strong or aged cheese, cured meats, smoked or process meats, liver (especially aged liver), pickled or fermented foods, sauces, soybeans, dried or overripe fruits, meat tenderizers, brewer's yeast, alcoholic beverages and caffeine- such as in tea, cokes and coffee are considered to be high in tyramine and should be avoided in clients taking MAOIs. 2. Incorrect: The following foods in the options listed above contain moderate to high levels of tyramine and should be avoided while taking MAOIs: smoked turkey, parmesan cheese, tea and liver.

The nurse is preparing a client for a renal biopsy. Which is most important for the nurse to assess prior to this procedure? You answered this question Incorrectly 1. BUN and creatinine 2. NPO status and signature on consent 3. Bleeding time and coagulation studies 4. Serum potassium and urine sodium

3. Correct: Yes. Before you insert a needle into an organ for a biopsy, it would be best to know the client's bleeding time because there is a risk of bleeding when the biopsy is performed. 2. Incorrect: Although both of these are carried out, they are not the priority over risk of bleeding. Always think what could be life threatening.

A nurse is at highest risk for blood-borne exposure during which situation? You answered this question Incorrectly 1. When removing a needle from the syringe. 2. While placing a suture needle into the self-locking foreceps. 3. Prior to inserting the intravenous (IV) line, the client moves causing a needle stick to the nurse. 4. A clean needle sticks the nurse through blood-soiled gloves.

4. Correct: A clean needle that moves through blood-soiled gloves to stick the nurse is considered to be potentially contaminated and results in a blood-borne exposure. All other answers are considered a clean stick. 3. Incorrect: This is considered a clean stick. The IV insertion device is sterile and has not been contaminated since it was not inserted into the client.

The nursing supervisor notified the charge nurse on a pediatric unit that a child with a history of developmental delays is being admitted with shingles. The nurses on the floor have the following assignments. It would be inappropriate for the charge nurse to assign the new admit to which nurse? Pick the worst nurse to give a shingles patient to You answered this question Incorrectly 1. A nurse caring for clients with nephritis, irritable bowel syndrome, and appendectomy. 2. A new nurse just out of orientation caring for clients diagnosed with RSV, asthma, and anorexia nervosa. 3. A nurse caring for clients diagnosed with spina bifida, Hirschsprung's Disease, and irritable bowel syndrome. 4. A pregnant nurse caring for clients with cystic fibrosis, myelomeningocele, and rheumatoid arthritis.

4. Correct: The information does not let you know if any of the nurses have had chickenpox or not. If a nurse has not had chickenpox, then they should not care for the client with shingles. The varicella zoster virus is responsible for chickenpox and shingles. The virus is lying dormant in the nerve ganglia and under certain conditions erupts (for example: stress). With the information you have, it would be best not to assign the new admit to the nurse who is pregnant. The other set of nurses and clients have no identified contraindications to taking care of the client with shingles. 3. Incorrect: This is an appropriate assignment. There are no identified contraindications for the nurse or clients to prevent the nurse from caring for a client with shingles.

A client had an abnormal maternal serum alfa fetoprotein (MSAFP) at 18 weeks gestation. She is now 22 weeks gestation, and an amniocentesis has just been completed for genetic analysis. Which nursing action has priority? You answered this question Incorrectly 1. Monitor the needle entry site for signs of infection. 2. Encourage the client to express her feelings. 3. Assess the maternal blood pressure for hypertension. 4. Monitor fetal heart tones and uterine activity.

4. Correct: There is a risk for pregnancy loss after amniocentesis. The priority nursing intervention is to monitor for fetal heart tones and uterine contractions. 1. Incorrect: There would not be signs of infection so soon after the procedure.

A client experiencing chest pain is prescribed an IV infusion of nitroglycerin. After the infusion is initiated, the occurrence of which symptom would prompt the nurse to discontinue the nitroglycerin? You answered this question Incorrectly 1. Frontal headache 2. Orthostatic hypotension 3. Decrease in intensity of chest pain 4. Cool, clammy skin

4. Correct: This assessment finding of cool, clammy skin is an indication of decreased cardiac output that could be the result of too much vasodilatation. Cardiac output could continue to decrease if the nitroglycerin is not discontinued. 1. Incorrect: A headache is an expected common side effect of nitroglycerin administration. The headache is treated with medication.

