SEE YOU IN 4TH!

The nurse on the surgical unit provides care for a client after an ileostomy. Which action is most important for the nurse to perform? 1. Empty the ileostomy bag from the bottom. 2. Apply lotion to the skin around the stoma. 3. Cover the ileostomy with gauze. 4. Measure the output from the ileostomy.

4) CORRECT— The output from an ileostomy is liquid and usually copious in amount. Include the amount in a client's intake and output to help keep the client balanced.

Injuries between T1-T6

Effect respiratory status, must monitor

Pleur Evac Drainage System

Water should fluctuate, rise when you inhale & fall when you excell

Upper/Lower GI

When barium enemas are ordered, lower GI is done first, because upper GI will change the results of lower GI if it's done first

The nurse monitors a client receiving the first of two units of packed RBCs. The client reports a headache and lower back pain approximately 2 hours into transfusion of the first unit. Which intervention does the nurse perform first? 1. Assess the client's vital signs and respiratory status. 2. Administer acetaminophen as prescribed and monitor response. 3. Stop the infusion of blood. 4. Notify the health care provider.

3) CORRECT— The symptoms indicate a possible hemolytic reaction. Immediately stop the transfusion, as continuing it may worsen the client's reaction and even result in death.

Wilms Tumor

Don't auscultate the abdomen because the tumor can break & metastesis Tumor is on abdomen & kidneys , can effect kidney function & cause hypertention Priority before surgery is to measure abdomen girt

Post Surgery- NPO

Maintain NPO until bowl sounds are heard - Early ambulation will help flatus - Avoid Catheter unless necessary

Alcohol & Hept

Should not consume alcohol for up to 6 months after recovery of Hepatitis

Care after Ileostomy

input/output is very important, post op - Empty pouch when it is 1/3 full - Avoid lotion around stoma, prevents good seal of stoma - Don't cover stoma with anything (gauze), only pouch

The nurse observes a client have a tonic clonic seizure lasting about 90 seconds, followed by a period of decreased consciousness lasting 2 minutes. Then the client begins to have another seizure. Which action is most important for the nurse to take? 1. Administer diazepam as prescribed. 2. Monitor serum glucose levels closely. 3. Assess the client's blood pressure and pulse. 4. Remove excessive clothing.

1) CORRECT— The client is experiencing repeated seizures. The nurse immediately administers diazepam to stop the seizures.

Fail Chest

Multiple rib fractures that cause paradoxical breathing

Evisceration- What to do?

Place patient in low fowlers position and instruct not to cough - Cover bowls wit sterile dressing that is soaked in normal saline

The nurse calls the mother of a school-aged child diagnosed 1 day ago with rubella. Which statement by the mother will the nurse respond to first? 1. "My sister-in-law is coming to visit next week. She just found out that she is pregnant." 2. "I have heard measles can cause serious complications. I do not know how to protect my child." 3. "My child is so upset about missing the class trip. It is my fault for not having my child immunized." 4. "My child feels very warm. I am going to give my child some aspirin to decrease the fever."

4) CORRECT - Administering aspirin to a child can cause Reye syndrome. Acetaminophen is effective in reducing the fever and is the preferred antipyretic for children. This is the statement that the nurse should respond to first.

Ascites Treatment

Is to administer Albumin, it pulls fluids back to the vascular space

Drinking Lots of Water but still Thirsty

Signs of type 1 Diabetes, Polydipsia, PolyPhagia, Polyuria, and weight loss

The nurse is teaching a group of clients who are all over the age of 50 years about the screening tests for colorectal cancer. Which screening recommendation does the nurse include in the teaching? 1. Annual prostate-specific antigen. 2. Fecal occult blood every 3 years. 3. Colonoscopy every 10 years. 4. Barium enema every year.

3) CORRECT - Clients who are 50 years of age or older should have a colonoscopy every 10 years.

A client's cardiac monitor shows a new onset of atrial fibrillation with a ventricular rate of 90 beats/min. Which actions will the nurse implement when providing care for the client? (Select all that apply.) 1. Perform rapid defibrillation. 2. Measure vital signs. 3. Assess for associated signs and symptoms. 4. Notify the health care provider. 5. Administer amiodarone.

2) CORRECT- The nurse should measure the client's vital signs to determine whether the client is hemodynamically stable and tolerating the arrhythmia. 3) CORRECT- The nurse should assess the client to determine whether associated signs and symptoms are present. 4) CORRECT- The nurse should notify the health care provider of the change in the client's condition.

A nurse plans to administer the live attenuated influenza vaccine (LAIV) at a county immunization clinic. Which client does the nurse identify as having a contraindication for receiving the vaccine? 1. A client receiving chemotherapy for cancer. 2. A client who smokes seven cigarettes per day. 3. A client with asthma and a peanut allergy. 4. A client who takes oral contraceptives. View Explanation

1) CORRECT - A client who is undergoing chemotherapy for cancer has a compromised immune system and should not receive any live vaccines.

The nurse assists the health care provider performing a thoracentesis in the client's hospital room. The nurse monitors for which symptom indicating a thoracentesis complication? (Select all that apply.) 1. Sudden dyspnea. 2. Decreased work of breathing. 3. Asymmetric chest excursion. 4. Acute abdominal pain. 5. Hematuria. 6. Tachypnea

1) CORRECT - A pneumothorax is a potential complication of a thoracentesis and sudden dyspnea is a symptom of pneumothorax. 3) CORRECT - A pneumothorax is a potential complication of a thoracentesis. Asymmetrical chest excursion is a symptom of a pneumothorax. 6) CORRECT - A pneumothorax is a potential complication of a thoracentesis, and tachypnea is a symptom of a pneumothorax.

The nurse answers the call light of a client reporting a severe headache 30 minutes after undergoing a lumbar puncture. Which action does the nurse take first? 1. Assess the puncture site. 2. Administer an analgesic as prescribed. 3. Assess the client's blood pressure. 4. Encourage the client to lie flat.

1) CORRECT - Headaches are a common side effect of a lumbar puncture procedure. However, assessing for leakage of cerebrospinal fluid or the presence of a hematoma is required to determine if further intervention is indicated.

The nurse provides care for a client who is scheduled to receive spinal anesthesia. It is most important for the nurse to take which action when providing care to this client? 1. Ensure that the client is adequately hydrated before the procedure. 2. Assess for allergies to iodine. 3. Ensure that the client does not eat for 12 hours before the procedure. 4. Determine the specific gravity of the client's urine.

1) CORRECT - This addresses the circulatory concern of hypotension. Spinal anesthesia is associated with hypotension. Adequate fluid hydration is key to prevent hypotension and hypotension-related injury.

The nurse educator plans a teaching program about risk factors for different types of cancers. Which group of individuals has the highest risk for lung cancer? 1. African Americans. 2. Caucasians. 3. Asians. 4. Hispanics.

1) CORRECT — African Americans have the highest risk of developing lung cancer, as well as the highest death rate.

A client receiving an IV fluid infusion of dextrose 5% and 0.45% normal saline at 125 mL/hr develops restlessness; rapid, shallow respirations; crackles in both lung fields; and distended neck veins. Which action is appropriate for the nurse to implement? 1. Contact the health care provider. 2. Clamp the intravenous catheter. 3. Administer diphenhydramine, as prescribed. 4. Place in the Trendelenburg position. View Explanation

1) CORRECT- The client exhibits signs of fluid overload (rapid, shallow respirations; distended neck veins; crackles on auscultation; and restlessness). The nurse should immediately contact the health care provider to prevent a delay in treatment.

The nurse provides care for a client admitted with weakness, confusion, and hypoactive bowel sounds. The client's lab results reveal sodium 140 mEq/L (140 mmol/L), ionized serum calcium 4.7 mEq/L (1.2 mmol/L), potassium 1.8 mEq/L (1.8 mmol/L), and blood glucose 110 mg/dL (6.1 mmol/L). Which action does the nurse initiate first? 1. Place the client on a cardiac monitor. 2. Place the client on 2 L/min of oxygen. 3. Administer potassium chloride (KCl) 20 mEq/hour. 4. Offer the client 240 mL of orange juice.

1) CORRECT— A decreased potassium level can result in cardiac dysrhythmia. Place the client on a monitor while preparing to administer the prescribed potassium chloride. A normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.1 mmol/L).

A 45-year-old male client presents to the emergency department with acute mid-abdominal pain and acute vomiting. The health care provider wants to rule out pancreatitis. Which question does the nurse ask based on the client's differential diagnosis? 1. "How much alcohol do you drink per day?" 2. "Do you have a family history of diabetes?" 3. "Do you have a history of peptic ulcer disease?" 4. "How frequently do you take laxatives?"

1) CORRECT— The client's symptoms indicate an acute episode of pancreatitis. Pancreatitis is associated with males ages 40 to 45 with a history of heavy drinking and females ages 50 to 55 diagnosed with biliary disease. As this is a 45-year-old male client, asking about alcohol intake will help confirm the diagnosis.

An adolescent client presents to the emergency department (ED) for an overdose of aspirin. Which action does the nurse perform first? 1. Determine the time of drug ingestion and the amount consumed. 2. Initiate an IV and administer protamine sulfate. 3. Start an IV and administer vitamin K. 4. Obtain an ABG and request respiratory therapy support.

1) CORRECT— The nurse first determines when the client consumed the aspirin. Charcoal, if given within two hours, will absorb particles of aspirin.

The triage nurse prioritizes clients for evaluation. Which client does the nurse determine needs to be seen first? 1. A woman at 6 weeks ' gestation who complains of left lower quadrant abdominal pain and vaginal spotting. 2. A toddler whose parents report nausea and vomiting for 2 hours and a fever of 102.8 °F (39.0 °C). 3. A patient who is diagnosed with renal disease who missed dialysis the day before and reports swelling in the feet and ankles. 4. A toddler who has a forehead laceration from a fall and who is smiling and playful

1) CORRECT— The symptoms are indicative of an ectopic pregnancy, which may result in death if allowed to progress.

The nurse provides care for four clients on a medical surgical unit. The nurse knows that which client is at risk for wound dehiscence and evisceration? 1. A client diagnosed with Parkinson disease who is 5 feet 8 inches (172.7 cm) tall , weighs 150 lb (68 kg), and had a stereotactic pallidotomy two days ago. 2. A client diagnosed with type 2 diabetes mellitus who is 5 feet 5 inches (165.1 cm) tall, weighs 195 lb (88.5 kg), and had an appendectomy one day ago. 3. A client with history of mitral stenosis who is 5 feet 2 inches (157.5 cm) tall, weighs 130 lb (60 kg), and had open-heart surgery for mitral valve reconstruction three days ago. 4. A client with a fractured femur who is 6 feet 1 inch (185.4 cm) tall, weighs 170 lb (77.1 kg), and had open reduction and internal fixation surgery four days ago. View Explanation

2) CORRECT - The client has three risk factors: being overweight, having type 2 diabetes mellitus (which impairs wound healing), and being post-abdominal surgery. Abdominal surgery is the most frequent type of surgery in which wound dehiscence and evisceration occur.

The clinic nurse assesses a client who presents with a documented history of a gastric ulcer. Current symptoms include nausea, vomiting, and diarrhea of 2 days' duration. Which client statement requires immediate intervention by the nurse? 1. "I take aspirin for headaches and arthritis pain, and antacids for this ulcer of mine." 2. "I have been drinking more fluids to keep from getting dehydrated, but I am urinating less than I thought I would." 3. "On my last visit to the health care provider, I was told I may be developing cataracts." 4. "I knew I was under a lot of stress at work, but I thought I was coping well."

2) CORRECT — It is particularly important to assess urine output because of the potential for fluid volume deficit and resultant shock. In the first stages of shock there is decreased urine output, even when there is normal fluid intake. It is especially important for the nurse to elicit information about fluid intake and output during the preceding 24 hours. This client has an ulcer, which might be bleeding and, in addition, the client is experiencing loss of fluid from vomiting and diarrhea. These could result in hypovolemic shock. This is an actual circulatory problem and is the highest priority.

The nurse prepares a client for a Holter monitor study. Which instructions will the nurse include when teaching the client about this study? (Select all that apply.) 1. Bathing and showering with the device on is permissible. 2. Trigger the event marker when pain or other symptoms occur. 3. Use a regular toothbrush instead of an electric toothbrush. 4. Keep a diary of activities, focusing on symptom occurrence. 5. Immediately report fast heart rate or difficulty breathing.

2) CORRECT — The nurse should instruct the client to trigger the event marker on the device whenever pain or other symptoms occur. 3) CORRECT — The nurse should instruct the client to avoid contact with electrical devices, such as shavers, toothbrushes, and electric blankets. 4) CORRECT — The nurse should instruct the client to keep a diary of activities while wearing the Holter monitor to determine the heart 's response to daily activities. 5) CORRECT — The nurse should instruct the client to immediately report symptoms such as fast heart rate or difficulty breathing.

The nurse assesses a client diagnosed with a descending colon tumor. Which characteristic symptoms of this type of tumor does the nurse ask the client about during the physical examination? (Select all that apply.) 1. Early satiety. 2. Rectal bleeding. 3. Colicky abdominal pain. 4. Flat, ribbonlike stools. 5. Alternating diarrhea and constipation.

2) CORRECT — This symptom is associated with this type of tumor. 4) CORRECT — This symptom is characteristic of this type of tumor. 5) CORRECT — This symptom is associated with this type of tumor.

The nurse discovers the IV infusion tubing disconnected from a peripherally inserted central catheter, and the client has tachycardia, chest pain, and shortness of breath. In which position will the nurse place the client? 1. Supine with the head of bed elevated 30 to 45 degrees. 2. Left side-lying Trendelenburg. 3. Right lateral decubitus. 4. Reverse Trendelenburg.

2) CORRECT- The client exhibits signs and symptoms of an air embolism. Therefore, the nurse should position the client on the left side in the Trendelenburg position to trap the air in the lower portion of the right ventricle.

The nurse provides care for a client diagnosed with laryngeal cancer who is scheduled for a laryngectomy. Which action does the nurse implement to assess the client's laryngeal nerve function? 1. Observe for excessive salivating. 2. Check the ability to swallow. 3. Assess the amount of neck edema. 4. Tap the neck and observe for facial twitching.

2) CORRECT- This effectively demonstrates the ability of the nerve to support the esophageal functions.

A client diagnosed with a head injury is being prepared for a lumbar puncture. Which action will the nurse take first? 1. Obtain informed consent. 2. Measure pre-procedure vital signs. 3. Explain the procedure to client. 4. Locate a lumbar puncture tray.

2) CORRECT— A change in vital signs could indicate increasing intracranial pressure, which is a contraindication for a lumbar puncture.

The nurse provides care to a client who is newly diagnosed with gastrointestinal bleeding. The client's hemoglobin level is 6.8 g/dL (68 g/L). Which intervention does the nurse perform first? 1. Obtain a type and crossmatch for blood administration. 2. Place the client on oxygen 2 L/min by nasal cannula. 3. Start an IV with at least a 20-gauge IV catheter. 4. Place the client on a cardiac monitor. View Explanation

2) CORRECT— A critically low hemoglobin level leads to decreased delivery of oxygen to cells and tissues. To reduce the risk for ischemia, administration of supplemental oxygen is the highest priority.

The nurse prepares a client for cardioversion. Which action is appropriate for the nurse to take prior to the procedure? 1. Administer acetaminophen with codeine PO. 2. Administer midazolam IV. 3. Palpate the pedal pulses. 4. Auscultate breath sounds.

2) CORRECT— A sedative/hypnotic is used for sedation for the procedure. Instruct the client that the medication may cause dizziness or drowsiness. A client is to avoid driving for 24 hours following administration of this medication. The client withholds digitalis 48 hours before the procedure to prevent ventricular fibrillation after cardioversion.

The triage nurse prioritizes clients for evaluation. Which client does the nurse determine should be seen first? 1. A young adult client who was a restrained passenger in a motor vehicle collision who reports neck pain. 2. A toddler who is making harsh, high-pitched noises on inspiration. 3. An infant with a temperature of 102.8°F (39.0°C) who received routine immunizations yesterday. 4. An adult client receiving warfarin who has a deep laceration to the right hand.

2) CORRECT— Stridor indicates an upper airway obstruction that requires immediate intervention. The airway takes precedence in all situations.

A nurse assesses an older adult client who reports a 2-day history of vomiting and diarrhea. Which findings will the nurse expect during the physical exam? (Select all that apply.) 1. Blood pressure 150/90 mm Hg. 2. Moist crackles. 3. Urine specific gravity 1.035. 4. Hematocrit 55% (0.55). 5. Weak, thready pulse.

3) CORRECT - Fluid volume deficit from gastrointestinal losses results in decreased vascular volume, decreased urine volume, and more concentrated urine. Therefore, the client's urine specific gravity is likely to be greater than the expected reference range. 4) CORRECT - Fluid volume deficit leads to decreased blood volume, which results in more concentrated blood and a hematocrit greater than the expected reference range. 5) CORRECT - Fluid volume deficit leads to decreased vascular volume and a weak, thready pulse.

The nurse provides care for a client following a tracheostomy. Which actions will the nurse take to prevent dislodgement of the tube during this time? (Select all that apply.) 1. Perform tracheostomy cleaning and care every 24 hours. 2. Ensure that the same size or larger tube is at the bedside. 3. Wait at least 24 hours to change the tracheostomy ties. 4. Maintain the client in a semi-Fowler 's position at all times. 5. Suction the tube when there is a moist cough or hypoxia.

3) CORRECT- Changing these too soon can irritate the trachea and cause dislodgement of the tube. 5) CORRECT- This should be done when excess secretions are evident to prevent severe coughing that can cause tube dislodgement.

The nurse discovers a pediatric client in bed clenching the teeth and making tonic-clonic movements of the extremities. Which action will the nurse implement? 1. Restrain the client's movements. 2. Insert an oral airway. 3. Gently turn the client to one side. 4. Insert a tongue blade.

3) CORRECT- The nurse should gently turn the client to one side to maintain a patent airway and prevent aspiration of secretions.

The nurse reviews the health histories for a group of clients. Which client does the nurse identify as being most at risk for developing breast cancer? 1. 29-year-old client who is nulliparous. 2. 40-year-old client whose mother developed breast cancer at age 60. 3. 55-year-old client who developed breast cancer at age 43. 4. 70-year-old client who experienced menopause at age 48.

3) CORRECT— A client who is over the age of 50 and has a personal history of breast cancer is most at risk for the disease.

The nurse plans care for a client diagnosed with meningitis due to Haemophilus influenza. It is important for the nurse to include which intervention in the client's plan of care? 1. Place the client in isolation until cerebrospinal fluid culture results are normal. 2. Monitor vital signs and perform neurological checks every 6 hours. 3. Dim the room lights, turn off the television, and reduce the noise level. 4. Encourage oral fluids and administer intravenous fluids as needed.

3) CORRECT— Reducing environmental stimuli is essential to reducing complications. Meningeal irritation causes headache, light sensitivity, and seizures.

The nurse provides postoperative care for a client who was intoxicated just prior to undergoing emergency surgery. Which postoperative intervention is important for the nurse to implement? 1. Administer a dose of intravenous magnesium. 2. Monitor weight to assess malnutrition. 3. Offer narcotics for pain relief only as needed. 4. Monitor for respiratory and cardiac problems.

4) CORRECT- Alcohol-induced central nervous system depression can lead to respiratory and cardiac failure in an alcoholic client.

The nurse provides care for a client who is intubated and receiving oxygen by T-piece at 50% FiO 2. The nurse notes the client's respirations are 24 breaths/minute with increased secretions, and the client appears anxious. Which action does the nurse take first? 1. Contact the health care provider. 2. Increase the FiO 2 delivery. 3. Administered a sedative as prescribed. 4. Auscultate bilateral lung fields.

4) CORRECT— Increased respiratory rate, restlessness, cyanosis, anxiety, and tachycardia are indications of hypoxia. The nurse first listens to breath sounds, assesses the need for suctioning, and suctions as needed.

During shift hand-off report, a client's ventilator alarm is activated. Which action does the nurse take first? 1. Notify the respiratory therapist. 2. Inspect the ventilator tubing. 3. Deactivate the alarm. 4. Auscultate breath sounds

4) CORRECT— The nurse must support the client while identifying and correcting the ventilator problem. The nurse observes rate and quality of respirations and assesses for hypoxia.

The nurse in the outpatient clinic assesses a school-age child brought to the clinic because of a skateboarding accident. Which question does the nurse ask first? 1. "When did the accident occur?" 2. "Were you wearing a helmet? 3. "How long have you been skateboarding?" 4. "Did you hit your head?"

4) CORRECT— The priority is to assess for head injury. This question assists the nurse to determine whether a head injury has occurred.

The nurse provides care for clients who may be at risk for developing deep vein thrombosis (DVT). In which order will the nurse provide care (beginning with the client at greatest risk and progressing to the client with the least risk of developing DVT? (Please arrange in order. All options must be used.)

An older adult who is on strict bed rest and smokes one pack per day has three risk factors: age (older than age 65), immobility, and smoking. This is the highest risk profile. An older adult who walks 2 miles per day, takes aspirin daily, and has a body mass index of 32 has two risk factors: age (older than age 65) and obesity (BMI greater than 30). This client exhibits the next greatest risk for DVT. A young adult who takes norgestimate-ethinyl estradiol daily has one risk factor: oral contraceptive use. Being sedentary for portions of the work day is not a risk factor. A job that is entirely sedentary is a risk factor. A middle-aged adult who takes aspirin daily and has a body mass index of 24 and has no known risk factors, exhibits the lowest risk profile for DVT development.

The nurse assesses a client receiving furosemide. Which finding is the most important for the nurse to report to the health care provider? 1. Blood glucose 180 mg/dL (9.99 mmol/L). 2. Report of hearing loss. 3. Potassium 3.2.mEq/L (3.2. mmol/L). 4. Uric acid 8.5 mg/dL (505.62.µmol/L).

3) CORRECT -A potassium level of 3.2.mEq/L (3.2.mmol/L) is below the expected reference range and places the client at risk for fatal dysrhythmias. Therefore, this is the priority finding the nurse should report to the health care provider.

The nurse prepares to insert a nasogastric tube in the client. In which order does the nurse complete the steps for insertion

Performing proper client identification complies with the Joint Commission's standards and is the nurse's first action. Anticoagulant therapy is a potential contraindication and must be assessed. Next, the nurse identifies the most appropriate nostril to use for success in tube insertion, using the side that appears to be the most open. Having the client swallow facilitates passage of the tube past the oropharynx and provides a slight sense of control for the client. A pH of 1 to 4 is a good indicator of correct tube placement. Once this is confirmed, the tube can be secured. An x-ray is currently the most accurate method of determining correct tube placement and is recommended after NG tube insertion.

Pre Lumbar Puncture

Assess Vital Signs, Because ICP is contraindicated with a Lumber Puncture

Laryngectomy Stoma Care

Cover with scarf when outside, protects from debris & secretions on cloths - Use humidifier or nebulizer to lesson secretions - Uncover in bubble baths for humidity - Apply vit A&D to remove old scabs with sterile tweezers

Ulcerative Colitis, Inf Bowl D, & Crons D- Diet

High protein, high calorie, low residue (no bowl movement) Foods to Avoid - Fruits - Whole grain - Beans - Bran cereal

A nurse manager notes a significant increase in inpatient client falls causing injury. To help resolve this problem, which action by the nurse manager is most appropriate? 1. Schedule a mandatory staff inservice about client safety and assessing fall risk. 2. Inform staff that evaluations and raises will reflect the unit's "zero falls" goal. 3. Convey to the staff the manager's confidence in their abilities to provide safe care. 4. Form a group to design and implement a plan to prevent further incidents.

4) CORRECT - Involvement of staff is likely to have a more permanent effect. Nurses have firsthand knowledge of why the problems are occurring

The nurse is providing care for an adult client during cardiopulmonary resuscitation (CPR). Which area will the nurse use to assess for a pulse? 1. The inguinal area midway between the symphysis pubis and anterior superior iliac spine. 2. The fourth to fifth intercostal space at the midclavicular line. 3. The medial edge of the sternocleidomastoid muscle in the neck. 4. The groove between the biceps and triceps muscle at the antecubital fossa.

3) CORRECT — This describes the area to palpate for the carotid pulse. It is used to assess the character of the pulse peripherally and during CPR.

Pulse Oximeter Probe

Can be placed on nose, ear lobes, fingers, toes, forehead - Keep site with probe attached away from light, or sunlight - Rotate site every 4 hrs, to prevent skin break down - Sa02 should be at 95%-100%, 86%-91% is an emergency, Below 70% is life threatening

The nurse provides care for a group of clients in the hospital. Which client does the nurse see first? 1. A client who reports pain 2 hours after a liver biopsy. 2. A client with a long leg cast who reports pain after taking medication. 3. A client 2 days postpartum who reports pain during breast-feeding. 4. A young child who reports a sore throat after a tonsillectomy.

2) CORRECT— Unrelieved pain for a client with a long cast may indicate compartment syndrome and should be assessed first.

The nurse teaches a class for senior citizens about the effects of aging. Which information does the nurse include in the presentation? 1. People lose interest in sex as they age. 2. Most older adults live at the poverty level. 3. All people will become senile if they live long enough. 4. Incontinence is not an expected change related to aging.

4) CORRECT - Although normal changes to all body systems occur with aging, the leaking of urine is not an anticipated or usual expectation in older adults.

Pancreatitis (acute)

Acute mid abdominal pain & acute vomiting, also causes diarrhea and fatty stools - Males between 40-45 increased risks - Need to assess for alcohol consumption

A client states to the nurse, "I am having difficulty seeing." Which cranial nerve will the nurse test first? 1. CN II. 2. CN IV. 3. CN VI. 4. CN VIII.

1) CORRECT— CN II controls vision. The nurse should use a Snellen chart to test far vision and have the client read a newspaper to test near vision.

The nurse teaches the parent of an infant who is two months of age about the Haemophilus influenzae type B (Hib) vaccine. The parent asks the nurse why the vaccine is necessary. Which response by the nurse is accurate? 1. "It prevents hepatitis B, which can cause liver failure." 2. "It prevents Hib disease, which can cause meningitis, brain damage, and deafness." 3. "It prevents Hib disease, which can cause sickle cell disease." 4. "It reduces the risk for human immunodeficiency virus." View Explanation

2) CORRECT—Before the Hib vaccine, Hib disease was the leading cause of bacterial meningitis in children younger than age 5 years. Hib disease can also cause pneumonia, sepsis, and death.

The nurse provides care for a client diagnosed with severe acute pancreatitis. Which finding requires immediate action? 1. Heart rate of 104 beats per minute. 2. Blood pressure of 100/62 mm Hg. 3. Respiratory rate of 34 breaths per minute. 4. Serum glucose of 236 mg/dL (13.1 mmol/L).

3) CORRECT - A respiratory rate of 34 breaths per minute is above the normal range of 12 to 20 breaths per minute. Pleural effusion, atelectasis, pneumonia, and acute respiratory distress syndrome are potential complications of pancreatitis.

The nurse provides care to an older adult client with partial and full thickness burns over 75% of the body. Which assessment indicates to the nurse the client is developing shock? 1. Epigastric pain and seizures. 2. Widening pulse pressure and bradycardia. 3. Cool, clammy skin and tachypnea. 4. Kussmaul respirations and lethargy.

3) CORRECT— The body responds to early hypovolemic shock by adrenergic stimulation. Vasoconstriction compensates for the loss of fluid and causes cool, clammy skin and a rapid rate of breathing.

The client is treated for deep vein thrombosis with IV unfractionated heparin. Which finding most concerns the nurse? 1. Increased anxiety. 2. Decreased heart rate. 3. Increased activated partial thromboplastin time (aPTT). 4. Decreased level of consciousness.

4) CORRECT - A major side effect of heparin administration is bleeding. A decrease in level of consciousness indicates intracranial bleeding and represents an immediate circulatory concern. This is the highest priority.

Which assessment by the nurse indicates that a client's nasogastric (NG) tube may be malpositioned? 1. The nasogastric tube aspirate is cloudy and green. 2. The pH of the nasogastric tube aspirate is 3. 3. Air injected through tube is auscultated over the epigastrum. 4. The external length of the nasogastric tube has increased.

4) CORRECT- Increased length of the NG tube may indicate outward migration, and the NG tube tip may be malpositioned in the esophagus instead of the stomach.

The nurse provides care for a client after surgery to establish a colostomy. Which behavior best indicates to the nurse that the client understands how to perform colostomy care? 1. The client who correctly describes each step of a colostomy irrigation. 2. The client who tells the nurse how to perform the colostomy irrigation while the nurse implements the procedure. 3. A client who takes a test about colostomy care and discusses with the nurse any incorrect answers. 4. A client who performs colostomy care while the nurse observes.

4) CORRECT— A return demonstration by a client is the best way to evaluate effectiveness of teaching colostomy care.

The nurse provides care for four clients. Which client does the nurse recognize is at risk for experiencing sensory overload? 1. A teenager listening to loud music with earphones. 2. A middle-age client in isolation with no family. 3. A young adult quadriplegic client in a private room. 4. An elderly client admitted for emergency surgery.

4) CORRECT— A sudden, unexpected admission for surgery may involve many experiences, such as lab work, X-rays, and signing surgical consent forms while the client is in discomfort. After surgery, the client may be in pain and possibly in a critical care setting.

The nurse provides care to a client who sustained severe crush injuries of both legs during a motor vehicle crash. The client is diagnosed with rhabdomyolysis. The nurse anticipates the health care provider will prescribe which intervention for the client? 1. Potassium chloride. 2. Fluid restriction. 3. Epoetin alfa. 4. Mannitol.

4) CORRECT— Administration of mannitol, an osmotic diuretic, is an appropriate intervention for the client diagnosed with rhabdomyolysis. Rhabdomyolysis is characterized by the release of massive quantities of myoglobin from damaged muscle cells, as well as the release of intracellular potassium (K +) due to cell lysis. Mannitol is administered to promote excretion of substances, including myoglobin and potassium.

The nurse prepares to administer the influenza vaccine to a client. Which client statement concerns the nurse? 1. "I am allergic to neomycin." 2. "I am allergic to penicillin." 3. "I am allergic to shellfish." 4. "I am allergic to eggs."

4) CORRECT— An allergy to eggs is a contraindication to the flu vaccine. The nurse should not administer the standard vaccination.

The nurse prepares to teach a client recovering from a spinal fusion on how to move from a supine to standing position at the left side of the bed with a walker. Which direction by the nurse is appropriate? 1. Raise the head of the bed to sit straight up, bend the knees, and swing the legs to the side and then to the floor. 2. Rock the body from side to side, going further each time until enough momentum is built up to be lying on the right side, and then raise the trunk towards the toes. 3. Reach over to the left side rail with the right hand, pull the body onto the left side, bend the upper leg so the foot is on the bed, and push down to elevate the trunk. 4. With the left elbow as a pivot, grasp the mattress edge with the left hand and push on the mattress with the right hand above the left elbow, and then slide the legs over the side of the mattress.

4) CORRECT— Using the arms maintains spinal alignment and prevents injury.

The client reports pain at an IV site. The nurse observes that the IV insertion site is pale, cool to the touch, and mildly swollen. Which intervention does the nurse implement? 1. Decrease the infusion rate and monitor the client's response. 2. Stop the infusion and notify the health care provider. 3. Discontinue the IV and apply a heating pad to the site. 4. Remove the IV and elevate the client's arm on a pillow.

4. Remove the IV and elevate the client's arm on a pillow.

The nurse provides care for a client during a wellness visit. The client reports constipation. Which self-care measures will the nurse discuss with this client? (Select all that apply.) 1. Eat low-fiber foods. 2. Use enemas daily to promote elimination. 3. Establish a bowel routine one hour after meals, if needed. 4. Drink two to four glasses of water per day. 5. Follow a regular exercise program.

5) CORRECTnbsp- The nurse should encourage the client to follow a regular exercise program. 3) CORRECTnbsp- The nurse should encourage the client to establish a bowel routine, as needed (1 hour after meals is typically best).

The home care nurse visits a client diagnosed with cardiomyopathy. The client asks the nurse, "How will I know if I am overdoing it? " Which response by the nurse is best? A. "If you feel fatigued, you have done too much. " B. "Follow the list that the health care provider gave you. " C. "Coughing up more sputum is a good indication. " D. "To prevent doing too much, allow your family to help you. "

A Fatigue is a useful guide in gauging activity tolerance in clients with decreased cardiac output.

Atrial Fibrillation & Cardioversion

Atrial Fibrillation is a cardiac dysrhythmia that is treated with synchronized mode cardioversion counter shock Pre-Op - Withhold digoxin for 48 hours before procedure, because it can cause Ventricular Fibrillation after cardioversion - Administer Versed (consciouss sedation/hypnotic), which will cause drowziness & dizziness post op for 24 hours, cant drive

Inderal- OLOL

Beta blocker used for hypertension as an antihypertension medication Side Effects - Bradycardia, brochospasms, Orthostatic hypotention Contraindicated - Diabetics- masks hypoglycemia s&s like tachycardia - Asthmatic patients - Heart problems & pulmonary edema Discontinue Gradually - Tachycardia, malaise , diaphorisis

Random

Colostomy- you can take baths & relax Hip replacement- Cant play tennis, will dislocate Joint replaement in knee- walking is encouraged

Aspirin & Tartrazine

Cross allergy between the two, if you are allergic to one you are allergic to the other - Taking aspirin with milk can decrease GI irritation

Cervical Cancer & Post Op

Expect slight bleeding after discharge, but if bleeding continues after 48 hrs, contact doctor - Avoid activities that cause straining, lifting, sports, babies for at least 6-8 weeks - Avoid sex & the use of tampons for at least 6-8 weeks, until follow up with doctor - Take showers & avoid baths for at least 2 weeks

Hypothermia Patients & risk

Hypothermia patients are at risk for Venticular Fibrilation, they must be cared for with genitally - Hypothermia cause irritability to the heart muscle and can cause rewarming shock

The nurse provides care for a client with an abdominal abscess draining into a bulb suction device. Which is the most important data for the nurse to assess when monitoring the drainage? 1. Amount. 2. Color. 3. Consistency. 4. Site leakage.

2) CORRECT - Assessing whether the drainage is purulent, sanguinous, serosanguineous, etc. is the most important characteristic to document. Dark green or yellow drainage may indicate the client has not improved. Pale yellow serous drainage may indicate clearing of the infection.

The nurse witnesses a neighbor fall from the roof of a house. The nurse goes to the victim and determines the need to open the airway. Which procedure does the nurse use to open the airway in this victim? 1. Flexed position. 2. Jaw thrust. 3. Head-tilt, chin-lift. 4. Modified head-tilt, chin-lift.

2) CORRECT - If a cervical spine injury is suspected, this is the maneuver used to open the airway to prevent further injury.

The nurse prepares to measure a client's central venous pressure (CVP). Which parameter is measured by the CVP? 1. Pulmonary artery pressure. 2. Right atrium pressure. 3. Cardiac output. 4. Left ventricle pressure.

2) CORRECT- Right atrium pressure is determined by blood volume, vascular tone, and the action of the right side of the heart. It is obtained from the CVP line.

A client receiving an IV infusion of heparin has an activated partial thromboplastin time (aPTT) that is greater than 150 seconds. Which is the priority action by the nurse? 1. Stop the heparin and administer protamine sulfate. 2. Stop the heparin and notify the health care provider. 3. Maintain the heparin at the current infusion rate. 4. Increase the infusion rate and notify the health care provider.

2) CORRECT— Heparin is an anti-coagulant. An aPTT of 150 seconds is above the therapeutic range and should be reported to the health care provider. The medication should be stopped.

The nurse supervises the care of a client with a stage 3 pressure injury of the sacrum that has foul-smelling purulent drainage. For which observation will the nurse intervene? 1. LPN/LVN enters the room wearing a gown and gloves. 2. Nursing assistive personnel enters the room wearing a mask. 3. Family member brings the client a milkshake. 4. Staff lifts the client to reposition every 2 hours.

2) CORRECT— Masks are not required to care for this client

A client requires a paracentesis. Which item is most important for the nurse to place at the client's bedside prior to the procedure? 1. Tape measure. 2. Emesis basin. 3. Blood pressure cuff. 4. Scale.

3) CORRECT - A blood pressure cuff should be placed on the client's arm before the procedure begins, and kept in place throughout the immediate post-procedure period. It is essential to continually monitor the client's blood pressure to assess for the development of shock from the removal of fluid.

An older adult client is admitted to the emergency department after wandering away from home. The client appears to be disheveled, restless, and confused. Which action does the nurse include in the client's plan of care? 1. Show approval for appropriate behavior. 2. Wait for the client to approach the nursing staff. 3. Maintain a stable and routine environment. 4. Make important decisions for the client.

3) CORRECT - A client who is confused benefits from a consistent routine and environment, which reduces anxiety caused by change.

The nurse assesses the skin of an older adult client. Which assessment finding indicates to the nurse that the client is experiencing a potential complication? 1. Wrinkling. 2. Deepening of expression lines. 3. Crusting. 4. Thinning and loss of elasticity.

3) CORRECT - Crusting on the skin indicates a potential complication such as infection, allergic reaction, or injury.

The nurse notes a client recovering from a pancreatectomy has minimal drainage from the nasogastric tube. Which action will the nurse take next? 1. Replace the nasogastric tube. 2. Increase the intravenous fluids. 3. Check the tubing for kinks. 4. Notify the health care provider.

3) CORRECT — Assessing the tube checks for kinks and ensures the tubing is in a dependent position.

The nurse discovers the IV infusion tubing disconnected from a central venous access device, and the client is coughing, short of breath, and cyanotic. Which action will the nurse take immediately? 1. Reconnect the tubing to the central venous access device. 2. Measure vital signs. 3. Notify the health care provider. 4. Clamp the central venous access device.

4) CORRECT-The nurse should immediately clamp the central venous access device to prevent further air from entering the client's circulation.

The nurse provides care for a client who has been raped. Which action by the nurse is most appropriate? 1. Address the immediate needs and concerns of the client. 2. Refer the client for crisis counseling. 3. Determine how the rape occurred. 4. Determine how the client previously responded to trauma.

1) CORRECT— The first action is to assist the client to identify immediate needs and concerns. The nurse should first ensure that the client is physically stable.

The nurse monitors the progress of a client recovering at home from a laryngectomy. Which client behavior requires the nurse to intervene? 1. Uses a finger to apply water-soluble ointment around the stoma. 2. Inserts a few drops of water into the stoma every evening. 3. Leaves the stoma uncovered when taking a bubble bath. 4. Covers the stoma with a cotton scarf when outside.

2) CORRECT - Humidification should be provided with a humidifier or nebulizer and not by inserting water into the stoma.

The nurse instructs a group of high school parents at a local health fair. Which statements by the parents during the discussion period require follow up by the nurse? (Select all that apply.) 1. "My teenager is very independent and doesn't need constant supervision after school." 2. "My teenager can be impulsive at times, but is improving on problem solving skills." 3. "Although I've made some mistakes in my life, I feel that I am a good role model for my teenager." 4. "My child is moody and requires some guidance when frustrated with homework." 5. "It is important to consistently tell my teenager what to do every day."

2) CORRECT - Impulsiveness in an adolescent should be explored in greater detail and requires follow up. 5) CORRECT - Needing constant direction does not contribute to an ideal level of development with this age group.

The nurse provides care for clients in the outpatient clinic. After testing positive for Chlamydia trachomatis, the client and spouse returned to the clinic for counseling. Which question is most important for the nurse to ask? 1. "Have you engaged in sexual activity with anyone else?" 2. "What is your understanding about the disease transmission?" 3. "Do you have questions about how the diagnosis was made?" 4. "What medications and substances are you allergic to?"

2) CORRECT - It is most important for the nurse to assess the client's understanding first, as a part of educating the client.

The community health nurse serves an urban Black American community. The nurse encourages the client population to attend a hypertension screening event at the local community center. This is an example of which type of prevention? 1. Primary. 2. Secondary. 3. Tertiary. 4. Environmental.

2) CORRECT - Secondary health promotion focuses on screening for early detection of disease, such as blood pressure screening for hypertension.

The nurse assesses a postoperative client. Which finding does the nurse document as subjective data? 1. Laboratory test results. 2. Client's description of pain. 3. Vital signs. 4. Electrocardiographic waveforms.

2) CORRECT - This data comes directly from the client and is usually recorded as a direct quotation that reflects the client's opinions or feelings about a situation.

TPN- Changing Procedure

TPN should be hang no more than 24 hours at a time - Discard anything left over when 24 hrs is up - Change TPN tubing & filter every 24 hours - Change catheter insertion site every 4 weeks Don't speed up the solution, cause hyper glycemia Don't slow the infusion, cause rebound hypo glycemia

Mouth Care for the Elderly

Use petro jelly for lips, saline or hydrogen peroxide for mouth wash, soft toothbrush - Avoid glycerin swabs cause dehydration & mouth irritation

Esophagogastric tube

Used for bleeding esophageal varices. Needs constant monitoring for hypotention, tachycardia, increased respiration= shock - Make sure ballon pressure is maintained

Potassium Rich Foods

- Potato, cantaloupe, spinach, broccoli, orange, banana, avocados, tuna, beets

The nurse provides care to an unconscious client with a cuffed endotracheal tube inserted after a drug overdose. Which observation most concerns the nurse? 1. The pilot balloon does not fill when air is injected. 2. Food-like material is present in the endotracheal tube. 3. An inner cannula is lying on the chest of the client. 4. There is condensation in the endotracheal tube on exhalation.

2) CORRECT - Food in the endotracheal tube indicates esophageal intubation. Therefore, there is no airway and the tube needs to be removed immediately. The client should be hyperventilated to prevent hypoxia before attempting another intubation with a new sterile tube.

The nurse provides care for a client who experienced a severe eye injury related to an acid splash. The nurse administers proparacaine hydrochloride before each eye examination. Which action is most important for the nurse to take? 1. Instruct the client about the action of the medication. 2. Measure the client's intraocular pressure. 3. Instruct the client not to touch the eye. 4. Inform the client that the numbing effect will last 15 minutes.

3) CORRECT - Rubbing or touching the eye when the eye is anesthetized may cause corneal damage. Instructing the client not to touch the eye ensures client safety and is the highest priority.

The nurse reviews the laboratory results of an older adult client diagnosed with a bacterial infection. Which result does the nurse expect to find? A. Severe thrombocytopenia. B. Elevated hematocrit. C. Decreased hemoglobin. D. Minimal leukocytosis.

D Leukocytosis refers to an increase in the number of white blood cells (WBCs). Although a bacterial infection typically triggers an increase in the WBC count, up to 40% of older adults with serious infections may not develop leukocytosis. As a result, absence of leukocytosis in an older adult does not necessarily rule out an infectious process.

Doxycycline (Vibramycin)

It is used usually to treat Clemedia - It cause photosensitivity & one should wear sunblock - Should avoid taking med before going to bed - Avoid anaacids within 1-3 hrs of taking medication - Use other forms of birth control, no hormones - Vaginal discharge, it may mean an infection- not expected

Child & Immunization- Normal vs Not normal Reactions

Normal Reaction- hours or few days - Low grade fever, irritability, reaction at injection site Not Normal - High fever, N/V, screaming, LOC Don't administer immunization if child has history of reactions

L1 Accident Injury

With an accident injury you can loose control of you bladder, and emptying your bladder completely Goal- Is to regain bladder control & empty bladder completely to prevent infections Cred E Maneuvers- Performing them daily at the same time (Manuel pressure to empty bladder) will help with reducing infections & gaining control of bladder over time - This control will help patient have a normal life

A nursing assistive personnel (NAP) was injured in an automobile accident. After rehabilitation, the NAP walks with a limp and a slow, unstable gate. The NAP returns to work on an acute care surgical unit. Which action by the nurse manager is best? 1. Survey other units for more suitable positions for the NAP. 2. Recommend the NAP apply for disability benefits. 3. Transfer the NAP to a less demanding shift on the unit. 4. Transfer a portion of the NAP's duties to other staff.

1) CORRECT - The American Disability Act (ADA) recommends that the NAP be offered a position that is appropriate. The manager could first evaluate the care the NAP is able to provide before offering reassignment.

The nurse reviews the blood-test results of four adult clients. Which result indicates to the nurse that the client has a high risk of falling? 1. Blood urea nitrogen (BUN) of 28 mg/dL (10 mmol/L). 2. Serum sodium (Na) of 140 mEq/L (140 mmol/L) and potassium (K) of 4.2 mEq/L (4.2 mmol/L). 3. Erythrocyte sedimentation rate (ESR) of 30 mm/hr (30 mm/hr). 4. Serum calcium (Ca) of 9 mg/dL (2.25 mmol/L) and magnesium (Mg) of 1.8 mEq/L (0.9 mmol/L).

1) CORRECT — The BUN is elevated in salt and water depletion and can cause confusion, disorientation, and convulsions, which could easily lead to falls. Water depletion could also result in falls due to orthostatic hypotension.

The nurse provides care to a client with stage 1 Lyme disease. Which finding will the nurse expect when assessing this client? 1. Flu-like symptoms. 2. Arthralgias. 3. Signs of neurological disorders. 4. Enlarged and inflamed joints.

1) CORRECT- In stage 1 Lyme disease, most people develop flu-like symptoms.

The nurse provides teaching to a client receiving ferrous sulfate 300 mg per day. Which client statement indicates that teaching is effective? 1. "I will have to eat more fresh fruits and whole-grain bread." 2. "This medication may cause fine motor tremors." 3. "My bowel movements may become light in color." 4. "I may have problems with blurred vision."

1) CORRECT— A side effect of ferrous sulfate is constipation. The client should increase intake of fruits, fiber, and fluids. Other side effects include gastric irritation, nausea, abdominal cramps, anorexia, vomiting, diarrhea, and dark-colored stools.

A client with a 20-year history of asthma experiences acute respiratory distress. Which breath sound does the nurse consider as ominous for this client? 1. Absence of wheezing. 2. Presence of crackles. 3. Absence of bilateral rales. 4. Presence of coarse rhonchi.

1) CORRECT— In a client with asthma, the absence of wheezing indicates acute respiratory distress. The small airways are completely constricted. This client needs immediate intervention.

An infant is scheduled for surgery to repair a congenital heart defect. The infant's parent begins to cry and says, "I'm a terrible parent!" Which response by the nurse is best? 1. "Do you think that you caused the heart defect?" 2. "Would you like a hug?" 3. "I will be back to check on you." 4. "This is a difficult time for you."

4) CORRECT— This open-ended statement reflects the emotion that the parent is expressing and encourages further communication.

The nurse provides an infant with a prescribed immunization. Which information will the nurse provide to the parents to aid in the client's comfort? 1. Give an alcohol bath for an elevated temperature. 2. Administer antipyretics for discomfort, irritability, and fever. 3. Place an ice bag on the leg for 1 hour. 4. Check the client's temperature every four hours for three days.

2) CORRECT -An antipyretic relieves the combination symptoms of discomfort, irritability, and fever.

The nurse provides care to a client reporting a cluster headache. Which nursing action is appropriate when providing care for this client? 1. Prepare for a head CT scan. 2. Administer 100% oxygen via facemask. 3. Measure erythrocyte sedimentation rate. 4. Withhold prescribed sublingual sumatriptan.

2) CORRECT — Acute treatment of a cluster headache includes the provision of 100% oxygen delivered at a rate of 6 to 8 liters per minute for 10 minutes. This may be repeated after a 5-minute rest. Oxygen relieves the headache by causing vasoconstriction and increasing the synthesis of serotonin in the central nervous system.

The nurse provides care to a client who is diagnosed with acute respiratory distress syndrome (ARDS). Which arterial blood gas (ABG) values are consistent with the client's medical condition? 1. pH 7.31, PaCO 2 31 mm Hg, HCO 3- 16 mEq/L. 2. pH 7.33, PaCO 2 55 mm Hg, HCO 3- 26 mEq/L. 3. pH 7.45, PaCO 2 37 mm Hg, HCO 3- 24 mEq/L. 4. pH 7.49, PaCO 2 50 mm Hg, HCO 3- 30 mEq/L.

2) CORRECT- ARDS is distinguished by a severe inflammatory process that causes widespread alveolar damage. Manifestations include rapidly-progressing pulmonary edema, bilateral lung infiltrates visible on chest x-ray, and hypoxemia that is unresponsive to supplemental oxygen. ABG results will indicate respiratory acidosis. Decreased pH in combination with increased PaCO 2 and normal or increased HCO 3- is reflective of respiratory acidosis. Normal ABG values include pH 7.35 to 7.45, PaCO 2 35 to 45 mm Hg, and HCO 3- 22 to 28 mEq/L.

The nurse conducts an education program for a client who is diagnosed with acute pancreatitis. The nurse includes which statement when teaching about the common causes of this type of pancreatitis? 1. "Autoimmune disorders and cystic fibrosis cause acute pancreatitis." 2. "Gallstone migration and alcohol abuse cause acute pancreatitis." 3. "Liver cirrhosis and pancreatic tumors cause acute pancreatitis." 4. "Wheat products and high fiber intake cause acute pancreatitis."

2) CORRECT- Gallstone migration and alcohol abuse are two of the most common causes of acute pancreatitis.

The nurse finds a client restless, cyanotic, and clutching the throat between the thumb and fingers. Which actions are appropriate for the nurse to implement? (Select all that apply.) 1. Slap the client on the back. 2. Call for help. 3. Insert a nasopharyngeal airway. 4. Deliver abdominal thrusts. 5. Ask if the client can speak.

2) CORRECT- The client exhibits signs of upper airway obstruction. Therefore, the nurse should call for help in case the client becomes unresponsive, requiring resuscitation. 4) CORRECT- After verifying the presence of complete airway obstruction, the nurse should stand behind the client, with arms wrapped around the waist. With one hand against the abdomen and the other grasping the opposite wrist, the nurse performs a rapid, upward thrusting motion until the foreign body dislodges or the client loses consciousness. 5) CORRECT- The nurse should ask if the client can speak or cough. If the client can do either, the client has a partial airway obstruction. The client should be encouraged to cough to dislodge the foreign body.

A graduate nurse expresses difficulty with time management when providing client care. Which is the best response from the graduate nurse's preceptor? 1. "I have some ideas to help you better manage your time." 2. "How much practice did you get in school taking care of groups of clients?" 3. "What ideas do you have as to the reasons for your time management difficulties?" 4. "Tell me how you feel about time in general."

3) CORRECT - The best first step is to assess the graduate nurse's perception of difficulty before offering solutions. This approach conveys respect, and allows for free expression and analysis of the problem.

During a physical assessment, the nurse instructs a female client about the appropriate use of condoms. Which client statement indicates to the nurse that further teaching is necessary? 1. "I will use a spermicide with the condom each time I have sex. " 2. "There should be a space at the tip of the condom. " 3. "My partner and I will not require condoms once we test negative for HIV. " 4. "I should use water-based lubricants. "

3) CORRECT— A condom prevents transmission of other STIs and pregnancy. A new condom should be used with each act of sexual intercourse, not to just prevent HIV.

The nurse assesses an older adult client for infection. Which nursing assessment is most important based on this data? 1. Temperature. 2. Blood pressure. 3. White blood cell count. 4. Respiratory rate.

4) CORRECT - Tachypnea, along with confusion and tachycardia, are the most reliable signs of infection in older adult clients.

DVT Care

Don't ambulate, bed rest for 5-7 days, because of pulmonary embolism (dislodge) - Keep leg elevated - Anti coagulation therapy - Apply warm moist packs

Ambulatory Electrocardiography

Monitors heart activity for 24 hours, you must keep journal & log, even when you become lightheaded just record it, don't call doctor - Don't shower for the 24 hrs, sponge bath is fine - Don't change diet

Alcohol Withdrawl Sysmptoms

N/V, tachycardia, fever diaphorisis, tremors, confusion, delusions, hallucinations

The nurse assesses a newborn and notes that the neonate is hypothermic. Which interventions are appropriate for the nurse to include in the newborn 's plan of care? (Select all that apply.) 1. Warm the newborn slowly to avoid potential apnea episodes. 2. Wrap the newborn in a warm blanket. 3. Place a hat on the newborn 's head. 4. Bathe the newborn quickly and then place under a radiant warmer. 5. Provide the newborn with skin-to-skin contact with the mother.

1) CORRECT - A hypothermic newborn should be warmed gradually because rapid warming can cause apneic spells and acidosis. 2) CORRECT - The nurse should wrap the newborn in warmed blankets immediately after birth 3) CORRECT - The nurse should keep the head well covered to avoid heat loss. 5) CORRECT - The ideal method for promoting warmth and maintaining neonatal body temperature is early skin-to-skin contact with the mother. The naked newborn is placed prone directly on the mother 's chest and both mother and newborn are then covered with a warm blanket.

The nurse observes the parent of an adult client crying in the waiting area. The parent says to the nurse, "My father died of meningitis and it was awful. Now my child may die of the same thing." Which is the best initial response by the nurse? 1. "The outlook for meningitis is better now than it was then." 2. "I can have the chaplain come speak with you if you like." 3. "This must be bringing back a lot of memories." 4. "Not necessarily. You can't make that assumption."

1) CORRECT - This response directly responds to the parent's expressed concerns and offers factual information (family teaching) of which the parent may not have been aware. This may help alleviate some distress.