A is the first letter in the alphabet and is the shortest acting. This is the primary option for controlling insulin levels throughout the day

A is for aspart humalog / aspart

when it comes to a priority question, what type of strategy should you be using

ABC's. Always be looking for the airway compomising question

The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat through a non-tunneled central venous catheter lumen with no other medication or fluid infusing. In what order should the nurse administer this prescription? You answered this question Incorrectly Cleanse access port Gently aspirate for blood Flush saline using push-pause method Administer phenytoin Connect 10 mL normal saline to access port Flush with normal saline, then with heparin

Cleanse access port Connect 10 mL normal saline to access port Gently aspirate for blood Flush saline using push-pause method Administer phenytoin Flush with normal saline, then with heparin RATIONALE: Proper administration of medication through a non-tunneled central venous catheter: First, cleanse the access port. Failure to cleanse the port first would increase the risk of infection from contamination when the port is accessed. Second, connect 10 mL normal saline to access port. This 10 mL syringe will be connected to first check patency and then for flushing prior to medication administration. At least 10 mL of normal saline is used to flush central lines. Third, gently aspirate for blood. Fourth, flush saline using push-pause method. This method is utilized to help clear the catheter of blood or drugs that could potentially adhere to the internal surface of the central line catheter. This creation of turbulent flow from pausing then pushing causes swirling of the fluid and theoretically removes blood and medications from the walls of the catheter, which reduces the risk of occlusion in the catheter. Fifth, administer phenytoin. Sixth, flush with normal saline, then with heparin. Standard flushing solutions used most frequently for central venous access devices include normal saline and/or heparinized sodium chloride. Low dose heparin flushes are generally used to fill the lumen of the central line between use in order to prevent thrombus formation and maintain patency of the catheter for a longer period of time.

Float RN's job duties remember

Get the assignments of an LPN since the don't work that area normally. Predictable outcome!!

intermediate insulin

IN = N so... NPH has an N in it

What route is TPN administered?

IV

What is tympany percussion?

Loud amplitude High pitch Musical and drum like quality Duration is sustained the longest *ex: over air-filled viscus like stomach or intestine*

a schizophrenic client is more likely to exhibit thinking that is a. concrete b. abstract

abstract thinking is the ability to hear a word and understand the nuance associated with it. Schizophrenics often take words and phrases literally.

what type of bleed is bright red blood indicative of

an active one

mental health Q's in SATA form should be answered with responses that focus on the problem

ask yourself prior to hitting submit, "do all of my answers focus on the problem?"

for a schizophrenic client, if you say something like "isn't it time to take a shower, maybe?" they will likely take your suggestion as an option

be direct AF.

if you want to administer a high cal high protein snack when would you get the most benefit from it's use between meals just before a meal

between meal admin of a high protein high calorie snack will reduce risk of the client not eating their regularly scheduled meals

what type of precautions would you place a client who is having a biopsy on

bleed and fall

orders for the RN accessing a PICC

cleanse connect a flush (10 mL of NS) check for blood flush site admin drug flush with NS flush w/ heparin after.

the best approach to communicating with a schizophrenic client is

clear, concise and direct communication

which would be better to apply to an inflamed area. Maybe even an itchy area... cold or heat

cold

we know schizophrenics appear unkempt at times, what other mental health issue presents with an unkempt appearance?

depression

excessive drooling and a weak cough. First thought going through your mind should be...

epiglottitis

what type of precautions make the most sense for a client on a nitro drip

fall and bleed precautions

what is more likely, anthrax exposure due to working in a 3rd world country or working with farm animals

farm animals with hoofs and wild animals can contract anthrax just like scrapies etc.

what 2 things do the kidneys do

filter blood and produce urine

where are we most likely to draw a blood sample from a newborn?

heel. pretty much common sense

the start of a GI obstruction will probably result in which assessment finding

high pitched bowel sounds

a teenager would be trying to accomplish this developmental task

identity vs role confusion

a pre school or younger child might seek to accomplish this stage in Erickson's developmental. During this task they will ask things like "why?" and during this they may experience too much failure and not meet the mark

initiation vs guilt

acidosis is a shift in which direction

left shift in the acid base balance

Left =

lethargy and negative symptoms

what type of fever will the client who has rheumatic fever present with

low grade

does a face shield prevent organisms from coming in contact with your upper face?

no, it only prevents bacteria that enters from the bottom

raising the clients legs and of a supine client is commonly used in shock. The client with autonomic dysreflexia will have HTN. Do you feel it's safe to instruct a client with HTN to force blood to their core?