The industrial nurse is called to see a worker who has a radiation burn. The worker appears anxious and reports lower right, intermittent abdominal pain. Which action does the nurse take first? 1. Assess the abdominal pain. 2. Encourage the client to relax. 3. Obtain an order for pain medication. 4. Begin the decontamination process.

1) CORRECT— The client with a radiation burn does not pose a health risk to medical personnel. The nurse must assess the worker's complaint before implementing a course of action.

The nurse provides care for a client who has just been intubated in preparation for mechanical ventilation. Which action does the nurse take next? 1. Assess lung sounds. 2. Call for a stat x-ray. 3. Obtain arterial blood gases. 4. Suction the endotracheal tube.

1) CORRECT— The priority is to assess for bilateral lung sounds and bilateral chest excursions. Always assess before implementing.

A client scheduled for a CT scan says to the nurse, "The health care provider had me sign that form for the scan. I thought I understood what was said, but now I 'm not so sure. " Which is the best response by the nurse? 1. "What is it that you are not sure you understand? " 2. "I 'll contact the health care provider so that you can get your questions answered. " 3. "Maybe I can help you. " 4. "There is nothing to this test. "

1) CORRECT— This response specifically addresses the client 's concerns so they can best be addressed. The nurse can clarify questions after the HCP has explained benefits and risks of the procedure to the client.

Which action involving the client does the nurse determine to be violations of the EMTALA (Emergency Medical Treatment and Active Labor Act)? (Select all that apply.) 1. Client is not provided with advance directives information. 2. Client who reports dental pain is denied a medical screening. 3. Client's protected health information is shared with those not participating in client's care. 4. Client prepares to sell kidney to the highest bidder. 5. Client is transferred to another facility before attempts are made to stabilize client.

2) CORRECT - Refusing to provide care violates EMTALA. All clients should receive medical screening examinations to determine whether emergency medical conditions exist. 5) CORRECT- A client should not be transferred prior to stabilization or until the transferring hospital has provided medical treatments within its capability.

The nursing team consists of a nurse, a LPN/LVN, and two nursing assistive personnel (NAPs). Which client does the nurse assign to the LPN/LVN? 1. A client 2 days postoperative after abdominal hysterectomy asking to ambulate in the hall. 2. A client with a colostomy requiring assistance with an irrigation. 3. A client with a right-sided cerebrovascular accident (CVA) requiring assistance with bathing. 4. A client refusing medication for treatment of cancer of the colon.

2) CORRECT — This is a stable client with an expected outcome who needs a task performed that is within the scope of practice of the LPN/LVN.

The nurse in the outpatient clinic receives a call from the parent of an adolescent diagnosed with infectious mononucleosis. The parent reports that the adolescent seems angry and depressed since the diagnosis. Which response by the nurse is most appropriate? 1. "Why do you think your child is angry?" 2. "Teens become frustrated because of feeling weak and fatigued." 3. "Would you like the health care provider to talk with your child?" 4. "My child had mono and was crabby all the time."

2) CORRECT — This provides objective information to the parent. Adolescents may react with anger and depression to the weakness and fatigue. The nurse should encourage the parent to allow the adolescent to vent and reassure the adolescent that activities can be resumed after the acute phase.

The nurse supervises care by an LPN/LVN to a client with an infected, open abdominal wound. The nurse notes a Penrose drain is in place and the wound is draining copious purulent drainage. The nurse determines care is appropriate if which action is observed? 1. The LPN/LVN applies clean gloves, removes the soiled dressing, and performs a clean dressing change. 2. The LPN/LVN applies clean gloves, removes the soiled dressing, dons sterile gloves, and performs a sterile dressing change. 3. The LPN/LVN applies sterile gloves, removes the soiled dressing, changes to clean gloves, and places clean bandages. 4. The LPN/LVN applies sterile gloves, opens needed supplies, and performs a sterile dressing change.

2) CORRECT- The LPN/LVN removes dressings with clean gloves, removes the clean gloves, and applies sterile gloves to perform sterile dressing change. The LPN/LVN should wash the hands between glove changes.

The nurse prepares to insert an indwelling urinary catheter into a client. Which action is important for the nurse to take? 1. Place all supplies close to the edge of the table. 2. Keep the field holding the supplies in front of the nurse. 3. Set up the field below the nurse 's waist level. 4. Add only clean supplies to the field.

2) CORRECT— Having the supplies in front of the nurse represents the best technique for a sterile field

The nurse notes that a client diagnosed with pancreatic cancer is jaundiced. Which client need will the nurse give the highest priority? 1. Urinary elimination. 2. Self-image. 3. Nutrition. 4. Skin integrity.

3) CORRECT - Severe anorexia and dramatic weight loss occur with pancreatic cancer.

The nurse evaluates a client's record at the end of the shift. The client's urinary output for 8 hours is documented as "475 mL of pale yellow urine." Which action does the nurse implement based on this data? 1. Assess the client for a rapid, weak pulse and poor skin turgor. 2. Instruct the staff about appropriate documenting. 3. Advise the client to continue drinking fluids as tolerated. 4. Obtain the urine specific gravity.

3) CORRECT - The client should be encouraged to continue drinking fluids as tolerated.

The office nurse meets with a high-school graduate who will be starting at a residential college in the fall. It is most important for the nurse to address which immunizations? 1. Diphtheria, tetanus toxoide, and acellular pertusis (DTaP). 2. Pneumococcal. 3. Meningitis. 4. Varicella.

3) CORRECT - The meningococcal meningitis vaccine is recommended for college freshmen, especially if the student will be living on campus in residence halls or dormitories.

The nurse provides care for a client diagnosed with ventricular tachycardia and angina. Which medication does the nurse administer first? 1. Nitroglycerin. 2. Morphine sulfate. 3. Amiodarone. 4. Metoprolol.

3) CORRECT - The nurse administers a drug that will terminate the rhythm causing the angina first. Ventricular tachycardia indicates severe myocardial irritability and causes chest pain, dizziness, and fainting. Amiodarone is the drug of choice for hemodynamically unstable ventricular tachycardia. This medication inhibits adrenergic stimulation and prolongs repolarization, allowing for a normal rhythm to occur.

The health care provider removes the peripherally inserted central catheter (PICC) from a client. A portion of the catheter breaks off. Which action does the nurse take first? 1. Check the client's radial pulse. 2. Turn the client to the right side. 3. Apply a tourniquet to the upper arm. 4. Instruct the unit secretary to call for an emergent x-ray.

3) CORRECT - The nurse will place a tourniquet close to the axilla. This prevents the catheter piece from advancing into the right atrium and acting as an embolism. After the tourniquet is applied, check for the presence of the radial pulse to ensure that arterial flow is not eliminated. The tourniquet will be kept in place until an x-ray is obtained and surgical retrieval attempted.

The nurse provides care for a client diagnosed with pneumonia who is pale and reports shortness of breath. Which laboratory test does the nurse expect the health care provider to prescribe to determine oxygenation status? 1. RBC count. 2. Sputum culture. 3. ABG analysis. 4. Urine culture and sensitivity.

3) CORRECT — ABGs evaluate gas exchange in the lungs, providing information about client's oxygenation status.

The client undergoes diagnostic testing for lung cancer and requests information about associated risk factors. Which risk factor does the nurse include? (Select all that apply.) 1. African-American ethnicity. 2. BRCA1 genetic mutation. 3. History of smoking. 4. Repeated respiratory infections. 5. Facial and neck edema.

3) CORRECT — Smoking is a known risk factor for lung cancer. 1) CORRECT — African-American men have the highest incidence of lung cancer.

A client is brought to the emergency department after overdosing on sleeping pills. The nurse is able to wake the client. Which question does the nurse ask first? 1. "Why did you take the medication?" 2. "Can you share what is bothering you?" 3. "How much medication did you take?" 4. "Were you trying to kill yourself?"

3) CORRECT— This assessment provides the nurse with key information to determine what emergency interventions should be implemented.

The client reports pain at an IV site. The nurse observes that the IV insertion site is pale, cool to the touch, and mildly swollen. Which intervention does the nurse implement? 1. Decrease the infusion rate and monitor the client's response. 2. Stop the infusion and notify the health care provider. 3. Discontinue the IV and apply a heating pad to the site. 4. Remove the IV and elevate the client's arm on a pillow.

4) CORRECT - Signs and symptoms of infiltration may include blanching or pallor of the skin, edema, and pain and tenderness at the IV insertion site. Management of infiltration includes removal of the IV catheter and elevation of the affected extremity. Application of a warm, moist compress to the affected area may be indicated.

The nurse provides care to a client who reports pain at an IV site. The nurse notes tenderness and redness at the insertion site and redness proximally along the vein. Which intervention does the nurse implement? 1. Slow the infusion rate and monitor the client's response. 2. Discontinue the infusion and notify the health care provider. 3. Remove the IV and apply a pressure dressing to the site. 4. Remove the IV and apply a warm, moist compress.

4) CORRECT - Signs and symptoms of phlebitis include pain and tenderness at the IV insertion site and redness along the affected vein. Management of phlebitis includes removal of the IV catheter and application of a warm, moist compress to the affected area.

A nursing team consists of a nurse, an LPN/LVN, and a nursing assistive personnel (NAP). Which client does the nurse assign to the NAP? 1. A client diagnosed with diabetes mellitus requiring a dressing change for a stasis ulcer. 2. A client diagnosed with terminal cancer being transferred to hospice home care. 3. A client diagnosed with cancer of the bone reporting pain. 4. A client diagnosed with a fracture of the right leg asking to use the urinal.

4) CORRECT — Assisting the client with the urinal is a standard unchanging procedure and may be safely assigned to the NAP.

The nurse provides care for a client diagnosed with respiratory failure. Which nutrient does the nurse instruct the client to limit in the diet? 1. Protein. 2. Calcium. 3. Water. 4. Carbohydrates.

4) CORRECT — Carbohydrates should be limited in clients with respiratory failure because metabolism of this nutrient causes increased carbon dioxide production.

A client receives IV theophylline for an acute respiratory problem. Which observation alerts the nurse to withhold the medication and notify the health care provider? 1. Hypertension. 2. Unresponsiveness. 3. Polyuria. 4. Tachycardia.

4) CORRECT— Tachycardia is an adverse effect of theophylline. Theophylline levels above 20 mcg/L (111 µmol/L) are considered toxic. After long-term use, clients may tolerate a higher blood concentration. Other adverse effects include hypotension, nausea, and vomiting.

Nocosomial Infections

Acquired from health care professionals to patients Risk Factor - Burn patients - Patients on NG tubes - Patients with Foley Cathters

Contraindications to Influenza, Dye, & MMR-Varicrlla-IPV

Influenza- Allergy to Eggs Dye- Allergy to shellfish & iodine MMR, varicella, IPV- Allergy to Neomycin

MRSA open Woumd Precautions

Non sterile, gloves and gown

Prostate Urinary Inconinence

Pelvic muscle exercises are best to control & strengthen bladder control but do not work in Spinal Cord Injury - Avoid artificial sweeteners, they cause bladder irritation 7 can cause more incontinence

The nurse notes a client recovering from a pancreatectomy has minimal drainage from the nasogastric tube. Which action will the nurse take next? A. Replace the nasogastric tube. B. Increase the intravenous fluids. C. Check the tubing for kinks. D. Notify the health care provider.

C Assessing the tube checks for kinks and ensures the tubing is in a dependent position.

The nurse teaches a client who was admitted and diagnosed with hyperkalemia. Which statement best indicates to the nurse that the client understands the teaching to prevent hyperkalemia? A. "I should take the potassium supplements on an empty stomach." B. "I should cut the potassium tablet in half to administer a decreased dose." C. "I should consume bananas and other foods rich in potassium." D. "I should avoid salt substitutes until my potassium level is under control."

D Many salt substitutes are potassium-based, which can cause continued hyperkalemia. This response indicates that the client understands the teaching.

CPR- Guidlines

Heel of the palm on the lower end of the patients sternum, hands straight and elbows locked, shoulders over the patient, keep correct posture to prevent injury - Check patients pulse after every minute

Creatine Clearance Test

Will have blood drawn & urine collected for 24 hrs, first void is discarded , drink fluids to void - Avoid gym for at lest 8 hrs

The home care nurse visits a client diagnosed with cardiomyopathy. The client asks the nurse, "How will I know if I am overdoing it? " Which response by the nurse is best? 1. "If you feel fatigued, you have done too much. " 2. "Follow the list that the health care provider gave you. " 3. "Coughing up more sputum is a good indication. " 4. "To prevent doing too much, allow your family to help you. "

1) CORRECT - Fatigue is a useful guide in gauging activity tolerance in clients with decreased cardiac output.

A client prescribed to receive a dose of nifedipine has a pulse rate of 50 beats per minute. Which action is the most appropriate for the nurse to take? 1. Withhold the medication. 2. Check urinary output. 3. Administer the medication. 4. Increase potassium intake.

1) CORRECT - Nifedipine is calcium-channel blocker used as an antihypertensive. Bradycardia is an untoward effect of this medication. The nurse should withhold the medication and notify the health care provider of the client's pulse rate.

The nurse provides care to a client with suspected influenza. To promote infection control, the nurse ensures implementation of which precautions? (Select all that apply.) 1. Standard precautions. 2. Neutropenic precautions. 3. Contact precautions. 4. Droplet precautions. 5. Airborne precautions

1) CORRECT - Standard precautions, the first line of infection control, are used during the provision of care to all clients, regardless of the source of infection. Second line precautions (such as airborne, droplet, and contact) are initiated as transmission-based precautions, based on the infectious agent. 4) CORRECT- Droplet precautions are required for clients with infections, such as influenza or meningococcus, to prevent transmission of infected respiratory or pharyngeal secretions.

The nurse provides care for several clients. Which client does the nurse assess first? 1. A middle-age female adult client reporting fatigue, severe nausea, and jaw pain. 2. An older adult male client reporting abdominal pain, vomiting, and diarrhea. 3. A middle-age female adult client reporting productive cough and shortness of breath. 4. An older adult male client reporting urinary hesitancy and weak urinary stream.

1) CORRECT - This client is having atypical symptoms of a myocardial infarction (MI). Women may not have severe, crushing, prolonged chest pain that is typically attributed to an MI.

The nurse provides care for a client who was sexually assaulted. Which action will the nurse take first? 1. Treat all urgent medical problems. 2. Document contusions and lacerations of perineum and cervix. 3. Contact the client's support person. 4. Provide supplies for client to clean self.

1) CORRECT - Treating urgent medical problems must occur first to stabilize the client. Then further assessment, documentation, and treatment can occur.

The nurse provides care for a client admitted because of seizures that occurred while the client was at work. The client has no previous history of seizures. Which intervention is most appropriate for the nurse to include in the client's plan of care? 1. Check the oral suction equipment. 2. Place a padded tongue depressor at the head of the bed. 3. Teach the client about epilepsy. 4. Talk to the client about the importance of wearing a medical identification tag.

1) CORRECT — Oral suction equipment may be needed to keep the client safe in the event of another seizure.

The nurse provides care to a client with the following assessment data: nonproductive cough, fever, lung crackles, headache, and myalgia. Which nursing concerns are appropriate? (Select all that apply.) 1. Acute discomfort. 2. Potential for aspiration. 3. Inefficient gas exchange. 4. Ineffective breathing pattern. 5. Potential for infection

1) CORRECT — This is an appropriate nursing concern related to inflammation in the lungs and muscle pain. 3) CORRECT — This is an appropriate concern related to the fluid buildup in alveoli. 4) CORRECT — This is an appropriate concern related to the inflammation and pain.

The professional development educator teaches novice nurses about the causes of systemic inflammatory response syndrome (SIRS). Which types of injury will the nurse include in the teaching? (Select all that apply.) 1. Burn injuries. 2. Crush injuries. 3. Major surgeries. 4. Bowel ischemia. 5. Viral infection.

1) CORRECT— Burn injuries cause mechanical tissue trauma, a trigger for SIRS. 2) CORRECT— Crush injuries cause mechanical tissue trauma, a trigger for SIRS. 3) CORRECT— Major surgeries can cause mechanical tissue trauma, a trigger for SIRS. 4) CORRECT— Bowel ischemia causes mechanical tissue trauma, a trigger for SIRS.

The nurse provides care for a client diagnosed with a closed head injury. The client begins to vomit. Which additional finding, if occurring with the noted emesis, does the nurse report to the health care provider (HCP)? 1. Increased lethargy. 2. Heart rate of 80 beats/min. 3. Sodium of 145 mEq/L (145 mmol/L). 4. Facial symmetry.

1) CORRECT— Changes in a client's level of consciousness, such as increasing drowsiness or difficulty arousing, are initial signs of increased intracranial pressure. Report these changes to the HCP immediately.

A client diagnosed with multiple myeloma experiences persistent lower back pain. In which position will the nurse place this client? 1. In bed with the head elevated 45 degrees and hips and knees moderately flexed. 2. In bed with the head elevated 60 degrees and arms resting on the overbed table. 3. In bed with the head of the bed elevated 15 degrees and legs extended. 4. In a straight-backed chair with feet resting on the floor.

1) CORRECT— Flexing the knees relieves pressure on the sciatic nerve and disk.

The nurse provides care for clients on an oncology floor. Which client does the nurse assess first after receiving report? 1. The client diagnosed with breast cancer with extensive bone metastasis who is irritable and confused. 2. The client who reports nausea and vomiting 6 hours after receiving chemotherapy. 3. The client diagnosed with lung cancer who reports fatigue and mild shortness of breath with ambulation. 4. The client with a WBC of 1600/mm 3 (1.6 × 10 9/L) who reports burning with urination.

1) CORRECT— Hypercalcemia, or more than 10.2 mg/dL (2.6 mmol/L), may occur as a result of bone destruction by the tumors. Elevated levels affect mental status and can negatively affect multiple organ systems.

The nurse observes prominent U waves on a client's electrocardiogram (ECG) rhythm strip. Based on this abnormality, for which condition will the nurse assess the client? 1. Hypokalemia. 2. Hyperkalemia. 3. Hypocalcemia. 4. Hypercalcemia.

1) CORRECT— Prominent U waves on a client's ECG strip signal hypokalemia, an abnormally low serum potassium level.

The nurse instructs a client and spouse on how to suction the client 's laryngectomy tube. Which observation indicates to the nurse that teaching is effective? 1. The client takes several deep breaths before the suction catheter is inserted. 2. The spouse selects a tonsil tip catheter to suction the laryngectomy tube. 3. The spouse applies suction while introducing the sterile catheter into the stoma. 4. The spouse suctions the mouth and then the laryngectomy tube.

1) CORRECT— Taking deep breaths hyper-oxygenates the client 's lungs and prevents anoxia during suctioning

Which fact in the health history of an adult client causes the nurse to question a prescription for aspirin? 1. An allergy to tartrazine. 2. A history of lead poisoning. 3. Maternal grandfather died suddenly. 4. Allergies to bee venom.

1) CORRECT— There is cross-sensitivity between tartrazine (yellow dye) and aspirin. An allergic response to one indicates a possible allergic response to the other.

A client is admitted to the emergency department (ED) with respiratory compromise. Which assessment finding does the nurse document as indicative of a pneumothorax? 1. Rapid respirations. 2. Deep, rapid respirations. 3. Respiratory depression. 4. Periods of hyperpnea alternating with periods of apnea.

1) CORRECT— This describes tachypnea, a symptom of pneumothorax.

A female adolescent client learns about having had intercourse 3 weeks ago with a person who has syphilis. Which manifestation does the nurse expect to see if the client has contracted syphilis? 1. A papule-like lesion in the vaginal area. 2. An abnormal Pap smear. 3. A non-reactive blood serology test. 4. A cluster of painful blisters on the genital area.

1). A Papule-Like lesion in the vaginal Area In primary syphilis a chancre develops within 2 to 6 weeks. It appears at the point of entry and starts as small papule that develops into a painless ulcer.

A client who developed acute respiratory distress syndrome (ARDS) after a motor vehicle crash (MVC) is being weaned from the ventilator. Which ventilator mode will the nurse utilize to wean the client? 1. Synchronized intermittent mandatory ventilation (SIMV). 2. Controlled ventilation. 3. Assist-control ventilation. 4. Positive end expiratory pressure (PEEP).

1. Synchronized intermittent mandatory ventilation (SIMV) 1). CORRECT— This ventilator mode allows for spontaneous breaths at the client's own rate and tidal volume between ventilator breaths. This mode facilitates weaning.

Pneumonia Risk Factors

- Advanced age - Lung diease - Smoking - Immuno suppressed - Bed riddin - Post- Op

Colostomy Care for Odor & Gas

- Place peppermint inside pouch Avoid Foods with Gas -onions, gum, beer, smocking, skipping meals, beans, cucumber Foods that are good - Yogurt, butter milk, cranberry juice, toast, crackers, parsley

The nurse coordinates care for clients in the emergency department (ED). Which activity can the nurse properly delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) 1. Determine appropriate room placement of clients. 2. Transport a client to the radiology department for a diagnostic procedure. 3. Discontinue a client's peripheral intravenous access. 4. Chaperone the health care provider during a client's pelvic examination. 5. Determine the size of equipment needed for a client's care. 6. Explain to a client the reasons to return to the ED for treatment.

2) CORRECT - The UAP can transport stable clients, so this activity can be delegated to the UAP. 4) CORRECT - The UAP can chaperone the health care provider for examinations as chaperoning merely requires the presence of another person in the room. Therefore, this activity can be delegated to the UAP.

A child is prescribed pancrelipase. The nurse observes that the child has trouble swallowing the capsule. Which action by the nurse is best? 1. Instruct the child to chew the capsule thoroughly, take a deep breath, close the eyes, then swallow the capsule. 2. Open the capsule, sprinkle the contents onto applesauce, and instruct the child to swallow the applesauce without chewing. 3. Open the capsule, pour the contents into a glass of milk, and instruct the child to drink the milk slowly. 4. Crush the capsule and give the remains to the child using a spoon and small sips of water.

2) CORRECT — The capsule can be opened since it contains enteric-coated microspheres. The contents should be mixed into a small amount of cool, soft food such as applesauce. The applesauce should then be swallowed immediately without chewing. Swallowing whole ensures that the microspheres will survive until reaching the intestines.

The psychiatric inpatient unit has four new admissions. Which client does the nurse see first? 1. A salesperson diagnosed with depression after the baby was born with Down syndrome and the spouse threatened to file for divorce. 2. A police officer with a history of post-traumatic stress disorder (PTSD) who was admitted with agoraphobia after two of his co-officers were killed. 3. A computer programmer admitted with a diagnosis of generalized anxiety disorder who has extensive debt and just filed for bankruptcy. 4. A college student admitted for depression and anxiety after a sibling committed suicide and a parent was recently diagnosed with lung cancer.

2) CORRECT- This client has a high potential for violence to self and/or others. There is easy access to weapons, and knowledge of how to use them. Agorophobia particularly causes this client to be uneasy in the new surroundings and potentiates acting out in fear.

An LPN/LVN reports to the nurse that a client admitted with persistent chest pain is experiencing moderate, spastic lower abdominal pain, nausea, and some vomiting. Which action does the nurse take first? 1. Determine what medications the client is receiving. 2. Perform a comprehensive abdominal assessment. 3. Ask the client about a history of GI problems. 4. Notify the admitting health care provider.

2) CORRECT— Abdominal pain is not usually associated with myocardial infarction. The nurse should assess for GI issues. The nurse should assess the abdomen prior to notifying the health care provider.

The nurse is eating lunch in a restaurant. Suddenly, a woman at the next table gasps for breath and grabs her throat. Which action does the nurse take first? 1. Lean the woman forward and administer back blows. 2. Offer the woman sips of water. 3. Ask the woman if she can speak. 4. Perform a finger sweep of the woman's mouth.

3) CORRECT — It is unclear whether this is a partial or complete airway obstruction from the question stem. The nurse should first assess the nature of the obstruction by asking the client to speak. If the client can speak or cough, then it is a partial obstruction. If they are unable to speak or cough, then they are experiencing a total obstruction and the Heimlich maneuver should be used.

The nurse provides care for a client with a nasogastric tube. The tube is attached to low suction. For which complication does the nurse monitor the client? 1. Metabolic acidosis. 2. Respiratory acidosis. 3. Metabolic alkalosis. 4. Respiratory alkalosis.

3) CORRECT — Loss of gastric fluid related to nasogastric suctioning or vomiting causes metabolic alkalosis.

The nurse provides care to a client from Somalia who is scheduled to have a basal cell carcinoma on the face excised. Which assessment is most important for the nurse to make? 1. Prior treatments for the same lesion. 2. Protected sun exposure. 3. Radiation treatment for acne. 4. Exposure to harsh skin irritants. View Explanation

3) CORRECT-Research has demonstrated that clients similar to this one, who had previous exposure to radiation treatment for acne, are developing basal cell carcinoma.

The nurse provides care for a client scheduled for a colostomy due to rectal cancer. The client's spouse is worried about the surgery. Which response by the nurse is best? 1. "Let me explain the surgical procedure to you." 2. "You can both sign up for classes about the colostomy." 3. "What are your specific concerns about the surgery?" 4. "Your spouse will be responsible for caring for the colostomy."

3) CORRECT— Encouraging the client and the client's spouse to talk about any fears will help alleviate anxiety and allow the nurse to address specific concerns

The nurse provides care for a client who experienced a spinal cord injury at the level of T-2. The nurse enters the room and notes that the client's face is flushed, is sweating profusely, and the blood pressure is 260/160 mm Hg. Which medication does the nurse prepare to administer? 1. Docusate sodium 100 mg PO. 2. Prochlorperazine 10 mg IM. 3. Hydralazine hydrochloride 10 mg IV. 4. Diazepam 20 mg IV.

3) CORRECT— Symptoms indicate autonomic dysreflexia with the elevated blood pressure as the most critical symptom. Hydralazine hydrochloride is a fast acting antihypertensive and relaxes smooth muscle. Side effects can include headache, angina, tachycardia, palpitations, sodium retention, anorexia, or a lupus erythematosus-like syndrome of sore throat, fever, muscle-joint aches, rash.

When arriving for a home visit, the nurse learns that a toddler has just swallowed another family members ' medication. Which action will the nurse take first? 1. Call poison control. 2. Notify the health care provider. 3. Assess the child. 4. Administer syrup of ipecac.

3) CORRECT— The child should be immediately assessed before implementing any actions. The child might need cardiopulmonary resuscitation or treatment of other symptoms, such as seizure activity.

A client undergoes personality changes and has difficulty with voluntary activities. The client is diagnosed with a brain tumor. Based on the client's symptoms, in which area of the brain should the nurse anticipate the tumor being diagnosed? 1. Parietal lobe. 2. Temporal lobe. 3. Frontal lobe. 4. Occipital lobe.