no. If anything you should lower the clients legs, to promote diuresis and decreases in BP.

people with hepatic encephalopathy are chronically confused. Is it safe for confused people to walk?

no. They shouldn't be using a walker because they are a huge fall risk

new surgical placement and any signs of a bleed. Your first thought should always be to reduce risk by

notifying the provider

your patient with a migraine. are they more likely to complain of excrutiating pain to the front, back one side or both sides of their brain a. front b. back of head c. one side of the head d. both sides of head

one side

positive pressure forces air in which direction

out of the room

an injury to the T spine will likely result in paralysis of which extremities

paraplegia

whats the difference between palliative care and end of life care

people like those with chronic disease states can go on palliative care to manage their symptoms better.

group b strep is associated with the following infections

pharyngitis

decreased calcium is associated with which type of symptoms

positive / excitable

If TPN is administered IV, you think an LPN can administer it?

probably not

palliative indicates chronic disease process right? so if someone has chronic pain are you gonna recommend or even think they're capable of exercising?

probably not. They went on palliative care for a reason

PKU is a disorder of the metabolic system that indicates the inability to metabolize what nutrient

protein

what is the most phenylalanine enriched source that you can think of?

protein

Agnosia is the inability to

recognize familiar objects. I know I don't have agnosia.

expected assessment findings after admin of nitroglycerin

relief of chest pain new or worsened headache warm dry skin orthostatic hypotension

an NG tube to suction is definitely in place with suction to do what remove things keep things balanced

remove things

what do we insert an NG tube for removing things keeping things balanced

removing things like secretions we add an NG because the patient cannot maintain homeostasis of other areas. The fluid and electrolyte imbalance as a result of the NG tube placement is usually handled with the use of things like fluids and TPN or perhaps bolus feeds through a tube

untreated group A - beta hemolytic strep infections usually results in which manifestation

rheumatic fever

the role of rheumatic fever in pregnancy and fetal well being

rheumatic fever is associated with GBS. Always ensure the mother gets tested for GBS

clients can have partial alterations in their feild of vision. conditions like visual aura's fall under this category. Clients who experience this disruption in vision like visual aura's which look like a small windshield crack in your field of vision what does the RN call this phenomenon

scotoma

Long acting

starts with L so lantus

when do you think you're more likely to experience exposure to blood borne pathogens? blood on your gloves and you stick yourself clean gloves, no patient care yet and accidentally stick yourself

sticking yourself prior to patient care

mucositis is also known as

stomatitis or mouth ulcers

how to d/c a picc

supine / Trendelenburg cut all sutures remove all dressings ask patient to turn their head away from PICC site ask client to hold breath and bear down remove the PICC cover the site tell the client they can stop holding their breath

the client you see in the ED has pain in both sides of their head with complaints of pressing and tightening. what are they most likely to have: a. frontal headache b. migraine c. tension headache

tension

the vaccines that aren't really allowed until after age 2 should be given by age 7 and are consistent with the acronym

the Motorvehicle will take you to get your grown up shots MMR varicella HPV

the most objective evaluation of pain is...

the pain intensity scale

RA Drugs DMARDS and cox 2 blockers

these drugs are already doing inflammatory stuff, would you really want them to take another

how do you know an asian client is attempting to show you respect while you discuss their care with them..?

they look down at the floor or avoid eye contact

why do we conduct a Guthrie test

to check for PKU

a spinal injury to the C spine will result in what type of paralysis

total

cost efficiency: if you contaminate a catheter tip, would you rather leave and go grab another kit or use a resource and ask someone to grab you one

using your resources is always priority over just wasting materials

do you think maintaining nutrition has the central goal of monitoring what goes in your body what leaves the body

what goes in the body

since an airborne precautions you're required to use a respirator, do you really need a face shield also? you've worn a respirator. Doesn't it cover your face?

yes

is prepping a client for surgery a predictable type of situation?

yes, so an LVN can definitely do this

can anthrax be found in the US?

yes, so don't immediately go to world wide travelling questions when you see a question about anthrax

we know depressive clients can often sleep too much, but would they possibly experience long periods of insomnia?

yes. This makes a lot of sense. Imagine they sleep way too much. Maybe they go through cycles where they sleep way too little also.

RN code of ethics. Can you refuse an assignment?

yes. but there are stipulations