3) CORRECT— The frontal lobe concerns personality, behavior, emotions, and intellectual function. Based on the client symptoms, the nurse should anticipate the tumor being diagnosed in the frontal lobe.

A client on a unit has died, and the charge nurse notifies the family to come to the unit. Prior to the client's family arriving, the staff express concern about having to interact with them. Which response by the charge nurse is most appropriate? 1. "The nursing supervisor will be here when the family arrives." 2. "I will notify the legal department of the death." 3. "Please wash the client and place pads under the client's perineum." 4. "The chaplain will greet the family."

3) CORRECT— This represents appropriate postmortem care. The staff's priority is to provide care for the deceased client and family. The charge nurse can offer the staff an opportunity to express their feelings after providing care for the client and family.

The nurse provides care for a client diagnosed with paranoia. Two days after admission, the client refuses to give any information other than name and age. Which action is most important for the nurse to take? 1. Tell the client that the hospital is a safe place. 2. Urge the client to reveal more information. 3. Focus on developing a trusting relationship with the client. 4. Introduce the client to other clients on the unit.

3) CORRECT— When caring for a client who is resistant and paranoid, the first priority is to develop a trusting relationship with the client.

The nurse provides cares for a client reporting pain at the intravenous (IV) access site. Upon assessment, the nurse notes tenderness and redness at the site and redness proximally along the vein. It is most important for the nurse to take which action? 1. Slow the infusion rate and monitor the client's response. 2. Stop the infusion and notify the health care provider. 3. Remove the IV and apply a pressure dressing. 4. Remove the IV and apply warm soaks.

4) CORRECT - The IV catheter will be removed to prevent further damage to the vein. Warm soaks decrease inflammation, swelling, and discomfort and should be applied.

The nurse provides care for the client diagnosed with septic shock. Which observation most concerns the nurse? 1. The peripheral pulses are strong and bounding and the respiratory rate is 26 breaths per minute. 2. The white blood cell differential results indicate that there are predominantly band neutrophils rather than segmented neutrophils. 3. The skin changes from warm, dry, and flushed to cool, clammy, and pale. 4. There is blood at a venipuncture site and around an intravenous catheter.

4) CORRECT - The bleeding is an indicator of disseminated intravascular coagulation (DIC), a life-threatening problem. Sepsis is the most frequent cause of DIC.

The nurse in the pediatric clinic notes that several preschool children have received a single dose of hepatitis B vaccine during infancy. Which action does the nurse implement based on this information? 1. Inform the children's parents that the children must start the hepatitis B series over again. 2. Note the immunization in the child's history. 3. Contact the health care provider. 4. Make an appointment for the children to continue the series of hepatitis B vaccine.

4) CORRECT - The nurse should continue the immunization series, which is a total of three doses. The nurse should schedule the third dose 3 to 4 months after the second dose, and the second dose 1 to 2 months after the first dose.

The nurse conducts an admission assessment for an older adult client who is at risk for developing deep vein thrombosis (DVT). Which preventive measures does the nurse expect to be prescribed? (Select all that apply.) 1. Low molecular weight heparin. 2. Bed rest. 3. Leg massage. 4. Compression stockings. 5. Sequential compression devices.

4) CORRECT - These promote effective blood flow in the deep veins of the legs to prevent thrombosis. 5) CORRECT - Air pressure in sequential compression devices squeeze leg tissues to promote blood flow towards the heart. Effective blood flow in the deep veins assists to prevent thrombosis. 1) CORRECT - This is utilized as an anticoagulant to prevent DVT.

The nurse performs discharge teaching for a client after a right side mastectomy. It is important for the nurse to include which instruction? 1. Place a heating pad under the right shoulder nightly. 2. Keep the right arm in a sling for 4 weeks. 3. Attend the Reach to Recovery support group every day. 4. Use the left arm to measure the blood pressure.

4) CORRECT— Do not use the affected arm to obtain a blood pressure or for a venipuncture because of potential circulatory impairment or infection due to alterations in lymphatic flow.

The nurse instructs a client who is prescribed furosemide. Which client statement indicates that additional teaching is required? 1. "I will take my medicine early in the day." 2. "I will contact the doctor if I feel dizzy." 3. "I will take my medicine with meals." 4. "I will avoid orange juice and bananas."

4) CORRECT— Furosemide is a loop diuretic that is potassium wasting. The client should be encouraged to increase the intake of potassium-rich foods, such as orange juice and bananas

The nurse provides care for a client receiving glipizide and prednisone. Which is the priority nursing assessment? 1. Monitor hemoglobin. 2. Monitor platelets. 3. Monitor photosensitivity. 4. Monitor serum glucose.

4) CORRECT— Glipizide is an oral hypoglycemic that decreases blood glucose by stimulating insulin release from the beta cells of the pancreas. Prednisone is a corticosteroid that can cause hyperglycemia. Serum glucose level is the priority nursing assessment.

The nurse screens clients for the risk of developing bladder cancer. Which question does the nurse to ask during the assessment process? 1. "Do you smoke cigarettes?' 2. "How often do you consume alcoholic beverages?" 3. "Do you have a sedentary lifestyle?' 4. "How often do you take aspirin?

1) CORRECT - There is a strong correlation between bladder cancer and cigarette smoking.

The nurse provides care for a client diagnosed with tuberculosis. Which transmission-based precautions will the nurse implement? 1. Standard. 2. Airborne. 3. Droplet. 4. Contact.

2) CORRECT— Tuberculosis is transmitted by airborne droplets. The nurse implements airborne precautions.

The nurse plans care for a client with toxic shock syndrome. Which client statement causes the nurse the most concern? 1. "I am very frightened of doctors and hospitals. " 2. "I vomited 12 times in the past 24 hours. " 3. "I have abdominal pain and pressure. " 4. "I use extra-absorbent tampons. "

2) CORRECT— Vomiting 12 times during the last 24 hours addresses the client's physical status. This amount of vomiting could lead to fluid volume deficit. Symptoms of toxic shock syndrome include a sudden onset of fever, hypotension, and rash.

The triage nurse is prioritizing adult clients to be evaluated in the emergency department. Which client does the nurse assess first? 1. A client with a temperature of 100°F (37.8°C). 2. A client reporting arm pain after falling off a chair. 3. A client reporting vomiting for the past several hours. 4. A client with a persistent nosebleed.

4) CORRECT - Compromised circulation takes precedence over the other client needs.

Weaning off TPN- Solution

Use hypertonic Dextrose to wean patients off TPN, prevents hypoglycemia

The school nurse teaches a group of high school students about the Heimlich/abdominal thrust maneuver. Which statement made by one of the students indicates to the nurse that teaching is effective? A. "The maneuver is used to dislodge food or other foreign bodies in the throat." B. "To begin the maneuver, you hit the person on the back several times." C. "The maneuver should not be done if the person is conscious." D. "The maneuver should be used as a last resort if all other efforts fail."

A The Heimlich/abdominal thrust maneuver uses the remaining air in the lungs to expel a foreign body.

The nurse provides care for a client who was sexually assaulted. Which action will the nurse take first? A. Treat all urgent medical problems. B. Document contusions and lacerations of perineum and cervix. C. Contact the client's support person. D. Provide supplies for client to clean self.

A Treating urgent medical problems must occur first to stabilize the client. Then further assessment, documentation, and treatment can occur.

CVA- Left Sided, Right sided, Brain Stem

Left Side Controls - Speech, language, math, thinking, concentration, reasoning, problem solving, numbers - Personality change Right Sided - Impulse, imagine, emotions, place, time, person, creative, color, music Brain Stem - Voluntary Bladder & bowl

Spinal Anesthesia- Post-Op

Must always assess for hypotention, gradually & slowly raise HOB

External Radiation For Breast Lump- Care

Protect site, don't apply lotion, cream, perfume, deoderent - Protect from cold and hot, don't apply anything hot or cold (even wheater), no sun, no cold - Wear loose, cotton bra, assess skin frequently

Diverticulosis- Foods to avoid

Seeds, nuts, corn, pop corn, cucumber, tomato, strawberry, figs,

The nurse provides care to an older adult client who is prescribed phenytoin. Which condition places this client at risk for a toxic reaction to the medication? 1. Impaired liver function. 2. Decreased hemoglobin and hematocrit. 3. Increased WBC and platelet count. 4. Depressed neurological functioning.

CORRECT— Phenytoin is metabolized and excreted by the liver. Because an older adult client may have some degree of liver impairment, the risk for toxicity is high.

Adriamycin

Chemo drug used to treat Leukemia Expected Side Effects - Red urine 1-2 days after use - Stomatitis (ulceration in the mouth), 5-10 days after use- Good mouth care with water, use sponge brush after eating & drinking - Alopecia- Avoid too much shampooing, brushing hair & blow dryer Report to Doctor - Bone marrow suppression - Sore throat - Fever - Infection

The nurse prepares discharge teaching for a client diagnosed with paraplegia caused by a T4 spinal cord injury. Which instruction is most important for the nurse to provide to this client? A. Watch for signs and symptoms of urinary tract infection. B. Make a daily assessment of skin. C. Perform range-of-motion exercises four times a day. D. Observe respiratory function.

D Spinal cord injuries at the level of T1 through T6 can cause decreased respiratory reserve. Respiratory function is a priority for this client.

The nurse administers a bolus of 0.9% normal saline to a client with severe sepsis. To evaluate the effectiveness of this fluid therapy, which parameter is important for the nurse to assess? A. Breath sounds and capillary refill. B. Blood pressure and oral temperature. C. Hemoglobin and hematocrit levels. D. Central venous pressure and output.

D The effectiveness of fluid resuscitation is best evaluated by the client's blood pressure, central venous pressure, and urine output.

Tracheostomy & child

If child is eating raisins its dangerous because he might accidentally place raisins in tracheotomy instead of mouth

The nurse prepares a client diagnosed with epilepsy for a positron emission tomography (PET) scan. Which direction to the client is most important for the nurse to include? 1. "Be prepared to feel a warm sensation when the dye is injected." 2. "You will want to empty your bladder before the test." 3. "Be sure to remove all your jewelry before you enter the testing area." 4. "You will be asked to think in different ways during the test." View Explanation

2) CORRECT — This ensures that the client will be comfortable and able to lie still throughout the procedure, which may last as long as 2 hours. After radioisotope administration, the client waits 30 to 45 minutes on stretcher or table so the substance can circulate to the brain. After this waiting period, the scan is performed.

The nurse provides care for a client receiving prednisone. The nurse determines that teaching is effective when the client makes which statement? 1. "I should take the medication with a glass of orange juice. " 2. "I should take the medication with a full meal. " 3. "I should take the medication in between meals. " 4. "I should take the medication on an empty stomach. "

2) CORRECT- Oral corticosteroids cause gastric irritation and should be taken with meals.

A client experiences a flail chest from a motor vehicle crash. Which finding does the nurse expect when assessing this client? 1. Chest on the affected side expands outward during inspiration and is pulled inward during expiration. 2. Chest on the affected side is pulled inward during inspiration and bulges outward during expiration. 3. A sucking sound is heard on inspiration and expiration. 4. Absent or restricted movement noted on the affected side.

2) CORRECT— A flail chest is caused by fractures of multiple adjacent ribs, causing the chest wall to become unstable and respond paradoxically. The chest then pulls in during inspiration and bulges outward during expiration.

The nurse performs teaching for a client being discharged on dexamethasone 0.75 mg PO daily. Which statement by a client helps the nurse to determine teaching is successful? 1. "I will take my medication when I first get up in the morning. " 2. "I will take my medication with breakfast. " 3. "I will take my medication 3 hours after eating. " 4. "I will take my medication before I eat lunch. "

2) CORRECT— Oral steroids have ulcerogenic properties and need to be administered with meals. If prescribed daily, they should be administered in the morning with breakfast.

The nurse finds a visitor slumped to the floor of a client's room during visiting hours at the hospital. Which action does the nurse take initially? 1. Start rescue breathing and chest compressions. 2. Call for help. 3. Shake the visitor and shout, "Are you all right?" 4. Listen for breath sounds.

3) CORRECT - The nurse should assess for unconsciousness. Then call for help.

The nurse manager observes a staff nurse perform tracheostomy suctioning and tracheostomy care. Which staff nurse action requires an intervention by the nurse manager? 1. Wearing clean gloves when removing the tracheostomy kit from its outer package. 2. Hyperoxygenating the client prior to suctioning the tracheostomy tube. 3. Wearing clean gloves while inserting the new inner cannula. 4. Leaving the old tracheostomy ties in place until the new ties are secured.

3) CORRECT — Sterile gloves are worn while inserting the new, sterile inner cannula to prevent introduction of organisms into the client's airway.

The nurse receives four new admissions. Which client is placed in a private room? 1. A client diagnosed with Lyme disease. 2. A client diagnosed with Staphylococcus aureus pneumonia. 3. A client diagnosed with meningococcal meningitis. 4. A client diagnosed with toxic shock syndrome.

3) CORRECT— Meningococcal meningitis requires droplet precautions until 24 hours after initiation of effective therapy.

An adolescent client continues to experience a headache 2 days after falling and losing consciousness, despite taking acetaminophen as prescribed. Which action will the nurse direct the client 's parent to take first? 1. Instruct the parent to darken the adolescent 's room. 2. Determine when another dose of acetaminophen can be provided. 3. Contact the health care provider. 4. Reassure the parent that this is expected.

3) CORRECT— The client is experiencing a persistent localized headache. This could indicate a skull fracture and should be evaluated by the health care provider.

As a part of a disaster drill, the school nurse reacts to an announcement that a "dirty" bomb exploded four miles away. According to the disaster plan, which action does the nurse take first? 1. Move food and water to an interior area in the school. 2. Contact parents to immediately pick up their children. 3. Turn off the air conditioners or forced-air heating units. 4. Encourage the staff and children to remain calm.

3) CORRECT— Turn off all units that bring fresh air in from the outside, close and lock all doors and windows, and move everyone to an inner room or basement. The primary principles for limiting exposure are to observe time, distance, and shield.

The nurse screens clients at a health fair. The nurse recommends priority follow-up with a health care provider for which client? 1. The client with an apical pulse of 54 beats/min who is a marathon runner. 2. The client with a family history of coronary artery disease who drinks one to two glasses of red wine nightly. 3. The client with a body weight that is 20% more than recommended who has a glycated hemoglobin (HbA1C) level of 5.8%. 4. The client with a blood pressure of 162/96 mm Hg who stopped smoking 2 weeks ago.

4) CORRECT - The client is demonstrating stage 2 hypertension. The relationship between hypertension and cardiovascular events is direct and independent of other risk factors. The higher the client's blood pressure is, the greater the chance for coronary, cerebral, renal, and peripheral vascular disease. This client needs to be evaluated.

The nurse answers a call light for a client who reports pain at the intravenous (IV) access site. Upon assessment, the nurse notes the IV insertion site is pale, cool to the touch, and mildly swollen. It is most important for the nurse to take which action? 1. Slow the infusion rate and monitor the client's response. 2. Stop the infusion and notify the health care provider. 3. Remove the IV catheter and apply a pressure dressing. 4. Remove the IV catheter and place the client's arm on a pillow.

4) CORRECT - The client is experiencing an infiltration of the IV access site. The nurse will remove the IV catheter and elevate the extremity to increase the rate of reabsorption of the fluid

When completing an audit of medical records, the nurse determines that which client is at highest risk for developing hospital-acquired pneumonia? 1. An adolescent client who has diabetes mellitus (DM). 2. An adult client who has smoked for 2 decades. 3. A middle-age adult client diagnosed with hypertension. 4. An older adult client diagnosed with chronic obstructive pulmonary disease (COPD).

4) CORRECT - The client's age and chronic lung disease place this client at highest risk for developing hospital-acquired pneumonia.

Which client does the nurse determine is at risk for injury when planning care? 1. The adolescent client who flushes the percutaneous endoscopic gastrostomy (PEG) tube with 20 mL of water after medications. 2. The adult client who injects prescribed subcutaneous insulin into the abdomen at a 90-degree angle. 3. The adult client with a spinal cord injury who washes the urinary catheter with soap and water between uses. 4. The infant client who is receiving prescribed intramuscular injections in the dorsogluteal site. View Explanation

4) CORRECT - The dorsogluteal site involves a high risk for sciatic nerve injury or piercing of a major blood vessel. This site is small and poorly developed in infants and children and is not used for intramuscular injections. This is a safety issue.

The nurse provides care for clients on the medical-surgical unit. The nurse notes that a client is anxious and in respiratory distress. In which position does the nurse place the client? 1. Flat on back with thighs flexed and legs abducted. 2. Lying with the head of the bed elevated 15 ° to 45°. 3. Lying on the left side with legs bent. 4. Lying with the head of the bed elevated 60 ° to 90°.

4) CORRECT - The high-Fowler position allows optimal pulmonary expansion. It also decreases venous return, which assists in lowering the ventricular output and pulmonary congestion.

An older adult client asks the nurse to explain therapeutic massage since the health care provider recommended it as treatment. Which response by the nurse is appropriate? 1. "It decreases fluid retention." 2. "It helps to resolve blood clots in legs." 3. "It decreases hypertension." 4. "It improves circulation and muscle tone."

4) CORRECT - Therapeutic massage will help improve circulation and muscle tone, particularly in older clients.

The nurse prepares to assess a client diagnosed with a subdural hematoma and cerebral edema caused by a motorcycle crash. Which symptom does the nurse expect to assess initially when providing care for this client? 1. Unequal and dilated pupils. 2. Decerebrate posturing. 3. Tonic-clonic seizures. 4. Change in level of consciousness.

4) CORRECT- The client diagnosed with a subdural hematoma and cerebral edema will have a change in consciousness. This client may be confused or exhibit stupor, as initial symptoms.

The nurse provides care to a client who is receiving enteral feedings via a nasogastric tube. Immediately after administering a tube feeding, the nurse ensures the client remains in which position? 1. The right lateral decubitus position for 60 minutes. 2. A high-Fowler position for 30 minutes. 3. A left lateral decubitus position for 30 minutes. 4. The semi-Fowler position for 60 minutes. View Explanation

4) CORRECT— In the semi-Fowler position, the head of the bed is elevated between 30-45 degrees. Elevation of the head of the bed 30-45 degrees for 30-60 minutes allows gravity to help prevent reflux and subsequent aspiration of gastric contents.

The nurse prepares discharge teaching for a client diagnosed with paraplegia caused by a T4 spinal cord injury. Which instruction is most important for the nurse to provide to this client? 1. Watch for signs and symptoms of urinary tract infection. 2. Make a daily assessment of skin. 3. Perform range-of-motion exercises four times a day. 4. Observe respiratory function.

4) CORRECT— Spinal cord injuries at the level of T1 through T6 can cause decreased respiratory reserve. Respiratory function is a priority for this client.

The nurse receives a phone call from a person who states, "The client in room 203 is my family member. Can you give me a status update?" Which response by the nurse is appropriate? 1. "The client is requiring intravenous pain medications." 2. "The client is scheduled for a colonoscopy in the morning." 3. "The client is receiving aggressive antibiotic therapy." 4. "I am unable to give you any information at this time."

4) CORRECT— The nurse should always exercise caution about the release of information on the phone because it is difficult to accurately identify the caller.

The nurse supervises a nursing assistive personnel (NAP). Which task is appropriate for the nurse to delegate to the NAP? 1. Postoperative exercise teaching. 2. Negative pressure wound therapy. 3. Elastic bandage application. 4. Abdominal binder application.

4) CORRECT— The skill of applying an abdominal binder can be delegated to the NAP. However, the nurse is responsible for assessment of the area where the binder will be applied and the client's comfort level after application.

The nurse provides care for a client with frequent premature ventricular contractions. Which assessment is most important for the nurse to complete on this client? 1. Causative factors such as caffeine. 2. Precipitating factors such as infection. 3. Sensation of palpitations. 4. Blood pressure and peripheral perfusion.

4) CORRECT - Premature ventricular contractions can cause hemodynamic compromise. Blood pressure and peripheral perfusion would be assessed to anticipate and to monitor the effects of the condition.

The nurse oversees care provided by an LPN/LVN and the nursing assistive personnel (NAP). Which task is most appropriate to delegate to the NAP? 1. Monitor a client during the first 15 minutes after the nurse begins a blood transfusion. 2. Determine the patency of a chest tube drainage system for a client with a pneumothorax. 3. Teach a client newly diagnosed with type 1 diabetes mellitus how to fill out the menu. 4. Implement bladder training measures for a client with urinary incontinence.

4) CORRECT - The NAP can be delegated activities related to bladder training. Establishing the bladder training program is the responsibility of the nurse.

The nurse provides care for an older adult client who is disoriented to person, place, and time. The client has an incontinence episode. Which statement by the nurse is most appropriate? 1. "Let's see about placing an indwelling catheter." 2. "Why didn't you call us for assistance?" 3. "Here are some dry clothes for you to wear." 4. "Let's clean up and put on some dry clothes.

4) CORRECT— This message conveys warmth, assistance, and concern for the client.

The nurse provides care for a client injured in a motor vehicle accident (MVA) that resulted in total blindness. Which action does the nurse initially take when assisting the client with the lunch tray? 1. Place client's hand on each food item and describe the specific foods. 2. Procure utensils specifically designed for visually impaired clients. 3. Cut up the client's food. 4. Inform client of location of food items using an imaginary clock face.

4) CORRECT— To maintain the client's self-esteem, the nurse should first use imagery to identify the location of each food item.

The nurse instructs a client diagnosed with diverticulosis. Which menu selection by the client validates that the nurse 's teaching is effective? 1. Fried chicken breast with french fries. 2. Biscuits and gravy with scrambled eggs. 3. Roast beef with gravy and corn on the cob. 4. Tuna sandwich on whole wheat toast with carrot sticks.

4) CORRECT— Tuna is nutritious and relatively low in fat, and whole wheat toast and raw carrots provide fiber that will increase bulk in the client 's stools.

The nurse provides cares for a client who sustained a T5 spinal cord injury four weeks ago. The nurse observes that the client is diaphoretic, nauseated, and reports a severe headache. Which action does the nurse take first? A. Place the client in a sitting position. B. Assist the client to empty the bladder. C. Examine the client's rectum. D. Administer hydralazine as prescribed.

A These symptoms reflect autonomic dysreflexia, which is a life-threatening condition that can occur with spinal cord injuries above T6. Causes include visceral distension and noxious stimuli, such as skin pressure and temperature extremes. A primary symptom, and of most major concern, is severe and rapid-onset hypertension. Another symptom includes bradycardia. Placing the client in a sitting position should be done immediately to help reduce intracranial pressure and prevent cerebral hemorrhage and seizures.

The nurse provides care for a client diagnosed with hepatitis A. The client reports fatigue, anorexia, and intolerance to odors. Which recommendation is appropriate for the nurse to provide? 1. "Eat small, frequent feedings." 2. "Restrict the amount of protein that you eat." 3. "Decrease your caloric intake to 1400 calories per day." 4. "Limit your alcohol intake to 3 oz of wine per day."

1) CORRECT - Because of anorexia, the client is unable to eat large meals. The nurse should encourage the client to eat small, frequent meals and snacks. If the client has nausea later in the day, offer morning meals that are rich in nutrients.

The nurse in the emergency department (ED) provides care for a client who states that the client's spouse, "Became angry and physically abusive." Which action does the nurse take first? 1. Encourage the client to verbalize feelings. 2. Assess the client for physical trauma. 3. Provide a list of shelters appropriate for the situation. 4. Assist the client to identify a support system.

2) CORRECT— First assess for trauma to determine the client's physical needs.

The nurse in the outpatient surgery center provides care for a client scheduled for an appendectomy. The client is expected in the operating room in 15 minutes. Which is the priority action for the nurse to implement with this client? 1. Perform preoperative teaching about having an appendectomy. 2. Check that the consent form is signed and attached to the medical record. 3. Perform a pre-operative shave and scrub with antibacterial soap. 4. Ask the client about allergies to food, medication, and other sources.

2) CORRECT - The nurse performs a last evaluation of the medical record and the client to make sure everything is ready. The consent form should be completed before going to surgery.

The nurse supervises the unlicensed assistive personnel (UAP). Which tasks can the nurse safely delegate to the UAP? (Select all that apply.) 1. Determine a client's risk for pressure injury development. 2. Anchor a nasogastric tube to a client's gown. 3. Provide nasal hygiene to a client with a nasogastric tube. 4. Answer questions about a patient-controlled analgesia (PCA) pump. 5. Change a client's peripheral intravenous (IV) site dressing.

2) CORRECT - This action can be delegated to the UAP. At this point, the nasogastric tube has already been secured to the bridge of the client's nose by the nurse. 3) CORRECT - This action can be delegated to the UAP.

The nurse in the outpatient clinic prepares a client for a pap smear. The client's only significant history is hypertension, for which the client takes an anti-hypertensive medication daily. It is most important for the nurse to follow-up on which client statement? 1. "I haven 't had a pelvic exam in 3 years." 2. "Black cohosh helps my hot flashes." 3. "I exercise eight times per week." 4. "I don 't like my partner using a condom."

2) CORRECT- Herbal remedies, such as black cohosh, used in management of menopausal symptoms may cause hypotension when used in combination with antihypertensive drugs. The use of this herbal product can affect blood pressure and circulation; therefore, this is the priority statement for the nurse to further assess.

The hospice home care nurse assists a terminally ill client with personal care. The client says to the nurse, "Why do you bother with me?" Which response by the nurse is most appropriate? 1. "Would you like to be alone?" 2. "I care about you and how you are doing." 3. "I understand how you feel." 4. "This is a difficult time, isn't it?"

2) CORRECT— The nurse conveys to the client that the client is important. This addresses the client's emotional concern.

The nurse provides care to a client recovering from a pancreatectomy. The nurse notes that there has been no drainage from the tube attached to low suction since the client returned from surgery. Which action will the nurse take first? 1. Notify the health care provider. 2. Check for a kink in the drainage tube. 3. Increase the suction. 4. Measure vital signs.

2) CORRECT— The nurse should assess the tubes and drainage devices to ensure patency and proper functioning in order to prevent stress on the surgical site.

The nurse prepares to perform the initial assessment on a school-age client. The client has an open wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which precaution will the nurse take? 1. Wear gloves only. 2. Wear gown and gloves. 3. Wear gown, gloves, and mask. 4. No precautions are necessary.

2) CORRECT— The nurse should wear clean, nonsterile gloves and gown when entering the client's room, if the nurse is going to have any contact with the client or with surfaces that the client touches.

The charge nurse in the emergency department receives a call from paramedics who are en route with four patients involved in a motor vehicle accident (MVA). Which client does the nurse plan to see first based on paramedic report? 1. An adult with an obvious deformity to the left knee, weak pedal pulses bilaterally, and reports of pain. 2. An adult with a decreased level of consciousness, a heart rate of 126 beats/min, and no obvious injuries. 3. A child with an obvious deformity to the right forearm, a strong radial pulse, and reports of pain. 4. A child, crying uncontrollably, with an abrasion on the forehead and a heart rate of 112 beats/min.

2) CORRECT— This client may be experiencing hypovolemic shock related to an unknown hemorrhagic injury and therefore takes priority.

The nurse visits the home of a family whose mother died 2 months ago in a motor vehicle accident. Which observation causes the nurse the most concern? 1. A 3-year-old explains that mother is sleeping at grandmother's house. 2. A 6-year-old experiences enuresis and temper tantrums. 3. A 9-year-old states that no one will play with him. 4. A 12-year-old spends time away from home with friends.

3) CORRECT - The inability to enjoy play is masked by this typical statement and is a hallmark sign of depression in children.

The parents of a preschooler bring their child to the emergency department during flu season. The parents state that the child has been reporting abdominal pain, is nauseated and vomiting, and refuses to eat. Which question is most important for the nurse to ask the parents? 1. "Did your child have the flu shot this year?" 2. "What new foods has your child been eating lately?" 3. "How long has your child been feeling like this?" 4. "Which came first: the pain, or the nausea and vomiting?"

4) CORRECT — The sequence of symptoms is the most reliable information from the history when assessing for possible appendicitis. The clinical symptoms with acute appendicitis are similar to those of many other medical conditions, but in acute appendicitis the pain usually comes prior to nausea and vomiting. Nausea and vomiting that come before abdominal pain frequently indicate gastroenteritis.

A Buddhist client dies on the medical unit in a private room from terminal cancer. Family and friends have gathered around the bedside. Which action by the nurse is best? 1. Provide a basin of warm water and a washcloth. 2. Hand the closest family members a clean white sheet. 3. Close the door to provide privacy for chanting around the bedside. 4. Call the hospital chaplain to tie a thread around the neck or waist.

3) CORRECT — In Buddhism, those at the bedside after the death often perform last rites of chanting. A Buddhist priest should be contacted by the nurse or family.

The nurse reviews the prescription for hormone therapy for a client with prostate cancer. Which goal of treatment will the nurse identify as important when planning care for this client? 1. Increase prostaglandin levels. 2. Increase testosterone levels. 3. Increase circulating androgens. 4. Limit the amount of circulating androgens.

4) CORRECT- Limiting the amount of circulating androgens is the desired outcome because prostate cells depend on androgen for cellular maintenance.

The client's cardiac monitor reveals ventricular fibrillation. The client is prepared for defibrillation. Which is the first nursing action when providing care to this client? 1. Set the machine to 50 joules. 2. Press the "sync" button on the machine. 3. Instruct the staff to stand clear of the client. 4. Place gel pads on the chest of the client. View Explanation

4) CORRECT— Gel pads should be used to deliver the shock. Better contact means less resistance to the current flow and prevents burns

The nurse auscultates 40 bowel sounds in 1 minute when assessing the abdomen of a client with pain, nausea, and vomiting. Which statement will the nurse use when documenting this assessment finding? 1. "Absent bowel sounds on auscultation." 2. "Hypoactive bowel sounds heard on auscultation." 3. "Normal bowel sounds heard on auscultation." 4. "Hyperactive bowel sounds heard on auscultation."

4) CORRECT— Hyperactive bowel sounds mean that more than 30 sounds are heard over 1 minute

The nurse provides care for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA). Which transmission-based precautions are essential for the nurse implement? 1. Standard precautions. 2. Airborne precautions. 3. Droplet precautions. 4. Contact precautions.

4) CORRECT— MRSA is transmitted through contact. It is essential for the nurse to implement contact precautions to prevent the spread of MRSA.

The unlicensed assistive personnel (UAP) calls the nurse and states, "The client in room 218 is reporting shortness of breath." Which response by the nurse is appropriate? 1. "Call the respiratory therapist and request an arterial blood gas be performed." 2. "Ask the client when the shortness of breath started." 3. "Ensure the nasal cannula is in the client's nares." 4. "Listen to the client's lung sounds and notify me if you hear wheezing or crackles."

3) CORRECT— Ensuring the nasal cannula is in the client's nares can immediately improve oxygenation. The skill of applying (not setting or adjusting oxygen flow) and adjusting a nasal cannula can be delegated to the UAP.

The nurse provides care for a client 2 hours after placement of a cuffed tracheostomy tube. When the nurse enters the client's room, the tracheostomy tube is displaced out of the stoma. Which action does the nurse take first? 1. Place oxygen at 6 L per minute over the stoma opening. 2. Auscultate bilateral breath sounds. 3. Check the client's pulse oxygenation reading. 4. Use a hemostat to dilate the opening of the stoma.

4) CORRECT— The client's issue is the loss of an airway. The first action is to open the airway. A newly placed tracheostomy will not stay open without the tube. Some stoma swelling is expected due to the recent surgical procedure as well. The nurse should utilize hemostats to open the airway.

A client experiences a pulmonary embolism after abdominal surgery. Which information in the client's history will contraindicate the use of thrombolytic therapy? 1. Has type 2 diabetes mellitus. 2. Takes medications as needed for angina pectoris. 3. Is recovering from a concussion that occurred 3 weeks ago. 4. Uses an inhaler for treatment of asthma.

3) CORRECT— Thrombolytic therapy is contraindicated in a client who experienced a trauma within the past 2 months. Other contraindications include active internal bleeding, history of hemorrhagic stroke, intracranial or intraspinal surgery, intracranial neoplasm, arteriovenous malformation, aneurysm, and severe uncontrolled hypertension.

The nurse provides care for a client admitted for elective surgery. The nurse assesses the client's vital signs. How does the nurse position the client for this part of the admission assessment? 1. Lying flat on back with knees flexed. 2. Side-lying with knees flexed. 3. Lying flat with extremities fully extended. 4. Sitting upright.

4) CORRECT - This position allows the nurse to easily access the anterior and posterior chest for auscultation of breath sounds and is the preferred position for measuring blood pressure. It allows for eye contact and helps client feel less vulnerable.

The emergency department nurse monitors the rewarming process of a homeless client brought in by police with a body temperature of 90°F (32.3°C). Which potential complication is the highest priority for the nurse? 1. Increased intracranial pressure (ICP). 2. Hyperglycemic hyperosmolar nonketotic syndrome (HHNKS). 3. Absent peripheral pulses. 4. Ventricular fibrillation.

4) CORRECT — Hypothermia causes myocardial irritability, which disrupts the conduction system of the heart and causes the heart to be near its fibrillation threshold, especially ventricular fibrillation. Hypothermic clients need to be handled gently and with extreme caution, as the active external rewarming techniques themselves can cause rewarming shock and a temperature afterdrop, which can lead to ventricular fibrillation.

A client diagnosed with an intact immune system is treated for herpes zoster. Which observations indicate to the nurse that this client's care is appropriate? (Select all that apply.) A. Airborne precautions implemented. B. Prescribed acyclovir by mouth. C. Door to the room is closed at all times. D. Assigned nurse has a positive history for chicken pox. E. Performs slow, rhythmic breathing.

B, D, E Acyclovir is an antiviral medication that is prescribed to decrease pain and slow the progression of the disease. The nurse with a positive history for chicken pox means the worker has immunity to the varicella virus. Susceptible health care workers should not enter the room if a caregiver who is immune is available. Slow rhythmic breathing encourages relaxation to help the client cope with the discomfort.

A client diagnosed with a myocardial infarction is prescribed IV morphine sulfate. Which reason will the nurse use when explaining the purpose of the medication to the client? 1. Decreases blood return to the right side of the heart and decreases peripheral resistance. 2. Increases blood return to the right side of the heart and increases peripheral resistance. 3. Decreases blood return to the right side of the heart and maintains peripheral resistance. 4. Increases blood return to the right side of the heart and decreases peripheral resistance.

CORRECT— Morphine sulfate decreases preload and afterload pressures and cardiac workload. It causes vasodilation and pooling of fluid in extremities and provides relief from anxiety.

The nurse obtains health information from a client scheduled for permanent pacemaker insertion. Which information is most important for the nurse to convey to the health care provider (HCP)? 1. Diagnosis of obsessive-compulsive disorder. 2. Uses a hearing aid in the left ear. 3. Works as a computer programmer. 4. Lives in a two-story house.

CORRECT— The hearing aid battery may affect the placement of the pacemaker. It should not be placed under the left clavicle in this client.

Contraindications to Thrombolytic Therapy - 10

- Accident or trauma or surgery within the past 2 months - Internal bleeding, arteriovenous malformation, spinal or cranial surgery, uncontrolled hypertension, history of hemorrhagic stroke, intracranial neoplasm, aneurysm,,

PVD-Venous or Arterial- Position

Avoid crossing the legs and constrictive clothing - Should sit with feet flat on the floor

Ventilators & Ambu Bags

If ventilators fail they use ambu bags to continue manual ventilation

Assessment, when started on ventilator

When pt/ is started on a ventilator, Cardiac Output decrease and will cause hypotention. Monitor Blood Pressure - Respiration is controlled by machine no need to check

A client with a history of hypertension experiences a subarachnoid hemorrhage, head laceration, and ulnar fracture from a motor vehicle crash. Which finding indicates to the nurse that the client's condition is deteriorating? (Select all that apply.) 1. Urine output 5000 mL in 24 hours. 2. Pink drainage on laceration dressing. 3. Radial and apical pulse 120 beats per minute. 4. Diminished pupillary response. 5. Glasgow Coma Scale score of 15.

1) CORRECT - A head injury can cause diabetes insipidus. A urine output of 5000 mL is extremely high, which is characteristic of diabetes insipidus. . 3) CORRECT - A rapid heart rate may indicate a hemorrhage. 4) CORRECT - A decreased pupil response is a finding associated with increased intracranial pressure.

The nurse provides care to a client recovering from a lumbar puncture. In which position will the nurse place the client? 1. Semi-Fowler. 2. Flat supine. 3. Reverse Trendelenburg. 4. High-Fowler.

2) CORRECT— The flat supine position prevents a headache caused by leaking of cerebrospinal fluid from the puncture site.

mononucleosis s&s

- Malaise, feverm sore throat, tired, no energy, headache, nose bleed

Incident Report

-Submit the report to the risk manager within 24 hrs - Never photocopy report, used against you in court

Candidates for Hep A Vaccine

-Traveling to asia, africa, south america - Chronic liver disease - Hemophilia receiving clotting factors

A client is scheduled to have a transabdominal pelvic ultrasound for evaluation of a uterine mass. The nurse includes which statement when preparing the client for the procedure? 1. "Do not eat anything for at least 8 hours before the test." 2. "You may feel a stinging sensation as the machine moves over your skin." 3. "Drink four glasses of water 1 hour before the test and do not urinate." 4. "Be prepared for the test to take 1 to 2 hours."

3) CORRECT - A full bladder is necessary for this test for several reasons, including the fact that it serves as a window for the ultrasound beam transmission. It also provides a less obstructed view by pushing the uterus away from the pubic symphysis, as well as by pushing the intestine out of the pelvis.

The nurse provides care to a client diagnosed with severe liver disease. Which intervention is appropriate for the nurse to include in this client's plan of care? 1. Low-sodium IV albumin. 2. Sodium polystyrene sulfonate enemas. 3. Sengsteken-Blakemore tube. 4. Low-protein, high-carbohydrate diet.

4) CORRECT - A low-protein, high-carbohydrate diet will help reduce the risks of hepatic coma by reducing the level of ammonia that results from the breakdown of proteins.

The nurse reviews telephone messages in the pediatric clinic. Which message will the nurse return first? 1. Parent states the extremities of a 2-day-old newborn extend and return to the previous position when the crib is bumped. 2. Parent states that the circumcision site of a 3-day-old newborn is covered with yellowish exudate. 3. Parent states that a 4-day-old newborn has had one stool per day for the past 2 days. 4. Parent states that the umbilical cord stump of a 5-day-old newborn is moist at the base and slightly red.

4) CORRECT - A moist and red umbilical cord stump in a newborn of this age indicates an infection. The cord should be dry with no redness.

A client diagnosed with a spinal cord injury is being treated for a neurogenic bladder. Which medication does the nurse expect to be prescribed as part of this client's bladder retraining program? 1. Diphenhydramine. 2. Diazepam. 3. Dicyclomine. 4. Bethanechol.

4) CORRECT - Bethanechol is a cholinergic or parasympathomimetic medication used to treat functional urinary retention. It mimics the action of acetylcholine.

Complications of Thorocentesis- 7

- Pulmanory edema, hypoxia, hemothorax, pneumothorax, subcutaneous emphysema, spleen and liver puncture

Ventilator settings

- Sigh is set at 1.5 times tidal volume to occur every 1-3 hrs - Lowest concentration of oxygen should be administered - Settings are based on ABGs - Never add water to tubing

Catheter removal & insertion & Pressure Ulcers

- Sterile gloves required when inserting a catheter but regular gloves for removal - Stage 1 pressure Ulcers, the skin is intact & gloves are not needed

EEG

- Stop all stimulants 24-48 hours before test, smoking, tea, coffee, cola - May be asked to hyperventilate for 3-4 minutes to see bright, flashing lights

NG Tube Feeding Guide

- Elevate HOB (aspiration) - Aspirate before feeding- Insures correct placement of tube in stomach - Warm food, prevents cramps - Feed for at least 30 minutes - Clamp tube proximal, to prevent air from entering tubing

Oral Candidiasis

- Avoid using commercial mouthwashes because contain alcohol - Can use warm saline & hydrogen proxide - Mycostatin is used for fungal infections, suspension, shke swish & swallow, allow time to stay in your system dont drink water or fluids right after - Avoid spicy, hot, acid foods & drinks

Aids & Home Care

- Can use same bathroom as family, Aids not in urine or feces unless has incontinent and diarrhea - Eat with family - Wash cloths with family, hot water & detergent destroys virus - Heavy soiled cloths with body fluid or blood, wash separate with bleach - Don't use same razor

The nurse teaches a client about measures to prevent deep vein thrombosis formation. Which client statement indicates to the nurse the need for further teaching? 1. "I'm glad I can travel by plane without any special precautions." 2. "I just bought some tight-fitting clothing. Now I can't wear it." 3. "It's going to be hard to remember to avoid crossing my legs when sitting." 4. "I sit at a desk all day. I'll have to remember to take a walk every hour or two."

1) CORRECT- The client should exercise the feet and legs while seated and walk around when possible during long plane trips.

The nurse provides care to several clients in an outpatient clinic. For which client does the nurse conduct a hearing assessment? 1. A client who is receiving cisplatin. 2. A client who is receiving levothyroxine. 3. A client who is receiving flurazepam. 4. A client who is receiving cimetidine.

1) CORRECT— Cisplatin, which is an antineoplastic medication, is ototoxic. For the client who is prescribed cisplatin, hearing acuity should be assessed.

The nurse assesses the client who has a distended bladder. Because the client is unable to void, the health care provider prescribes catheterization. Which action does the nurse perform immediately after the catheter is inserted? 1. Clamps device after 500 mL of urine has drained. 2. Keeps the client in a prone position. 3. Asks the client to take deep breaths. 4. Asks if client has had the problem before.

1) CORRECT— The rapid decompression of the bladder can result in bladder wall damage, causing hematuria. The nurse clamps the catheter at 500 mL increments for 5 to 10 minutes to avoid damage to the bladder wall.

The nurse provides care for the client diagnosed with esophageal cancer. Which goals does the nurse establish in the plan of care? (Select all that apply.) 1. Client will experience remission of the cancer. 2. Client will swallow liquids without aspiration. 3. Client will state an acceptable level of pain. 4. Client will maintain weight within normal range. 5. Client will agree to hospice consult.

1) INCORRECT - This outcome is not associated with appropriate nursing diagnoses or care. This is a goal for the medical diagnosis. 2) CORRECT - Risk for aspiration is an appropriate nursing diagnosis for this client, and this is an appropriate goal for that diagnosis. 3) CORRECT - Pain is an appropriate nursing diagnosis for this client, and this is an appropriate goal for that diagnosis. 4) CORRECT - Risk for imbalanced nutrition is an appropriate nursing diagnosis for this client, and this is an appropriate goal for that diagnosis. 5) INCORRECT - This is not an appropriate outcome goal. There is no indication that hospice is needed at this time, and the nurse honors clients' right to autonomy (right to make their own decision).

The nurse obtains a client's orthostatic vital signs. Which series of steps does the nurse implement to obtain this client's vital signs? 1. Have client lie still in the supine position for 2 to 3 minutes, check BP; assist the client to sit on the side of the bed, check BP; stands the client up, and check BP. 2. Have the client sit in the chair, check BP; have the client get back to bed to the supine position and check BP. 3. Have the client lie still in the supine position for 2 to 3 minutes, check BP; assist the client to the chair, and check BP. 4. Have the client sit on the side of the bed, check BP; have the client walk to the bathroom, check BP; have the client walk back to the chair, and check BP.

1. Have client lie still in the supine position for 2 to 3 minutes, check BP; assist the client to sit on the side of the bed, check BP; stands the client up, and check BP

The nurse provides care for a client with a complete heart block (CHB). The nurse questions which prescription from the health care provider? 1. Administer lidocaine 50 mg IV push for premature ventricular contractions in excess of six per minute. 2. Prepare and administer epinephrine 2 to 10 mcg/min, titrating based on response. 3. Anticipate scheduling the client for a temporary pacemaker if the pulse continues to decrease. 4. Mix and administer 10 mL of 1:5000 solution of isoproterenol in 500 mL D 5W for sustained bradycardia below 30 beats/min.

1.) CORRECT - In CHB, the atrioventricular node blocks all impulses from the sinoatrial node, so the atria and ventricles beat independently. Because lidocaine suppresses ventricular irritability, it may diminish the existing ventricular response, causing cardiac arrest.

The nurse provides care for a client hospitalized for increased dyspnea. Admitting vital signs are BP 130/70 mm Hg, HR 84 beats/min, RR 26 breaths/min, and oxygen saturation of 100% on 6 L/min oxygen per nasal cannula. Which intervention does the nurse perform first? 1. Remove the the client's supplemental oxygen. 2. Place the client in a semi-Fowler position. 3. Administer prescribed aminophylline. 4. Obtain prescribed ABG.

2. Place the client in a semi-Fowler position. 2) CORRECT— Proper positioning maximizes respiration and decreases respiratory effort. The head of the bed is raised first

The nurse auscultates a client's breath sounds. The nurse hears a continuous, high-pitched whistling sound. How does the nurse document this finding in the medical record? 1. Stridor. 2. Biot respirations. 3. Wheezes. 4. Sonorous respirations.

3) CORRECT—The nurse should document the finding as wheezes when hearing a continuous high-pitched whistling or musical sound that occurs primarily during expiration, but can also occur during inspiration.

The nurse overhears two nursing assistive personnel (NAP) discuss a client's protected health information (PHI) in a public elevator. Which action does the nurse take next? 1. Assess the elevator for visitors and nonstaff passengers. 2. Contact the supervisor on the floor where the NAPs work. 3. Instruct the NAPs to stop the conversation immediately. 4. Notify the hospital risk manager and ethics committee.

3) CORRECT—The nurse's priority action is to stop the conversation before additional, confidential information about the client is shared. PHI should not be discussed in public spaces where information can be heard by those who do not have a "need to know."

After receiving a report on the client, the nurse finds the client unconscious with extremities jerking. Which action does the nurse take? (Select all that apply.) A. Place the head of the bed flat. B. Remain with the client. C. Restrain the client's arms. D. Notify the health care provider. E. Remove all items from the client's bed.

A, B, D, E The client should be placed flat to avoid injury during the seizure. The nurse should remain with the client during the seizure. The nurse should notify the health care provider immediately so that appropriate medications can be prescribed. The nurse should remove all items from the client's bed to avoid injury during the seizure.

Dumping Syndrome

Avoid carbohydrates with meals, because they are fast digested and we want slow digestion foods

The nurse follows up a community education session by asking clients to describe ways to reduce their cancer risk. Which client statement requires clarification by the nurse? (Select all that apply.) A. "I will limit my exposure to second-hand smoke." B. "I will walk for 30 minutes, at least 5 days a week." C. "I should stop eating meat." D. "I will lose 20 pounds." E. "I should not go outside on very sunny days." F. "I will avoid being around persons consuming alcohol."

C, D, E, F The nurse should clarify that it is not necessary to give up all meat. If the client desires to omit meat, the nurse may inform the client of ways to meet dietary requirements without meat. The nurse should clarify that persons should strive for a normal weight. Each client will have different weight loss or maintenance goals, depending on age, gender, height, and weight. the nurse should clarify that clients may spend a moderate amount of time in the sun, as long as they use sunscreen and wear a protective hat and clothing. The nurse should clarify that clients should limit alcohol intake, but being around persons who drink is not a risk factor for cancer.

Pancrease Capsules

Can be opened & sprinkled over cool, soft food (applesauce) and swallowed immediately, without chewing - Avoid chewing capsules - Don not pour capsules into milk, ice cream, yogurt because pancrease enzymes will spoil milk products

Urine Catheter After urine retention

Clamp down catheter after 300-500 ml of urine output, rapid emptying of bladder can cause bladder wall damage

Surgery & Taking Prednisone

If patient is taking Prednison ( steroid), doctor will increase dosage because surgery will create a higher demand for steroid because of stress

Child Abuse

If you suspect child abuse always ask parents what happened or what caused the injuries - Best way to know is to see if injuries match with what parents explain what happened

ICP Signs in Infants

Irritability, high pitched cry, bulging anterior fontanels, increased frontal occipital circumference - Posterior fontanel can't be bulging with 4 months infant because it closes at 2 months _ Trick

Physiological Jaundice & Pathological Jaundice

Physiological Jaundice - Occurs after 24 hrs of birth, peaks at 72 hrs and last for 5-7 days - Immature liver that can't clear bilirubin from the blood Pathological Jaundice - Occurs with first 24 hrs - Caused by mothers Rh blood killing immature RBC of the infant, incompatibility of bloods

Providing care to an infected abdominal wound

Remove soiled dressing with clean gloves, remove & wash hand, than put on sterile gloves & place sterile dressing

Increased ICP

- Coughing or deep breathing increases ICP - Don't suction, increases ICP - HOB elevated 15-30 degrees - When patient has ICP, it effects gag reflex & cough reflex, must assess them before starting feeding ( Aseess cough reflex & ability to swallow)

Post- Op Cateter

- Take Tylenol for pain but avoid Aspirin - If it itches, apply cold compressess - Yellow, green drainage with pain, or swollen means infection

PJP, Guillain-Barré syndrome, Cutaneous anthrax Precautiions

Standard Precaution

An older adult client with pneumonia has a temperature of 101.2o F (38.4o C), pulse of 112 beats/min, respirations of 22 breaths/min, and BP of 90/50 mm Hg. For which findings will the nurse notify the health care provider? (Select all that apply.) 1. Lactic acid level 5.0 mEq/L (0.555 mmol/L). 2. White blood cell count of 15,000 (15 x 103/microL). 3. Blood pressure of 90/50 mm Hg. 4. Apical heart rate of 112 beats per minute. 5. Oral temperature of 101.9 degrees F (38.8 degrees C).

1) CORRECT - A normal lactic acid level is 0.5 to 2.2 mEq/L (0.0555 to 0.2442 mmol/L). Elevated levels indicate inadequate oxygenation in the body or the presence of shock. Based on the 2016 Surviving Sepsis Campaign, this client is experiencing severe sepsis; therefore, nurse reports this finding to the health care provider. 2) CORRECT - An elevated white blood count indicates an infection, which is an expected finding for pneumonia. Based on the 2016 Surviving Sepsis Campaign, this client is experiencing severe sepsis; therefore, nurse reports this finding to the health care provider. 3) CORRECT - A drop in blood pressure indicates potential shock, which could be life-threatening in the client with pneumonia. Based on the 2016 Surviving Sepsis Campaign, this client is experiencing severe sepsis; therefore, nurse reports this finding to the health care provider. 4) CORRECT - A rapid apical heart rate occurs with an infection. Based on the 2016 Surviving Sepsis Campaign, this client is experiencing severe sepsis; therefore, nurse reports this finding to the health care provider. 5)CORRECT - An elevated oral temperature indicates an infection, which is an expected finding with pneumonia. Based on the 2016 Surviving Sepsis Campaign, this client is experiencing severe sepsis; therefore, nurse reports this finding to the health care provider.

The nurse teaches a client with chronic pancreatitis about the dietary modifications needed to manage the condition. Which foods will the nurse teach the client to limit in the diet? (Select all that apply.) 1. Fried foods. 2. Fatty foods. 3. Meat. 4. Whole milk. 5. Vegetables.

1) CORRECT - Fried food can lead to bouts of nausea, vomiting, diarrhea, and malnutrition because of the inability to adequately digest fats. 2) CORRECT - Fatty food can lead to bouts of nausea, vomiting, diarrhea, and malnutrition because of the inability to digest them. 4) CORRECT - Whole milk can lead to bouts of nausea, vomiting, diarrhea, and malnutrition because of the fat content and the inability to adequately digest it.

The nurse prepares a client for a skin biopsy. Which client statement will the nurse report to the health care provider? 1. "I've been taking aspirin for my sore knees." 2. "Using lotion has helped my dry skin." 3. "I went to the tanning salon yesterday." 4. "I had a big breakfast this morning."

1) CORRECT -Aspirin compounds can increase bleeding time and should not be taken prior to a surgical procedure.

The home health nurse visits a client who has been diagnosed with human immunodeficiency virus (HIV) and lives alone in an apartment. Which observation of the home environment most concerns the nurse? 1. The client has a cat, two birds, and a tropical fish tank, and the client says, "I don't know what I would do without my pets to keep me company." 2. There is a covered pitcher of water in the refrigerator, and the client says, "I know it is important for me to drink fluids, so I always keep water handy." 3. There are silk houseplants and flowers throughout the apartment, and the client says, "I'm not much of a gardener but I love nature, so I pretend all these are real." 4. The dishwasher is broken and the apartment water pressure is low, and the client says, "Getting the maintenance person to make any repairs is almost impossible."

1) CORRECT — Clients who are immunocompromised are at risk for infection. Various fungi, protozoa, and bacteria can be in the excrement of pets such as birds, cats, and tropical fish. If it is impossible to avoid contact with excrement, gloves should be worn while handling and hands washed immediately afterward. Deep breathing during cleaning should be avoided to prevent organisms from being inhaled. The client may be encouraged to wear a mask during this process.

A client is placed on NPO status because of an esophageal mass. A family member gives the client juice, which is vomited immediately. Which are appropriate nursing actions? (Select all that apply.) 1. Suction the client 's mouth with an oral suction. 2. Elevate the head of the bed to 45 degrees. 3. Notify the health care provider immediately. 4. Auscultate the client 's breath sounds frequently. 5. Draw blood for arterial blood gas assessments.

1) CORRECT — This is an appropriate nursing action. Suctioning with oral suction can clear secretions and vomitus from the mouth, decreasing the risk of aspiration or reducing the amount of aspirate. 2) CORRECT— This is an appropriate nursing action. Elevating the head of the bed 30 to 45 degrees or higher can prevent or reduce aspiration that can occur with vomiting. 3) CORRECT— Once the nurse has implemented bedside interventions and performed a focused assessment, the health care provider should be informed that the client may have aspirated juice, vomitus, or both. 4) CORRECT— This is an appropriate nursing action. Adventitious sounds may indicate aspiration of food/vomitus.

The school nurse instructs a group of high school students about the prevention of sexually transmitted infections (STIs). Which student statement indicates teaching is successful? 1. "The use of condoms does not totally eliminate the risk of sexually transmitted infections." 2. "Because some sexually transmitted infections have no symptoms in women, they cannot be that serious." 3. "I have had plenty of sex already and have not gotten a single disease. I think I am immune." 4. "I am glad I use birth control pills. I do not have to worry about sexually transmitted infections."

1) CORRECT- Condoms reduce, but do not eliminate, the risk of transmission of HIV and other STIs.

The nurse provides care for a client who has a pulmonary injury. Which clinical manifestation indicates to the nurse that the client is experiencing a tension pneumothorax? 1. Tracheal deviation. 2. Hypertension. 3. Flattened neck veins. 4. Bradycardia.

1) CORRECT- Tracheal deviation toward the unaffected (i.e. uninjured) side is a late sign of tension pneumothorax. Breath sounds may be diminished or absent over the affected lung. Shifting of the heart and great vessels will cause decreased cardiac output and hypotension. Additional manifestations of tension pneumothorax include tachycardia and distended neck veins. Tension pneumothorax is a life-threatening medical emergency that requires immediate treatment. Interventions may include needle decompression to release air trapped in the pleural space and chest tube insertion.

The nurse discharges a client with a permanent pacemaker. Which instruction is most important for the nurse to include? 1. "Take your pulse every day. " 2. "Eat foods that are low in sodium. " 3. "Weigh yourself on the same scale weekly. " 4. "Measure your abdominal girth daily. "

1) CORRECT— A change in heart rhythm or rate can signal a malfunction of the pacemaker. Instruct client to take the pulse for 1 full minute at the same time each day and document. Client should also take the pulse if feeling any symptoms,

A client receives a prescription for clopidogrel. Which laboratory results are important for the nurse to monitor based on this new prescription? (Select all that apply.) 1. Hemoglobin. 2. Hematocrit. 3. Platelet count. 4. International normalized ratio (INR). 5. Activated partial thromboplastin time (aPTT).

1) CORRECT— Clopidogrel is an oral antiplatelet medication that interferes with platelet aggregation. Adverse effects include hemorrhage, bleeding, hematuria, and hemoptysis. A decreased hemoglobin may indicate bleeding. 2) CORRECT— A decreased hematocrit may indicate bleeding.

The nurse on the pediatric unit provides care for a toddler diagnosed with epilepsy. Which equipment does the nurse have available at the bedside at all times? 1. Suction machine and oxygen setup. 2. Urinary bladder catheterization set. 3. An intermittent positive pressure breathing machine (IPPB). 4. Intravenous pump with lactated ringer (LR) solution. View Explanation

1) CORRECT— These are used to remove secretions and provide for a patent airway. Because hypoxia occurs during seizures, oxygen should be applied.

The nurse provides care for a client 8 hours after abdominal surgery. The client reports pain, and the nurse administers morphine 8 mg intravenously. Two hours later, the client reports no relief from the pain. Which action by the nurse is appropriate? 1. Assess the client's mental status. 2. Contact the health care provider. 3. Remove the abdominal wound dressing to assess. 4. Explain that abdominal wounds are painful.

2) CORRECT - Morphine is effective for 2.5 to 3 hours. The health care provider may have to change the prescription. An increased dose of 25% to 50% should be administered until there is a 50% reduction in pain or the client reports pain relief.

The nurse prepares to administer an influenza vaccine to the client. Upon review of the client's history, which medications cause the nurse to question the administration of the vaccine? (Select all that apply.) 1. Methylprednisolone. 2. Rimantadine. 3. Fluconazole. 4. Acyclovir. 5. Zanamivir.

2) CORRECT - The nurse needs to question if the vaccine should be administered, for giving the influenza vaccine with an antiviral may decrease the efficacy of the vaccine. 5) CORRECT - The nurse needs to question if the vaccine should be administered, for giving the influenza vaccine with an antiviral may decrease the efficacy of the vaccine.

A client diagnosed with deep vein thrombosis (DVT) is prescribed warfarin. Which information in the client's medical history prompts the nurse to hold the medication and contact the health care provider? (Select all that apply.) 1. History of cataract removal one month ago. 2. Recent diagnosis of peptic ulcer disease. 3. Regular consumption of up to six beers per night. 4. Current treatment with aspirin therapy. 5. Colonoscopy one week ago that revealed polyps.

2) CORRECT - Active peptic ulcer disease is a contraindication to anticoagulation therapy due to an increased risk for uncontrolled gastric bleeding. 3) CORRECT - Regular alcohol consumption may decrease the action of warfarin. Liver impairment, including liver dysfunction due to alcohol abuse, may cause warfarin's effects to be increased, which increases the risk for bleeding. 4) CORRECT - In combination with aspirin, warfarin therapy poses an even greater risk for causing bleeding. In most cases, aspirin and warfarin are not concurrently administered.

The nurse makes rounds on clients on the medical-surgical unit. It is important for the nurse to intervene for which observation? 1. A client 10 hours post-tonsillectomy sits in a bedside recliner watching television. 2. A client admitted 4 hours ago with a closed head injury lies flat in bed with legs elevated. 3. A client 3 days post-below knee amputation (BKA) lies prone in bed. 4. A client admitted yesterday with COPD sits with the head of the bed elevated 45 degrees.

2) CORRECT - Clients with closed head injuries are prone to increased intracranial pressure. A modified Trendelenburg is dangerous for the client. Elevate head of bed 30 to 45 degrees to promote venous drainage.

The nurse provides care for a client receiving chemotherapy. The medication is an alkylating agent. Which actions will the nurse implement to minimize adverse effects? (Select all that apply.) 1. Prevent ileus formation by encouraging frequent ambulation. 2. Administer anti-emetics prophylactically and as needed. 3. Offer frequent high fat meals to prevent weight loss. 4. Teach client to use saline mouth rinse before and after meals. 5. Encourage client to increase fluid intake for the next 3 days. 6. Educate client about the benefits of exercise to manage fatigue.

2) CORRECT - Nausea and vomiting are common and should be prevented if possible. 4) CORRECT - Stomatitis is a common adverse effect of chemotherapy, and it may be prevented or minimized with meticulous oral care. Salt water, usually mixed with baking soda, is used to rinse the mouth after every meal as a way to reduce particles and reduce oral acidity. 5) CORRECT - Cystitis occurs with many chemotherapeutic agents and may be prevented with increased fluid intake. 6) CORRECT - Mild to moderate exercise, along with frequent rest periods, will help to manage the fatigue often experienced during chemotherapy.

A mother of five children states to the nurse, "The father of my children passed away 3 weeks ago. We had been separated for several years, but the children have taken his death really badly. When will it hit me that he is gone?" Which response by the nurse is appropriate? 1. "Did he use drugs? It is known that some drugs can cause a heart attack." 2. "It is common to experience shock and denial early in grief." 3. "You certainly have your hands full right now, and you are doing a wonderful job." 4. "How helpful was he to you in raising and supporting the children?"

2) CORRECT - This responds directly to mother's statement and provides factual information and reassurance.

The nurse receives an informal mid-shift report from the nursing assistive personnel (NAP) assisting with client care. Which report does the nurse respond to first? 1. A client diagnosed with lung cancer keeps coughing, is on oxygen, and can hardly breathe, but asked me for a cigarette. It makes me so mad that the client is sick because of smoking and still wants to smoke. 2. A client after a Billroth II procedure (gastrojejunostomy) wanted to lie down right after eating even after I told the client to sit up for at least half an hour to let the food digest. 3. A client recovering from a myocardial infarction started crying while I was providing care stating, "I should be grateful but I am terrified thinking about what if it happens again." 4. A client after a right-below-the-knee amputation keeps complaining of pain in the toes and calf of the right leg. Although reminded that the leg is no longer there, the client insists that the leg hurts.

2) CORRECT — The client action requires immediate intervention. After a gastrojejunostomy, dumping syndrome can occur, and lying down after eating is recommended in order to delay the gastric emptying process. Eating lying down or semirecumbent is another measure that can be taken. The desire to lie down may be one of the early manifestations of dumping syndrome, which also includes vasomotor disturbances of syncope. The client needs evaluation and clarification of proper procedure, and the NAP needs to be taught that this client situation is the exception to the rule of not lying down after eating.

The home care nurse visits a young adult with a diagnosis of hepatitis A. Which client statement indicates to the nurse that further teaching is needed? 1. "I have been very careful to wash my hands after I go to the bathroom." 2. "I have taken acetaminophen several times this week for this sinus infection I have." 3. "I have been very careful not to handle my child's toys or eating utensils." 4. "My spouse has been preparing all of the meals since I have been sick."

2) CORRECT — The client should be cautioned about taking any drugs not approved by the health care provider, and this may become dangerous because of the liver's inability to detoxify and excrete acetaminophen.

An older client with a history of smoking one pack per day for 50 years and consuming three beers per day demonstrates right middle lobe wheezing associated with a nonproductive cough, shortness of breath, and chest discomfort. Which prescription will the nurse implement first? 1. Sputum culture. 2. Chest X-ray. 3. Echocardiogram. 4. Pulmonary function tests.

2) CORRECT — The client's symptoms suggest lung cancer and the wheezing is consistent with the associated constrictive airways.

The nurse supervises the staff providing care to four clients receiving blood transfusions. Which client will the nurse see first? 1. Reporting a headache. 2. Experiencing emesis. 3. Reporting itching 4. Experiencing neck vein distention.

2) CORRECT- Emesis is a symptom of a hemolytic reaction, which is the most dangerous type of transfusion reaction. Symptoms include nausea, vomiting, pain in lower back, and hematuria. Treatment is to the stop blood transfusion, obtain a urine specimen, and maintain blood volume and renal perfusion.

A client seeks emergency care for blood draining from the right ear after being in a motor vehicle crash (MVC). Which action will the nurse take first? 1. Notify the health care provider that the client 's condition could become critical. 2. Examine external ear for injuries. 3. Ask if the ear hurts. 4. Complete appropriate forms.

2) CORRECT— Although bleeding from the ear is generally associated with a severe brain injury, the bleeding could be localized. The external ear should be assessed first for injuries.

The nurse is delivering external cardiac compressions to a client while performing cardiopulmonary resuscitation (CPR). Which action is most important for the nurse to take? 1. Maintain a position close to the client 's side with the nurse 's knees apart. 2. Maintain vertical pressure on the client 's chest through the heel of the nurse 's hand. 3. Recheck the nurse 's hand position after every 10 chest compressions. 4. Check for a return of the client 's pulse after every eight breaths by the nurse.

2) CORRECT— It is most important that the elbows should be locked, arms straight, shoulders directly over the hands when delivering chest compressions. Incorrect pressure can cause damage or fail to produce adequate circulation.

Which assessment findings indicate to the nurse that a client is experiencing anaphylactic shock? (Select all that apply.) 1. Hypertension. 2. Bradycardia. 3. Oliguria. 4. Stridor. 5. Restlessness.

3) CORRECT - A client who develops anaphylactic shock is likely to develop oliguria or anuria as blood supply to the kidneys shuts down, leading to renal failure. 4) CORRECT- A client who develops anaphylactic shock is likely to develop respiratory distress, including dyspnea, stridor, wheezes, laryngospasms as a result of constriction of the bronchioles in response to histamine release. 5) CORRECT - Anaphylactic shock can progress rapidly, usually within 20 minutes of exposure to the antigen. The client will start to feel restless and anxious as a result of respiratory distress and widespread swelling of the lips, eyelids, tongue, and hands.

The nurse follows up a community education session by asking clients to describe ways to reduce their cancer risk. Which client statement requires clarification by the nurse? (Select all that apply.) 1. "I will limit my exposure to second-hand smoke." 2. "I will walk for 30 minutes, at least 5 days a week." 3. "I should stop eating meat." 4. "I will lose 20 pounds." 5. "I should not go outside on very sunny days." 6. "I will avoid being around persons consuming alcohol." View Explanation

3) CORRECT - The nurse should clarify that it is not necessary to give up all meat. If the client desires to omit meat, the nurse may inform the client of ways to meet dietary requirements without meat. 4) CORRECT - The nurse should clarify that persons should strive for a normal weight. Each client will have different weight loss or maintenance goals, depending on age, gender, height, and weight. 5) CORRECT - the nurse should clarify that clients may spend a moderate amount of time in the sun, as long as they use sunscreen and wear a protective hat and clothing. 6) CORRECT - The nurse should clarify that clients should limit alcohol intake, but being around persons who drink is not a risk factor for cancer.

The nurse screens clients for the risk of developing gastric cancer. Which question does the nurse ask the client during the assessment process? 1. "Do you have a history of colon polyps?" 2. "How often do your drink caffeinated beverages?" 3. "Do you have a history of peptic ulcer disease?" 4. "How many carbonated soft drinks do you drink each day?"

3) CORRECT - The presence of H. pylori in the stomach increases the risk for gastric cancer. H. pylori causes peptic ulcer disease.

The nurse in the emergency department provides care for a client with a bee sting. The nurse notes the client is sneezing and coughing, is flushed, has hives, and reports feeling warm. Which action does the nurse take first? 1. Continue to monitor the client. 2. Immediately administer prednisone. 3. Establish an intravenous normal saline infusion. 4. Ask the client about previous reactions to bee stings.

3) CORRECT - The priority is to monitor and support the client's circulatory status, maintain blood pressure, and provide IV access for emergency drug administration.

The nurse assesses a school-age child after the surgical removal of a brain tumor. Which sign indicates to the nurse that brainstem involvement occurred during the surgery? 1. Orthostatic hypotension. 2. Hearing loss. 3. Elevated temperature. 4. Swallowing difficulty.

3) CORRECT - The temperature may be elevated because of hypothalamus or brainstem involvement during surgery.

The parish nurse knows that it is most important to encourage which parishioner to obtain screening for prostate cancer? 1. A Caucasian young adult computer programmer diagnosed with cryptorchidism. 2. An Asian-American adult restaurant owner diagnosed with ulcerative colitis. 3. An African-American middle-aged adult factory worker in automobile tire manufacturing. 4. A Caucasian older adult retired house painter who has been smoking for 40 years.

3) CORRECT — This client has three major risk factors for prostate cancer: his age, race, and employment. Prostate cancer is found most commonly in men age 50 and over. African Americans are affected more than other ethnic groups. Occupation and environment are other definite risk factors, particularly exposure to carcinogens found in urban areas (which have a higher incidence of prostate cancer) and in occupations such as fertilizer, rubber, and textile industries.

The nurse provides care for clients at risk for colorectal cancer. Which client does the nurse identify as being at highest risk for the development of colorectal cancer? 1. Caucasian client with a family history of adenomatous polyposis, consumes 2 servings of red meat per week, avoids alcohol, and is physically active. 2. African American client with a history of gastrectomy, consumes diet high in fruits and vegetables, avoids red meats, and is physically active. 3. African American client with a history of inflammatory bowel disease, smokes cigarettes, consumes 12 alcoholic beverages per week, and avoids red meats. 4. Caucasian client with a body mass index of 32, avoids alcohol, smokes cigarettes, and has a first-degree relative with a diagnosis of colorectal cancer.

3) CORRECT- This client has four risk factors, which include being African American, having a history of inflammatory bowel disease, smoking, and having an alcohol intake of >4 drinks per week. This client is at highest risk for developing colorectal cancer.

The nurse plans to assess cranial nerve (CN) III in a client. Which item does the nurse use to test cranial nerve III? 1. Coffee. 2. Cotton ball. 3. Penlight. 4. Sugar and salt.

3) CORRECT— A penlight is used to assess CN III (the oculomotor nerve). To test this nerve, assess the pupils for size, equality, and reactivity to light.

The nurse provides care to a client in active labor. The client is scheduled to receive an epidural block. The nurse anticipates the client will be prescribed an IV bolus of which fluid? 1. 10% dextrose in water (D 10W). 2. 5% dextrose in water (D 5W). 3. Lactated Ringer's solution (LR). 4. 0.45% sodium chloride (NaCl).

3) CORRECT— A solution of LR is a dextrose-free isotonic solution that causes no fluid shift between the intravascular and intracellular space. The electrolyte composition of LR closely mimics the concentration of electrolytes normally found in the blood serum and plasma.

The nurse oversees care provided by the LPN/LVN, and the nursing assistive personnel (NAP). Which client will the nurse assign to the NAP? 1. Client with a 5-day-old ostomy requiring stoma care and application of an ostomy appliance. 2. Client in a coma after experiencing a head injury requiring cranial nerve assessment and Glasgow coma scale evaluation. 3. Client with a spinal cord injury requiring range-of-motion exercises and instruction about autonomic dysreflexia. 4. Client with chronic lung disease and type 1 diabetes mellitus requiring a sputum sample for culture and sensitivity and capillary blood glucose monitoring.

4) CORRECT - Collecting a sputum specimen and measuring capillary blood glucose are tasks that are standardized. The NAP can be assigned this client. The nurse should instruct the NAP about the type of specimen to collect, the timing, the collection container, and correct way of labeling.

The nurse on the burn unit orients new staff to infection control issues. Which measure is most important to emphasize for this particular type of unit? 1. Wear gowns, gloves, masks, as well as shoe and hair covers. 2. Ensure that no equipment is shared between clients. 3. Assign clients diagnosed with infection to private rooms with negative-pressure air flow. 4. Wash hands using a thorough and consistent approach.

4) CORRECT - Correct and consistent handwashing is the single most effective technique for preventing infection transmission on burn units. This is the priority measure for the nurse to communicate.

The triage nurse prioritizes clients to be evaluated in the emergency department. Which client does the nurse assess first? 1. A 3-year old with a fever, an earache, and vomiting since yesterday. 2. A 5-year old reporting leg and arm pain after falling from a treehouse. 3. A 21-year old at 8 weeks' gestation reporting unilateral abdominal pain. 4. A 40-year old who reports nausea, general anxiety, and is diaphoretic.

4) CORRECT - Even though not complaining of chest pain, these symptoms should be treated as a potential MI. A cardiac workup should be performed immediately.

The nursing manager is observing a graduate nurse conduct a physical examination on a newly admitted client. Which action made by the graduate nurse requires an immediate intervention by the nurse manager? 1. The nurse uses the ball of the hand to palpate for tactile fremitus. 2. The nurse depresses the client's tongue slightly off center when using a tongue depressor to inspect the uvula. 3. The nurse uses a stethoscope to palpate the client's abdomen, with fingers moving over the edge of the diaphragm. 4. The nurse completes inspection of the client's thorax for cardiac assessment and then begins auscultation.

4) CORRECT - The correct sequence during cardiac assessment is inspection, palpation, and then auscultation.

The nurse administers a bolus of 0.9% normal saline to a client with severe sepsis. To evaluate the effectiveness of this fluid therapy, which parameter is important for the nurse to assess? 1. Breath sounds and capillary refill. 2. Blood pressure and oral temperature. 3. Hemoglobin and hematocrit levels. 4. Central venous pressure and output.

4) CORRECT - The effectiveness of fluid resuscitation is best evaluated by the client's blood pressure, central venous pressure, and urine output.

The nurse plans care for a client diagnosed with Clostridium difficile. Which transmission-based precautions should the nurse implement? 1. Standard precautions. 2. Airborne precautions. 3. Droplet precautions. 4. Contact precautions.

4) CORRECT— A client diagnosed with Clostridium difficile must be placed under contact precautions . Initiating contact precautions is essential when the organism can be transmitted by direct contact.

The nurse provides care to a client with second-degree heart block. Which equipment will the nurse place at the client's bedside? A. Respirator. B. Suction machine. C. Temporary pacemaker. D. Pulse oximeter.

C Pacemaker placement is needed to provide a stimulus for cardiac contractions. In second-degree heart block, only some of the impulses from the atria are conducted to the ventricles. The client may require a pacemaker to ensure a steady rhythm and adequate cardiac output.

The nurse evaluates a client's record at the end of the shift. The client's urinary output for 8 hours is documented as "475 mL of pale yellow urine." Which action does the nurse implement based on this data? A. Assess the client for a rapid, weak pulse and poor skin turgor. B. Instruct the staff about appropriate documenting. C. Advise the client to continue drinking fluids as tolerated. D. Obtain the urine specific gravity.

C The client should be encouraged to continue drinking fluids as tolerated. The nurse knows that normal urine output should be at least 30 mL/hour. Since this client's 8 hour output is 475 mL, the client is voiding as expected and the client should be encouraged to continue taking oral fluids as desired.

The nurse receives hand-off communication on assigned clients with traumatic injuries. In which order will the nurse prioritize the care of these client? (Please arrange in order. All options must be used.)

First, the client experiencing indigestion may be an indication of cardiac ischemia and the client is interpreting the discomfort as indigestion. This client is the priority. Second, the client requiring blood should be attended to. Blood products have short expiration times and the client's condition may warrant immediate transfusion. Third, the client experiencing pain as 9/10 needs to be addressed. Incisional pain deters effective ventilation and ambulation. And finally, the client prescribed preoperative medication is addressed last. This client will not experience life-threatening consequences if the medication is delayed.

The home care nurse visits a client undergoing external radiation therapy after a lumpectomy of the right breast. Which statement, made by the client, indicates that the nurse's teaching is effective? 1. "I should wear a loose-fitting bra made of 100% cotton." 2. "I can apply scented lotion to the right side of my chest." 3. "I should expose my right breast to the air and sun." 4. "I can apply cold compresses to the right side of my chest."

I) CORRECT— The client should wear cotton clothing to prevent irritation and avoid restrictive or tight-fitting clothing to prevent skin chafing or irritation. Cotton is a breathable fabric that will reduce the perspiration buildup on the skin

The nurse provides care for the client diagnosed with pneumonia. During a routine assessment, the nurse notes an SpO 2 reading of 89%, pulse of 100 beats/min, and respiratory rate of 30 breaths/min. In what order will the nurse respond when providing care to this client? (Please arrange in order. All options must be used.)

Placing the client in high-Fowler's position will maximize respiratory effort and help open the airway. This is an intervention the nurse can perform immediately at the bedside to provide quick relief. Supplemental oxygen increases the oxygen percentage of inspiratory air, and the nurse takes this action after maximizing lung expansion by raising the head of the bed. The nurse should assess lung sounds, assess for relational factors, and may need to suction. After completing interventions and assessments, having the most current oxygen saturation level before calling the health care provider (HCP) is the priority. This helps the HCP and nurse know if those initial interventions were effective. The HCP may need to conduct further assessments or prescribe additional interventions, but the nurse provides emergent care first.

Toxic Shock Syndrome

Severe onset of fever, hypotension, and rash - Change tampons every 3-6 hrs - Use sanitary napkins at night - Do not use extra absorbent tambons - Monitor for fluid volume deficit

Back pain & Driving

Sit close to the pedals with back support. Far from the pedal will cause extension of the hips & legs & will cause more pain

The nurse volunteers at a marathon race and has been asked to identify participants most at risk for developing heatstroke. Arrange the participants in rank order from greatest risk to least risk of developing heatstroke. (Please arrange in order. All options must be used.)

The 72-year-old who takes furosemide and atenolol daily has three risk factors. Those include age (> 65), diuretic use, and beta blocker use. Older adults have decreased ability to perspire, decreased thirst mechanism, and decreased ability to vasodilate and vasoconstrict. They also may not drink adequate amount of fluids because of fear of incontinence or secondary to a decreased sense of thirst. The 74-year-old who uses a tiotropium inhaler daily and takes ibuprofen daily has two risk factors. Those include age (> 65) and use of anticholinergic medication daily. The 39-year-old who has a fasting blood glucose of 256 mg/dL (14.21 mmol/L) has one risk factor, which is hyperglycemia. Diuresis occurs as the body attempts to eliminate glucose, which may add to the dehydration experienced during the marathon. The 46-year-old whose parent had a stroke at the age of 44 has no known risk factors, as family history of CVA is not directly related to heatstroke.

The nurse provides care for clients in the gastroenterology clinic. In which order does the nurse rank these clients regarding the risk for developing colorectal cancer? (Arrange in order from greatest to least risk of developing colorectal cancer. All options must be used.)

The nurse needs to be aware of the risk factors associated with specific diseases and conditions. When evaluating which client is at greatest risk, the nurse needs to add up the known risk factors for each client based on their personal and medical history. Keep in mind that risk factors can include issues that cannot be altered, such as gender or age. Likewise, some risk factors can be altered when associated with lifestyle choices, such as diet, smoking, and exercise.

The graduate nurse prepares to apply a sequential compression device (SCD) for the first time. Which statement by the nurse to the nurse manager reflects a correct understanding of the proper procedure? 1. "I will wrap the sleeves snugly, but I will be certain I can fit one finger between the sleeve and the leg." 2. "I will put the antiembolism stockings on before I wrap and secure the sleeves." 3. "I will start by positioning each sleeve under the leg so that the opening is at the ankle." 4. "I will measure the circumference of the midcalf and the midthigh to ensure that the sleeves are the correct size.

2) CORRECT - This is a correct action. It is acceptable, though not essential, to apply antiembolism stockings prior to applying the sequential compression device sleeves. The stockings can decrease the itching, sweating, and heat that can build up under the plastic sleeves, thereby causing discomfort and skin irritation.

The nurse teaches a new nurse about the prevention of acute respiratory distress syndrome (ARDS). Which action is the nursing priority in ARDS prevention? 1. Elective intubation for septic clients. 2. Adequate staffing in intensive care units. 3. Early mobility for clients with pneumonia. 4. Prevention of client aspiration.

4) CORRECT— Aspiration is one of the most common causes of ARDS. Prevention of aspiration is a priority action to reduce the risk of ARDS.

The nurse provides teaching to a client scheduled for radiation therapy for cancer. Which client statements require intervention by the nurse? (Select all that apply.) 1. "I will shower with a mild soap." 2. "I won't use any lotion on the radiation area." 3. "If my skin starts to ooze, I will clean it with saline." 4. "I will not go swimming while I'm still getting radiation treatments." 5. "I will keep the radiation area covered at all times." 6. "I will only stay outside for short intervals when the sun is shining." View Explanation

5) CORRECT — Clients should allow air to circulate freely over and around the radiation area to minimize wet desquamation. 6) CORRECT — Clients should avoid sun exposure to the radiation area. Protective clothing and sunscreen should be used on the radiation area only after treatment has concluded.

The nurse provides care to a client who is experiencing dyspnea. Which symptom does the nurse expect to observe in the client? 1. Tachycardia. 2. Shortness of breath. 3. Hemoptysis. 4. High blood pressure.

2) CORRECT- Dyspnea refers to a persistent feeling of inadequate ventilation, or "air hunger," and is often accompanied by difficult and labored breathing. Shortness of breath is commonly associated with dyspnea.

The nurse provides care for a client receiving a full strength tube feeding. Which complication is the nurse likely to assess in this client? 1. Vomiting. 2. Hypervolemia. 3. Diarrhea. 4. Hypokalemia.

3) CORRECT - Intolerance of the feeding solution or the feeding rate most often result in runny stools.

The nurse provides care for a school-age child diagnosed with acquired immunodeficiency syndrome (AIDS) who is scheduled for a CD4+ blood test. The parent asks the nurse what is the purpose of the test. Which body system does the nurse tell the parent that the test assesses? 1. Renal system. 2. Cardiovascular system. 3. Neurological system. 4. Immune system.

4) CORRECT — The test is a useful tool to assess the status of the immune system in an infected young child.

The nurse assesses four assigned clients. Which assessment finding does the nurse immediately report to the health care provider? 1. A client diagnosed with chronic atrial fibrillation who reports blurred vision. 2. A client admitted for treatment of meningitis who reports a headache. 3. A client whose bowel sounds are absent 4 hours after undergoing a laparotomy. 4. A client experiencing diarrhea after an abdominal computed tomography (CT) scan with contrast.

1) CORRECT - Amiodarone and digoxin may be used to treat atrial fibrillation. These medications may cause halos or blurred vision, which are signs of an adverse reaction and require immediate intervention.

The nurse performs discharge teaching for a woman treated for cervical cancer with a cesium 137 implant. The nurse learns that the client works 40 hours per week in a factory and has a toddler and preschooler at home. Which client statement indicates that further teaching is needed? 1. "I will call the health care provider if I am still bleeding after a couple of days." 2. "I will abstain from sexual intercourse and not use tampons for 2 weeks." 3. "I cannot lift either of my children for 2 months." 4. "I will take showers for the next 2 weeks."

2) CORRECT — The client can resume normal activities after discharge, but is instructed to avoid sexual intercourse and tampons until a follow-up visit with the health care provider, which occurs about 6 weeks after discharge.

Following the removal of a brain tumor from a child, the nurse observes a colorless drainage on the dressing. Which action does the nurse take first? 1. Notify the health care provider. 2. Document the findings. 3. Continue to monitor for increase in drainage. 4. Outline the drainage on the bandage.

1) CORRECT — The nurse should report the presence of colorless drainage immediately because it may be cerebrospinal fluid. The nurse will monitor for signs of increased intracranial pressure, hemorrhage, and meningitis.

The nurse provides care for a client with an ileostomy. For which acid-base disorder does the nurse monitor the client? 1. Metabolic acidosis. 2. Respiratory acidosis. 3. Metabolic alkalosis. 4. Respiratory alkalosis.

1) CORRECT - Intestinal secretions are high in bicarbonate that may be lost through enteric drainage tubes, an ileostomy, or diarrhea. This causes metabolic acidosis.

The nurse provides care to a client diagnosed with sinus arrhythmia. The nurse uses which site to assess the client's pulse? 1. Apical. 2. Radial. 3. Femoral. 4. Carotid.

1) CORRECT- Apical pulse assessment is indicated for use during initial cardiac examination or if the client's pulse is irregular. Sinus arrhythmia, which is most common among children and young adults, refers to minor variations in pulse regularity that occur in relationship to the respiratory cycle. In infants and children up to 3 years old, the apical pulse is the routine site for cardiac assessment. Apical pulse assessment is also indicated prior to administration of certain medications, such as digoxin.

The nurse provides care for the client with a radium implant. Which action is most important for the nurse to take? 1. Evaluate the position of the applicator every 2 hours. 2. Place the client on a low-residue diet to decrease bowel movements. 3. Encourage the use of the bedside commode every 1 to 2 hours. 4. Decrease fluid intake to decrease radiation in the bladder

2) CORRECT — Bowel movements can dislodge the radium implant. This diet will decrease the amount of stool and number of bowel movements.

The nurse notes that an adolescent client without any previous health problems is prescribed intravenous and oral fluids to treat meningitis. For which serious complication does the nurse monitor this client? 1. Heart failure. 2. Hypovolemic shock. 3. Cerebral edema. 4. Pulmonary edema.

3) CORRECT - Since the client has inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure.

The nurse assesses a client with a colostomy. Which stomal appearance indicates a prolapse has occurred? 1. Protruding. 2. Narrowed and flattened. 3. Sunken and inverted. 4. Dark, bluish colored.

1) CORRECT - A prolapsed stoma is protruding and indicates that the bowel is protruding through the stoma.

The nurse assesses the newly-admitted client. Which data indicate the client is at risk for having a latex allergy? (Select all that apply.) 1. The client has an allergy to avocado. 2. The client received blood transfusions. 3. The client has a history of chronic bronchitis. 4. The client has undergone multiple surgeries. 5. The client is employed as a health care worker.

1) CORRECT - People with a food allergy to avocado are at increased risk for latex allergy. 4) CORRECT - A client with a history of multiple surgical procedures is at increased risk for latex allergy. 5) CORRECT - Health care workers are at increased risk for latex allergy secondary to increased exposure to latex.

The school nurse educates preschool faculty and staff about hepatitis A. Which information does the nurse include in the teaching? 1. Anorexia is one of the most common symptoms of hepatitis A among children. 2. The majority of young children who contract hepatitis A will develop jaundice. 3. The hepatitis A vaccine is administered to clients beginning at 1 month of age. 4. Black, tarry stools often occur among children diagnosed with with hepatitis A. View Explanation

1) CORRECT - Among pediatric clients, symptoms of hepatitis A often are flu-like in nature. Common symptoms of hepatitis A among young children include anorexia, fever, malaise, and lethargy. However, among children 6 years of age and younger, up to 70 percent of individuals who contract hepatitis A will be asymptomatic.

The nurse provides care to a client receiving an epinephrine infusion following a cardiac arrest. Which assessment findings demonstrate that treatment is effective? (Select all that apply.) 1. Blood pressure 130/67 mm Hg . 2. Apical heart rate 99 beats/min. 3. Pedal pulses +1 and weak bilaterally. 4. Pupils constricted and equal bilaterally. 5. Capillary refill less than 2 seconds.

1) CORRECT - Epinephrine is a vasopressor and is used off-label to help maintain an adequate blood pressure. A BP within normal limits indicates the treatment is effective. 2) CORRECT - Epinephrine is a vasopressor and is used off-label to help maintain an adequate heart rate and rhythm. An apical pulse within normal limits indicates the treatment is effective. 5) CORRECT - A capillary refill of less than 2 seconds indicates normal tissue perfusion and adequate cardiac output.

The nurse provides a client with a prescribed dose of hydrocodone for pain. Which findings related to the current prescribed pain medication cause the nurse to follow-up with the health care provider? (Select all that apply.) 1. Client reports pain is 8 out of 10. 2. Assesses respiratory rate as 8 breaths per minute. 3. Notes petechiae on the client's abdomen and forearms. 4. Notes potassium level is 3.4 mEq/L (3.4 mmol/L). 5. Notes urine output is 60 mL over the past 2 hours.

1) CORRECT — A pain level of 8 out of 10 indicates pain that is unrelieved by the current medication prescription and requires follow-up by the nurse. The client may need an increased dose or change in pain medication. 2) CORRECT — A respiratory rate of 8 breaths per minute is a sign of over-sedation. The client's prescribed medication dose may need to be altered by the health care provider. 3) CORRECT — Petechiae are a sign of an allergic reaction and should be reported to the health care provider.

The nurse prepares a client to receive a prescribed dose of cisplatin. For which laboratory values will the nurse withhold providing this medication? (Select all that apply.) 1. Platelet count 60,000/mm3 (60000.00 x 109/L). 2. Blood urea nitrogen 24 mg/dL (8.57 mmol/L). 3. Potassium 3.0 mEq/L (3.0 mmol/L). 4. Sodium 150 mEq/L (150 mmol/L). 5. White blood cells 2,000/mm3 (2.00 ×109/L). 6. Creatinine 2.0 mg/dL (176.8 µmol/L).

1) CORRECT — Cisplatin should be held if the platelet count is <100,000/mm3 (100,000.00 x 109/L). 5) CORRECT — Cisplatin should be held if the white blood cell count is <4,000/mm3 (4.00 ×109/L). 6) CORRECT — Cisplatin should be held if the creatinine level is greater than 1.5 mg/dL (132.60 µmol/L).

A client is admitted to the emergency department following a motor vehicle accident. The client reports seeing sudden black dots and flashes of light and states that it feels as if a curtain is being closed over the right eye. Which action does the nurse take based on this data? (Select all that apply.) 1. Instruct the client not to get out of bed. 2. Have the client lie on the right side. 3. Lower the head of the bed. 4. Administer steroid eye drops. 5. Prevent the client from eating or drinking.

1) CORRECT — This client is reporting manifestations of a detached retina. Bed rest prevents further detachment of the retina. 2) CORRECT — Lying on the affected side prevents further detachment of the retina. 5) CORRECT — The client should be NPO in anticipation of surgery to correct detachment of the retina.

A client develops an obstruction of the lower intestine. Which finding does the nurse anticipate when assessing the client? 1. Nausea, vomiting, abdominal distention. 2. Explosive, irritating diarrhea. 3. Abdominal tenderness with rectal bleeding. 4. Midepigastric discomfort, tarry stool.

1) CORRECT- With an obstruction of the lower intestine, the nurse can expect distention above the level of the obstruction and hyperactive bowel sounds upon initial assessment. There would be no stool, as motility distal to (below) the obstruction would cease. The obstruction causes the client to develop nausea, vomiting, and abdominal distention.

A client develops post-concussion syndrome caused by a head injury sustained from a fall. For which client statements will the nurse intervene? (Select all that apply.) 1. "The concussion showed up on the head computed tomography scan." 2. "I may have a persistent headache for 2 weeks or longer." 3. "I should notify the health care provider if I have repeated episodes of vomiting." 4. "I can immediately resume contact sports at school." 5. "I may have trouble remembering details from one day to the next." 6. "I have no recollection of the events surrounding the incident."

1) CORRECT— A concussion does not appear on a head computed tomography scan. Concussion is a clinical diagnosis based upon symptoms. 4) CORRECT— After a head injury, the client should refrain from contact sports due to the risk of reinjury and worsening of the condition until it has cleared.

Following a train accident, the nurse triages a group of victims. When the nurse asks how one of the clients is feeling, the client states matter-of-factly, "Look at all the rescue trucks. It 's like watching a movie. " Which defense mechanism does the nurse identify that the client is using? 1. Dissociation. 2. Regression. 3. Projection. 4. Denial.

1) CORRECT— Dissociation is an unconscious separation of painful feelings from a difficult situation, idea, or object. The client is focusing on what is happening around them, not to them.

The nurse leads group therapy for clients diagnosed with substance abuse. A client diagnosed with alcoholism, and who occasionally uses marijuana and cocaine, attends the meeting. During the meeting the client states, "I am having trouble sitting still. Am I bothering anybody? Maybe I should not come to these meetings." Which action by the nurse is most appropriate? 1. Encourage the client to share problems with the group. 2. Remove the client from the group and further assess needs. 3. Recognize this as manipulative behavior and encourage the client to remain in the group. 4. Tell the other group members to ignore the client and continue with the group meeting.

1) CORRECT— The client is probably experiencing some mild level of anxiety. The nurse should reinforce and encourage the client to share feelings and attend the meeting.

The nurse provides care for a client during a wellness visit. The nurse teaches the client about the effects of stress. Which statement by the client indicates that teaching was successful? 1. "If I do not do something to relieve my stress, I am putting myself at risk for cancer or infection." 2. "My blood sugar level decreases when I am stressed, putting me at risk for hypoglycemia." 3. "Antianxiety medications are the only effective way to reduce stress." 4. "I will sleep my anxiety away."

1) CORRECT— The effects of stress can suppress the immune system increasing the risk for cancer and severe infections.

The nurse performs skin checks for cancer at a local community center. Which observation most concerns the nurse? 1. A lesion with an irregular surface and variegated colors. 2. A flat, red lesion that is nonpalpable. 3. A circumscribed lesion filled with fluid. 4. A lesion that is shiny and translucent.

1) CORRECT— This describes a lesion that is characteristic of malignant melanoma.

The nurse provides care for a client diagnosed with hypovolemic shock. Which action does the nurse take first? 1. Assess for dehydration. 2. Administer intravenous fluids. 3. Insert a urinary catheter. 4. Prepare the client for surgery.

2) CORRECT - Hypovolemic shock results from severe dehydration. Administering fluids is the emergency treatment for this critical condition.

The nurse teaches a community education program about cancer prevention for both men and women. Which strategy is most important for the nurse to include in the teaching? 1. Regular examination of reproductive organs. 2. Smoking cessation. 3. Routine colonoscopies. 4. Protection from ultraviolet light.

2) CORRECT - Lung cancer is the leading cause of cancer deaths in the United States for men and women. Stopping the use of tobacco is one of the most important cancer prevention behaviors.

The spouse of a client diagnosed with multiple myeloma asks the hospice nurse for pain control suggestions since the prescribed medication makes the client sleepy. Which responses by the nurse are appropriate? (Select all that apply.) 1. "It is all right for your spouse to sleep all the time. We don't want your spouse to be in pain." 2. "Let me show you some techniques of massage, which may help relieve the pain." 3. "Please locate some of your spouse's favorite music and see if listening to it helps with relaxation." 4. "I will contact the health care provider about changing the pain medication." 5. "Since pain control is getting to be a problem, it is time to consider placing your spouse in an inpatient setting." 6. "I can see you are worried about your spouse. You may want to ask your health care provider for medication to help you cope with this difficult situation." View Explanation

2) CORRECT — Massage can help reduce both acute and chronic pain. The nurse is actively showing the spouse how to help the client. 3) CORRECT — Music is used as a cognitive therapy for relaxation and a distraction from pain.

The home care nurse teaches the adult child of an older adult client about the parent's hydration status. Which statement from the adult child most concerns the nurse? 1. "I should check my parent's mouth for dryness." 2. "I should pinch a fold of skin on the back of my parent's hand." 3. "I should check my parent's eyes for dryness." 4. "I should make sure that my parent stands up slowly." View Explanation

2) CORRECT — The elasticity of the skin in this area is affected by aging. It will give an inaccurate assessment of hydration status. The adult child should be taught to use other indicators or to pinch a fold of skin over the chest wall, which is less likely to be affected by aging and sun exposure.

As the nurse administers medications to a group of clients, an unlicensed assistive personnel (UAP) approaches the nurse to report that a client has a large amount of thick, dry mucus on one side of the tracheostomy tube. Which response does the nurse provide the UAP in this situation? 1. "Please take these medications into the medication room for me. " 2. "Is the client having difficulty breathing or appear different? " 3. "Take a sterile cotton swab and remove the mucus, please. " 4. "Please find another nurse to take care of the client. "

2) CORRECT- The UAP can observe whether a client is in distress. If the client is not in distress, the nurse can complete the current task prior to assessing the client with sputum. Clients with tracheostomies often cough large amounts of sputum through the stoma. As long as there is not an additional plug of mucus, indicated by client distress, this is a normal occurrence.

A client is prescribed a subcutaneous injection of heparin 5000 units. Which technique will the nurse use to administer this medication? 1. Gently massage the injection site. 2. Avoid aspirating after inserting the needle. 3. Use a 1-inch, 18- to 20-gauge needle. 4. Administer in the deltoid muscle.

2) CORRECT— Aspirating the syringe when providing a subcutaneous heparin injection will cause bruising. This should not be done.

A client diagnosed with arterial insufficiency calls the nurse in the outpatient clinic and reports being awakened at night by lower extremity pain. Which suggestion by the nurse is best? 1. Elevate both legs on two pillows. 2. Sit on the side of the bed. 3. Place a bed cradle over the legs. 4. Wear cotton pants to keep the legs warm

2) CORRECT— Lowering the legs over the side of the bed enhances arterial blood supply and oxygen to the lower legs. This will help with the client 's pain.

The nurse provides care for a client diagnosed with leukopenia due to acute lymphocytic leukemia. Which type of room does the nurse request for this client? 1. A private room to prevent infecting other clients and health care workers. 2. A private room to prevent the client from contracting infection from other clients. 3. A semiprivate room to provide stimulation during the hospitalization. 4. A semiprivate room to give the client the opportunity to express an emotional response to the illness.

2) CORRECT— The client has a depressed white blood cell count, which leaves the client vulnerable to infection. A private room should be requested to protect the client from exogenous bacteria.

The nurse placed a client on therapeutic hypothermia 1 hour ago. Which action does the nurse take to determine whether the client is having an adverse reaction to therapeutic hypothermia? 1. Install a working suction setup. 2. Monitor the client for seizure activity. 3. Measure the Braden Scale score. 4. Assess bowel sounds every 2 hours.

2) CORRECT— The client is monitored for seizure activity, which is an adverse reaction to hypothermia.

When caring for a client postpartum, the nurse provides education regarding proper perineal care. Which client statement indicates that additional teaching is needed? 1. "I will wash my hands before and after I use the bathroom." 2. "I will change my peri-pads when soiled." 3. "I will remember to wipe my bottom from front to back." 4. "I will soak my bottom in warm or cold water, whichever feels best."

2) CORRECT— This statement indicates that the client needs additional teaching. Peri-pads should be changed every time the client uses the bathroom regardless if the peri-pad is soiled or not. The client should not place a used peri-pad against a clean perineum.

The nurse provides care for a toddler diagnosed with pneumonia who is in an oxygen tent. The mother indicates that the toddler's birthday is tomorrow and she would like to have a party. Which statement by the mother is important for the nurse to address? 1. "I plan to bring paper streamers to put on the wall." 2. "My child loves to look at Mylar balloons." 3. "I found the neatest candles to put on the cake." 4. "My child's grandparents are planning to come.

3) CORRECT - Oxygen is combustible and can cause a fire if it comes in contact with an open flame or electrical equipment. The nurse needs to inform the mother that the candles cannot be lighted.

The nurse assigns a client prescribed a continuous bladder irrigation to an unlicensed assistive personnel (UAP). Which tasks can be delegated to the UAP? (Select all that apply.) 1. Assess patency of the three-way urinary catheter. 2. Manually irrigate the catheter if outflow is decreased. 3. Do perineal care and clean around the catheter. 4. Report pain and bladder spasms to the nurse. 5. Record the intake and output as prescribed.

3) CORRECT - Perineal and hygiene care related to the catheter is within the scope of practice of the UAP. 4) CORRECT - Informing the nurse if the client reports pain or signs of bladder spasm is within the scope of practice of the UAP. 5) CORRECT - Recording intake and output is within the scope of practice of the UAP.

The nurse receives hand-off communication from the previous shift. Which client does the nurse see first? 1. Client recovering from coronary artery bypass graft surgery who is having the atrioventricular wires removed later in the day. 2. Client with type 1 diabetes mellitus who is scheduled for a cardiac catheterization later today. 3. Client recovering from surgery a day ago with an spinal anesthesia in place. 4. Client with cardiomyopathy who is being evaluated for a heart transplant.

3) CORRECT - Spinal anesthesia is used for pain relief. The client needs monitored for urinary incontinence, hypotension, respiratory depression, and nausea and vomiting.

The nurse collaborates with an unlicensed assistive personnel (UAP) to provide care to a client who was admitted for evaluation of dyspnea. The nurse delegates collection of which data to the UAP? 1. Chest symmetry. 2. Apical pulse. 3. Blood pressure. 4. Lung sounds.

3) CORRECT - Tasks that may be delegated to the UAP include collection of vital signs, such as blood pressure. Because additional skill and knowledge are required to perform apical pulse auscultation, this task is not usually delegated to the UAP. Chest symmetry and auscultation of lung sounds are components of client assessment. Assessment may not be delegated to the UAP.

The nurse prepares a client diagnosed with cervical cancer for the insertion of an internal radiation implant. Which client statement requires immediate follow-up by the nurse? 1. "Unless I have a bowel movement every day, I just do not feel right." 2. "I am glad this whole process is only going to last 3 days." 3. "I will get up only when I have to urinate, and then I will go right back to bed." 4. "If it were not for my children, I would not be going through all of this."

3) CORRECT - This is the priority concern. The client will be on strict bed rest, supine with the head of the bed elevated no more than 20 degrees. Movement is restricted and an indwelling catheter is inserted into the bladder in order to prevent the implant from being dislodged by a full bladder or by voiding attempts. Severe radiation burns can result from a distended bladder or from the client attempting to go to the bathroom and void.

The nurse instructs the unlicensed assistive personnel (UAP) to put antiembolitic stockings on a client scheduled for surgery. Which statement by the UAP requires the nurse to intervene? 1. "I will apply talcum powder to the client's feet and legs before applying the stockings." 2. "I will elevate the client's legs before applying the stockings." 3. "I will apply the pair that I found in the supply room." 4. "I will make sure there are no wrinkles in the stockings."

3) CORRECT - To ensure that the stockings fit properly, the UAP needs to measure the client first to determine the appropriate size for the client. This statement would require the nurse to intervene.

The nurse provides care for a client who reports shortness of breath. The nurse notes that the client's respirations are 26 breaths per minute and labored. The bed is currently in the flat position. Which position does the nurse place the client's bed? 1. Reverse Trendelenburg. 2. Supine. 3. High-Fowler. 4. Trendelenburg.

3) CORRECT — The High-Fowler position is a semi-sitting position at 90 degrees that should ease the client's breathing.

The nurse provides care for a client diagnosed with Hantavirus pulmonary syndrome (HPS). Which action by the nurse is most appropriate? 1. Assess the client for signs/symptoms of seizures. 2. Assess the client for signs/symptoms of renal failure. 3. Assess the client for signs/symptoms of thrombocytopenia. 4. Assess the client for signs/symptoms of liver failure.

3) CORRECT — Thrombocytopenia is caused by HPS. The nurse should observe for hematuria, hematemesis, bleeding gums, and melena.

Which client on the pediatric unit requires the immediate attention of the nurse? 1. A client with epilepsy who has a loose tooth. 2. A client experiencing diarrhea with a sickle cell crisis. 3. A client saying the arm cast feels too tight. 4. A client who is blind and has a nosebleed.

3) CORRECT- A cast that is too tight may indicate compartment syndrome. This child has a current neurovascular status threat and is the priority patient.

A client with cancer asks the nurse about late effects of chemotherapy and radiation treatments. Which late effect will the nurse include when responding to this client? 1. Nausea and vomiting. 2. Third space syndrome. 3. Secondary malignancies. 4. Continuing myelosuppression.

3) CORRECT- Alkylating chemotherapy and high-dose radiation are likely to cause secondary malignancies as late effects of treatment.

The nurse determines which client is at highest risk of developing colorectal cancer? 1. An adult client who teaches high school and has a history of endometrial cancer. 2. An adult client who owns a restaurant and has a history of alcoholism. 3. An older adult client who is a cattle farmer diagnosed with Crohn disease. 4. An older adult client who is a bus driver and has a hiatal hernia and obesity.

3) CORRECT— Age is a general risk factor for cancer. A history of inflammatory bowel disease is a significant risk factor that is specific to colorectal cancer. This is enough information to place this client at higher risk. However, the nurse might also assess that the cattle farmer enjoys a high quantity of red meat, further increasing the risk of developing colorectal cancer.

The nurse instructs the client who is diagnosed with mastitis of the left breast about breastfeeding the client's infant. Which statement by the client best indicates understanding of the instructions? 1. "I will feed the baby only from the right breast until this infection clears." 2. "It will be necessary for me to wean my baby from breastfeeding very quickly." 3. "Everyone in my family should use good handwashing techniques at all times." 4. "I should wear a tight compression bra to decrease the tenderness."

3) CORRECT— Anyone who is in contact with the infant should use good handwashing techniques to prevent the spread of infection.

The home care nurse provides care for an adult client diagnosed with gastric cancer. Which observation most concerns the nurse? 1. The client reports indigestion. 2. The client has lost 1 lb (0.45 kg) in the past 2 weeks. 3. The client's skin develops a yellow color. 4. The client is fatigued after radiation treatments.

3) CORRECT— Jaundice is a sign of liver involvement. This may signal metastatic disease or a complication from treatment.

The nurse provides care for a comatose client. The nurse is unable to elicit a reaction after applying the trapezius squeeze, supraorbital pressure, mandibular pressure, and sternal rub. Which action does the nurse take next? 1. Administer diuretics as prescribed. 2. Lower the head of the bed. 3. Press a pencil to a finger or toe of each limb. 4. Begin cardiopulmonary resuscitation.

3) CORRECT— When assessing a client 's response to pain, begin with the least noxious stimulation (speak to client) and proceed to more painful stimulation such as the trapezius squeeze, supraorbital pressure, mandibular pressure, and sternal rub that are central stimulation. If there is no response to central stimulation demonstrating brain function, apply peripheral stimulus to the extremities. A client 's finger or toe should be braced on the nurse 's thumb and a pencil placed sideways on top of the nail bed at the base of cuticle and pushed down hard. Use peripheral assessment only on extremity that did not move.

The nurse educator prepares a class on crisis management. Which principle is most important for the nurse to emphasize when teaching this class? 1. The most charismatic person should assume leadership during a crisis. 2. During a crisis, leadership should be equally shared by the team members. 3. A well-prepared team does not require leadership during a crisis. 4. One person should be in charge during a crisis.

4) CORRECT - Autocratic or directive leadership, in which the leader maintains strong control and issues commands rather than makes suggestions or seeks input, is appropriate in a crisis or emergency situation.

The nurse leads an in-service on the ethical principle of beneficence and discusses the recent case of a client just diagnosed with breast cancer. Which is the best action for the nurse to take? 1. Make a treatment decision for the client. 2. Tell the client that the breast tumor is non-malignant. 3. Explain to the client about the right to privacy at this time. 4. Remain with the client when the client experiences anxiety.

4) CORRECT - Beneficence is taking positive actions to help others. This illustrates the principle of beneficence in action.

Which action, if observed by the charge nurse, indicates appropriate care for a client diagnosed with increased intracranial pressure (ICP)? 1. The LPN/LVN encourages the client to cough and breathe deeply. 2. The nurse performs nasopharangeal suctioning on the client every 2 hours. 3. The unlicensed assistive personnel (UAP) places the client in a prone position. 4. The nurse assesses for the cough reflex before administering oral fluids.

4) CORRECT - Increased ICP can adversely affect the cough (gag) reflex and increase the possibility of aspiration.

The nurse provides care to a client who is prescribed an IV infusion of lactated Ringer (LR) solution for treatment of dehydration. The client appears restless and reports difficulty breathing. Auscultation of the client's lungs reveals bibasilar crackles. Which intervention does the nurse perform first? 1. Notify the health care provider. 2. Lower the head of the client's bed. 3. Administer furosemide as prescribed. 4. Discontinue the client's infusion.

4) CORRECT - Manifestations of fluid volume overload include restlessness, dyspnea, and development of crackles (rales) in the lung bases. Priority interventions for the client who demonstrates signs and symptoms of fluid overload include discontinuing the infusion of IV fluids.

The nurse teaches a client who was admitted and diagnosed with hyperkalemia. Which statement best indicates to the nurse that the client understands the teaching to prevent hyperkalemia? 1. "I should take the potassium supplements on an empty stomach." 2. "I should cut the potassium tablet in half to administer a decreased dose." 3. "I should consume bananas and other foods rich in potassium." 4. "I should avoid salt substitutes until my potassium level is under control."

4) CORRECT - Many salt substitutes are potassium-based, which can cause continued hyperkalemia. This response indicates that the client understands the teaching

The nurse assists in the care provided by the LPN/LVN for client who had a mastectomy. The client has a wound drainage evacuator in place. Which observation concerns the nurse? 1. The LPN/LVN secures the drainage evacuator to the client's gown without applying tension on the drainage tubing. 2. The LPN/LVN fully compresses the drainage evacuator with one hand, while replacing the spout plug with the other hand. 3. The LPN/LVN uses an alcohol wipe to clean the drainage evacuator's spout and plug prior to reestablishing the vacuum. 4. The LPN/LVN releases manual pressure on the drainage evacuator after the plug is in place, and the unit rapidly inflates.

4) CORRECT - Rapid reinflation indicates an air leak is present. If this occurs, the nurse should compress the unit again and check the plug for a secure fit.

The nurse in the pediatric clinic performs a physical assessment on an adolescent male client. Which finding by the nurse requires an immediate intervention? 1. The client reports his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes. 2. The nurse notes that the client has unilateral breast enlargement. 3. The client's scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass. 4. The client's scrotum appears enlarged and red. The nurse palpates a thickened and swollen spermatic cord.

4) CORRECT - These findings represent torsion of the spermatic cord. This is very painful and is an emergency situation, which requires immediate surgical repair. Testicular torsion is the most common cause of testicular loss in young males due to hypoxic injury to the testicle.

The nurse provides care for a client who reports flank pain. The health care provider (HCP) writes a client prescription that states, "CT scan to rule out cerebrovascular accident (CVA)." Which action does the nurse take first? 1. Assess if the client has metal implants. 2. Determine if the client has peripheral IV access. 3. Ask if the client has an allergy to contrast media. 4. Contact the provider for clarification.

4) CORRECT — The nurse should question the HCP about the prescription. Flank pain does not support a CT scan to rule out CVA. The prescription will likely need to be rewritten.

During the initial period following a spinal cord injury, which action is most important for the nurse to take? 1. Prevent contractures and atrophy. 2. Prevent urinary tract infections. 3. Promote rehabilitation. 4. Prevent flexion or hyperextension of the spine.

4) CORRECT — The primary goal in the acute period is to protect the spine from strain and further damage while the injury heals.

A tornado has just leveled a large housing division near the hospital, and the disaster alarm has been announced at the hospital. The nurse working on the postpartum/pediatric unit considers which client is most appropriate for discharge within the next hour? 1. A postpartum client who delivered 4 hours ago and has an intact perineum. 2. A postpartum client diagnosed with an infection who has been receiving antibiotics for the past 24 hours. 3. A toddler with newly diagnosed type 1 diabetes mellitus, diarrhea, and vomiting. 4. A 3-day-old breastfeeding neonate with a total serum bilirubin of 14 mg/dL (239 µmol/L).

4) CORRECT- This is the most stable client. Phototherapy is considered for the neonate with a total serum bilirubin greater than 15 mg/dL (257 µmol/L) at 72 hours of age. The upper limit for the breastfed neonate is 15 mg/dL (257 µmol/L). Therefore, the current serum bilirubin level does not indicate the need for treatment.

The nurse determines that a client brought to the urgent care center may be in shock. Which action does the nurse implement? 1. Placing the client in the Trendelenburg position. 2. Elevating the head of the client's bed to 45 °. 3. Placing the client on the left side. 4. Elevating the client's lower extremities.

4) CORRECT— Raising the lower extremities improves circulation to the brain and vital organs without increasing workload or impairing respiratory effort. This, therefore, is an appropriate action by the nurse.

A cast is applied to an infant for the treatment of talipes equinovarus (clubfoot). Which instruction is most essential for the nurse to give the parent regarding care at home? 1. Provide blocks to use during playtime. 2. Return for a checkup in 7 days. 3. Provide liquid acetaminophen for pain control. 4. Evaluate the color of the foot frequently.

4) CORRECT— The nurse should instruct the parent to assess the feet for temperature, color, and sensation. Pale color indicates compromised blood flow and should be reported immediately to the health care provider. The nurse should also provide information on cast care.

The nurse is assigned to provide care to four clients on the medical-surgical unit. After receiving change-of-shift report, which client does the nurse assess first? 1. A client admitted 3 hours ago with a gunshot wound and 1.5 cm area of dark red drainage noted on the dressing. 2. A client who underwent a mastectomy 2 days ago with 23 mL of serosanguinous fluid noted in the bulb-suction drain. 3. A client with a collapsed lung due to an accident and no drainage noted from the chest tube in last 8 hours. 4. A client who underwent an abdominal perineal resection 3 days ago and who reports chills.

4) CORRECT— This client is the highest priority for assessment. The client's assessment findings indicate a potential complication may be developing. The client who undergoes abdominal perineal resection is at risk for developing peritonitis. Because chills may indicate infection, immediate assessment of the client is indicated.

The nurse provides care for clients at the student health clinic. Which data cause the nurse to suspect the student is using cocaine? 1. Reports of frequent sneezing, a sore throat, and T 100°F (37.8°C). 2. Reports of diarrhea, vomiting, and abdominal pain. 3. Reports of fatigue, dilated pupils, and anorexia. 4. Reports of insomnia, rhinorrhea, and facial pain.

4) CORRECT—These signs and symptoms are associated with cocaine use by inhalation. The nose is the most common route for administration of cocaine, which causes rhinorrhea and facial pain.

An older adult client is admitted to the hospital from a long-term care facility. The nurse establishes a nursing diagnosis of decreased fluid volume related to poor intake and fever. Which symptoms most concern the nurse? A. The client's temperature is 102°F (38.4°C), pulse is 120 beats per minute, and blood pressure 88/54 mm Hg. B. The client has difficulty breathing in the supine position or with minimal activity. C. The client's skin is pale and cool to touch with pitting edema in dependent areas. D. The client has ascites and prominent veins across the abdomen.

A An increased pulse rate with thready quality, decreased blood pressure, and elevated temperature indicate that the client may be experiencing hypovolemic shock related to decreased fluid volume. This is a priority concern.

The nurse provides care for a client diagnosed with spinal cord injury at the level of T1. The nurse notes profuse sweating, and the client reports a pounding headache and nasal stuffiness. In which order does the nurse provide care for this client? (Please arrange in order. All options must be used.)

Autonomic dysreflexia is reaction of the autonomic (involuntary) nervous system to overstimulation. It occurs in clients with spinal cord lesions above the level of T6 after spinal shock has subsided. Indications include pounding headache, profuse sweating (especially of forehead), nasal congestion, piloerection, and hypertension. Nursing care includes placing the client in a sitting position to help lower the blood pressure. Catheterize or irrigate an existing catheter to reestablish patency and check the rectum for a fecal mass. Administer hydralazine hydrochloride IV slowly if symptoms are not relieved. Place instructions on the client's record for awareness of all staff. Lastly, instruct the client regarding symptoms, causes, and methods for relief.

A client experiences a flail chest from a motor vehicle crash. Which finding does the nurse expect when assessing this client? A. Chest on the affected side expands outward during inspiration and is pulled inward during expiration. B. Chest on the affected side is pulled inward during inspiration and bulges outward during expiration. C. A sucking sound is heard on inspiration and expiration. D. Absent or restricted movement noted on the affected side.

B A flail chest is caused by fractures of multiple adjacent ribs, causing the chest wall to become unstable and respond paradoxically. The chest then pulls in during inspiration and bulges outward during expiration.

The nurse provides care for a client diagnosed with ventricular tachycardia and angina. Which medication does the nurse administer first? A. Nitroglycerin. B. Morphine sulfate. C. Amiodarone. D. Metoprolol.

C The nurse administers a drug that will terminate the rhythm causing the angina first. Ventricular tachycardia indicates severe myocardial irritability and causes chest pain, dizziness, and fainting. Amiodarone is the drug of choice for hemodynamically unstable ventricular tachycardia. This medication inhibits adrenergic stimulation and prolongs repolarization, allowing for a normal rhythm to occur.

The nurse provides care for an adult client on a mechanical ventilator. Which finding most concerns the nurse? A. The client's Babinski response is negative. B. The client's pulse changes from 80 bpm to 70 bpm. C. The client's extremities are twitching. D. The client is moving about restlessly in bed.

D Confusion, agitation and restlessness suggest hypoxemia. The nurse should assess for hypoxemia and manually ventilate the client with 100% oxygen. This is a breathing concern that represents an immediate risk of harm to the client. This is the priority concern.

The nurse provides care for a client 2 hours after placement of a cuffed tracheostomy tube. When the nurse enters the client's room, the tracheostomy tube is displaced out of the stoma. Which action does the nurse take first? A. Place oxygen at 6 L per minute over the stoma opening. B. Auscultate bilateral breath sounds. C. Check the client's pulse oxygenation reading. D. Use a hemostat to dilate the opening of the stoma. View Explanation

D The client's issue is the loss of an airway. The first action is to open the airway. A newly placed tracheostomy will not stay open without the tube. Some stoma swelling is expected due to the recent surgical procedure as well. The nurse should utilize hemostats to open the airway.

Inotropin/Dopamine

Given to resolve shock, best way to know positive response is to check Blood Pressure/Vital Signs

Foods for child with diarrhea

If there is no indication of dehydration, then start child back on regular normal diet, so he can gain weight fast & reduce effects of sickness (needs carbs, protein, electrolytes) BRAT diet is not recommended for children with diarrhea (banana, rice, apples, toast)

Barium Enema- Procedure

Instruct pt. to take a slow deep breath through the mouth as the nurse inserts the barium, it help pt. not defecate

Defibrillation

Jolts are 200, 300, 360 - Place pads securely on patient, the better on patient the less shock & resistance - Cream, gel, saline soaked gauze

Internal Radiation

Lasts inside 1-3 days - On strict bed-rest with no ambulation, urinary cath is place to prevent abdominal distention, low fiber to prevent bowl movement (enema is used pre op to clean bowls & prevent bowl movement) - HOB elevated no more than 20 degrees

Upper GI Enema

Must be done last because it interferes with colons copy, x ray, ultrasound Does not effects EKG

Acute Pancreatitis Interventions

NG suction to empty stomach & prevent abdominal distention -NPO - Food & ambulation cause pancreatic enzyme secretion, bed rest and NPO is ordered - Pain med- is Demerol not morphine=spasms= more pain

The nurse provides care for the client receiving radiation therapy for breast cancer. Which client statements indicate to the nurse that further intervention is needed due to the effects of radiation? (Select all that apply.) 1. "I'm having trouble swallowing these days." 2. "I need to work from home most days." 3. "I have not moved my bowels in three days." 4. "I seem to have a rash under my arm." 5. "I have been pulling my hair out in clumps."

1) CORRECT - Difficulty swallowing indicates pain and/or swelling and requires further intervention. Radiation therapy causes inflammation of nearby epithelial cells, and this can result in further consequences such as malnutrition. 2) CORRECT - This statement may indicate fatigue, a common side effect of radiation therapy. If the fatigue is severe enough to interfere with daily activities, further assessment and possible intervention is warranted. 4) CORRECT - Redness or desquamation can occur from radiation and can be severe if not managed properly. At a minimum, the nurse must assess that the client is not using deodorant or applying commercial lotions to the area.

The nurse provides care for a client who had a transurethral resection of the prostate (TURP). The client has a three-way urinary catheter connected by gravity with continuous bladder irrigation (CBI) of normal saline. Which observations require the nurse to intervene? (Select all that apply.) 1. Temperature of 101.4°F (38.3°C). 2. Urinary output of 100 mL in 4 hours. 3. Fluid leakage around the catheter tubing. 4. Blood pressure of 112/76 mm Hg. 5. 230 mL of sanguinous fluid in the catheter bag. 6. Client reports pressure in the pelvis.

1) CORRECT— An elevated temperature may indicate an infection, which is a complication of TURP. 2) CORRECT— The client should produce at least 30 mL of urine per hour, so should have a minimum of 120 mL in 4 hours. In addition, the client will have the bladder irrigation fluid. 3) CORRECT— Fluid leakage from the urethra around the catheter suggests a concern with the catheter. The nurse should assess for balloon inflation and proper positioning of the catheter. 5) CORRECT— Hemorrhage is the greatest danger following TURP. While pink-tinged urine with occasional clots is expected, the client should not have sanguinous drainage, as it suggests hemorrhage.

The nurse instructs a client about how to collect a 24-hour urine specimen. The nurse determines that teaching is effective if the client makes which statement? 1. "I should discard my first morning specimen, collect all urine for 24 hours, and place the urine in one container." 2. "I should begin the collection at 8:00 a.m., collect all urine voided between 8:00 a.m. and 8:00 p.m., and place the urine in one container." 3. "I will collect each voided urine in separate sterile containers for the next 24-hour period." 4. "I will call the lab to let them know what time I began the test so they know when it is complete." View Explanation

1) CORRECT— Discarding the first morning specimen removes residual urine from the bladder.

A client is being evaluated for an acute onset of seizures. Which diagnostic test does the nurse expect to be completed first? 1. Magnetic resonance imaging. 2. Cerebral angiography. 3. Electroencephalogram. 4. Electromyogram.

3) CORRECT— An electroencephalogram records electrical activity of the brain, which is malfunctioning with seizure activity. The nurse anticipates this to be the first test prescribed for this client. Preparation for this test includes washing the hair, avoiding stimulant medications and other stimulants such as caffeine, cola, tea, and cigarettes.

The nurse in the emergency department provides care for a client admitted with a possible cervical spinal cord injury (SCI). Which action does the nurse perform first? 1. Ask how the accident occurred. 2. Assess neurological functioning. 3. Auscultate respirations. 4. Ask about previous medical conditions.

3) CORRECT— Assessing respiratory and breathing function is the priority assessment, especially for the client with a suspected cervical injury.

The nurse in the outpatient clinic identifies which client as having the lowest risk for developing pneumonia? 1. A homeless young adult client who consumes a quart of wine daily. 2. An adult client who is NPO due to a resection of a perforated bowel. 3. An adult client diagnosed with mitral valve prolapse. 4. An older adult client with dysphagia following a cerebrovascular accident.

3) CORRECT— The client has no risk factors for pneumonia.

The home health nurse visits a client who has urinary incontinence following a prostatectomy. The client reports that he is changing incontinence pads every 2 hours. Which action by the nurse is appropriate? 1. Encourage the client to drink 1000 mL per day. 2. Instruct the client to use artificial sweetener. 3. Instruct the client to do pelvic muscle strengthening exercises. 4. Administer terazosin 1 mg orally per day.

3) CORRECT - Performing pelvic muscle strengthening exercises several times a day is an appropriate action for incontinence. The exercises will improve bladder control.

The nurse reading an electrocardiogram (EKG) rhythm strip determines that there are 8 QRS complexes in 30 large squares for a 6-second strip. Which heart rate does the nurse calculate? 1. 60 bpm. 2. 70 bpm. 3. 80 bpm. 4. 120 bpm.

3) CORRECT - Thirty large squares on the EKG paper represent 6 seconds. The nurse will multiply the number of QRS complexes found in 30 large squares by 10 (8 × 10 = 80 beats per minute).

The charge nurse precepts a newly-hired nurse. Which action by the new nurse would requires an intervention by the charge nurse? 1. The nurse tests the plantar reflex with a pointed object and notes flexion of all toes. 2. The nurse assesses a client's muscle strength by asking the client to push the foot against the nurse's hand. 3. The nurse assesses a client's grip strength by asking the client to squeeze the nurse's first two fingers of both hands. 4. The nurse obtains a Glasgow Coma Scale (GCS) score by asking the client to count backwards from 100 by 3s

4) CORRECT - Glasgow Coma Scale is an objective and widely accepted tool for neurologic assessment and documentation of level of consciousness. It establishes baseline data for eye opening, motor response, and verbal response. The client is assessed and assigned a numerical score for each of these areas. A score of 15 represents normal neurologic functioning, and a score of 3 represents a deep coma state.

The nurse reviews the documentation by a student nurse after a routine physical on a healthy adult. The nurse determines that the student nurse properly inspected the client's anterior chest if which entry is found in the client's chart? 1. "Diaphragmatic excursion equal bilaterally measuring 4 cm." 2. "Smooth, symmetrical chest expansion noted." 3. "Vesicular breath sounds present over lung periphery." 4. "Ribs with symmetric interspaces and 90-degree costal angle." View Explanation

4) CORRECT - Inspection of the anterior chest includes shape and configuration of the chest, facial expression, level of consciousness, color and condition of skin, and quality of respirations.

A client states to the nurse, "I was just bitten by a tick." The client asks to be tested for Lyme disease. Which action does the nurse implement based on this information? 1. Refer the client for an immediate blood test for Lyme disease. 2. Inform the client that there is no test for Lyme disease. 3. Tell the client that testing is only done if a rash develops. 4. Instruct the client to return in 4 weeks for testing. View Explanation

4) CORRECT - It takes 1 to 2 months after the tick bites to get a reliable result because of the antibody formation process.

The staff nurse is reviewing the preparation for insertion of a central venous catheter (CVC) in a client with the nurse supervisor. Which statement by the staff nurse most concerns the nurse supervisor? 1. "I will instruct the client to turn her head to the left until the procedure is complete." 2. "I will shave the skin at the insertion site the night before." 3. "I will inform the client that she will be positioned with her head lower than her feet during the insertion procedure." 4. "I will instruct the client to breathe deeply during the procedure to help her relax."

4) CORRECT - The client should not breathe deeply during the insertion procedure, as this increases the risk for air embolism, which poses an immediate risk of harm and potential death to the client. Clients should be instructed to perform the Valsalva maneuver instead. This is the greatest concern.

The nurse provides care to an older adult client with metastatic colon cancer. Which difference in pain tolerance because of the client's age will the nurse expect to assess? 1. Decreased. 2. Unchanged. 3. Increased. 4. No effect.

1) CORRECT- Aging lowers pain tolerance because of diminished adaptive capacity.

The nurse provides care to a client who is vomiting brown material that has a fecal odor. Which condition does the nurse suspect is causing this type of vomitus? 1. Gastric outlet obstruction. 2. Obstruction below the pylorus. 3. Intestinal obstruction. 4. Excessive hydrochloric acid in the gastric area.

3) CORRECT— A bowel obstruction is indicated with vomitus that is brown with a fecal odor as described.

The nurse prepares to complete an assessment of cranial nerves IX and X. Which supplies will the nurse obtain to complete the assessment? 1. A cotton ball. 2. A tuning fork. 3. An ophthalmoscope and Snellen-like chart. 4. A tongue depressor and flashlight.

4) CORRECT— Cranial nerves IX and X are the glossopharyngeal and vagus nerves, which control the client's ability to swallow and the gag reflex. A tongue depressor and flashlight are needed.

A client receives intravenous doxorubicin hydrochloride. Which observation causes the nurse the most concern? 1. Mouth ulcer. 2. Red urine. 3. Alopecia. 4. Fever.

4) CORRECT— Doxorubicin hydrochloride causes bone marrow depression. A fever is a sign of an infection and should be reported to the health care provider.

The nurse placed a client on therapeutic hypothermia 1 hour ago. Which action does the nurse take to determine whether the client is having an adverse reaction to therapeutic hypothermia? A. Install a working suction setup. B. Monitor the client for seizure activity. C. Measure the Braden Scale score. D. Assess bowel sounds every 2 hours.

B The client is monitored for seizure activity, which is an adverse reaction to hypothermia.

Central venous catheters including PICCs

- Must be done using sterile technique; this would include cap, mask, sterile gloves, sterile gown, and a large sterile sheet - Insertion site, some use transparent dressing and some sterile gauze dressing while taping down all 4 corners

The nurse provides care to a client receiving total parenteral nutrition (TPN). Which intervention will the nurse include in the care plan for this client? 1. Change the solution bag every 24 hours. 2. Maintain the client on complete bed rest. 3. Stop the infusion every 4 hours to give medications. 4. Flush the line with water prior to starting nutritional support.

1) CORRECT - For clients receiving TPN, solutions should be changed every 24 hours in order to prevent bacterial overgrowth due to hypertonicity and the amount of glucose in the solution.

The nurse receives hand-off communication on assigned clients from the previous shift. Which client will the nurse assess first? 1. Client in sickle-cell crisis with an infiltrated intravenous access line. 2. Client with leukemia who has received 0.5 unit of packed red blood cells. 3. Client scheduled for a bronchoscopy. 4. Client complaining of a leaky colostomy bag.

1) CORRECT - For the client with sickle-cell crisis, intravenous fluids are critical to reduce clotting and reduce pain. This client is the priority.

A client is brought to the emergency department following a motor vehicle accident. Which observation of the client most concerns the nurse? 1. Client's blood pressure of 96/50 mm Hg, pulse 112 beats/min. 2. Client reports presence of abdominal pain and nausea. 3. Abrasions are present on the client 's abdomen. 4. Client exhibits a staggering gait with ambulation.

1) CORRECT— The client has tachycardia and hypotension, which are indicative of shock. This is a circulatory concern that represents an immediate risk to client safety and is the priority concern.

The nurse administers an immunization to an adult client. Which observations made after the injection cause the nurse to immediately intervene? (Select all that apply.) 1. The client is clearing the throat and coughing. 2. The client has nasal drainage and sneezing. 3. The client is anxious and exhibits rapid breathing. 4. The client is feverish and sweating profusely. 5. The client reports dizziness upon standing. 6. The client has a diffuse rash across the trunk.

1) CORRECT - An anaphylactic reaction may begin with the client clearing the throat and coughing due to swelling in the airway. The nurse should assess the client for other signs of anaphylaxis and be prepared to intervene. 3) CORRECT - Tachypnea and feelings of impending doom occur with anaphylaxis. This client needs immediate assessment and care. 5) CORRECT - Dizziness upon standing may be indicative of hypotension, which occurs with anaphylaxis and shock. The nurse should immediately assess this client's vital signs.

The oncology nurse is reassigned to the medical-surgical unit. The charge nurse for the medical-surgical unit assigns which clients to the oncology nurse? (Select all that apply.) 1. Client who is receiving total parenteral nutrition (TPN) following gastrectomy 48 hours ago. 2. Client who will be discharged to home today following total hip replacement 72 hours ago. 3. Client who requires administration of pain medication after undergoing bariatric surgery 6 hours ago. 4. Client admitted yesterday who is newly diagnosed with atrial fibrillation. 5. Client who requires QID dressing changes for treatment of a MRSA-positive stage 4 pressure injury. 6. Client admitted 3 days ago who is prescribed IV antibiotics for treatment of pneumonia.

1) CORRECT - Based on the available client data, no unexpected assessment findings are present and there is no apparent deterioration of the client's condition. The TPN administration requires application of the nurse's fundamental knowledge and skills. 5) CORRECT - Based on the available client data, no unexpected assessment findings are present and there is no apparent deterioration of the client's condition. Dressing changes and implementation of MRSA precautions require application of the nurse's fundamental knowledge and skills. 6) CORRECT - Based on the available client data, no unexpected assessment findings are present and there is no apparent deterioration of the client's condition. Administration of IV antibiotics requires application of the nurses's fundamental knowledge and skills.

A client is scheduled for knee replacement surgery and expresses a desire to make an autologous blood donation. Which client statement about autologous blood donation is most important for the nurse to follow up on? 1. "I will make the first donation this week since my surgery is scheduled in 8 weeks." 2. "I may have to start taking oral iron supplements." 3. "I am glad that I can give up to 6 units of blood." 4. "I have to make the last donation at least 1 week before surgery."

1) CORRECT - Blood for the autologous donation is collected 6 weeks before the scheduled surgery. This statement would require additional follow up by the nurse.

The nurse prepares to perform a breast examination on a 20-year-old female client. Which question is most important for the nurse to ask before beginning the examination? 1. "When was your last menstrual period?" 2. "Do you have a family history of breast cancer?" 3. "How much caffeine do you consume a day?" 4. "Have you ever had a mammography?"

1) CORRECT - Breast examination is ideally done about 1 week after the onset of menses, when hormonal influences on the breasts are at a low level.

The nurse notes that the spouse of a client, having a routine physical examination, died 2 months ago of colon cancer. Which initial statement is most appropriate for the nurse make to this client? 1. "I understand that your spouse died 2 months ago." 2. "I am so sorry that you lost your spouse." 3. "What brings you here today?" 4. "What can we do for you?"

1) CORRECT - Caring, direct acknowledgment aids in the grieving process.

The nurse provides care for a client who underwent a supratentorial craniotomy to remove a brain tumor. In which positions can the nurse safely place the client? (Select all that apply.) 1. Semi-Fowler position. 2. Left-lateral position. 3. Head midline. 4. Neck flexed. 5. Minimal hip flexion.

1) CORRECT - Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. 3) CORRECT - The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. 5) CORRECT - The client is positioned to avoid extreme bending of the hip

Which information will the nurse include when teaching the client about the self-management of an implantable cardioverter/defibrillator (ICD)? (Select all that apply.) 1. Continue taking antidysrhythmic medications until the health care provider directs otherwise. 2. Do not wear tight clothing or belts over the ICD generator. 3. Notify the local fire department about having an ICD. 4. Avoid activities that involve rough contact with the ICD. 5. Report symptoms such as nausea, fainting, and weakness.

1) CORRECT - Even after ICD placement, the client will need to continue taking antidysrhythmics until otherwise directed by the health care provider. 2) CORRECT- Tight clothing and a belt could cause irritation to the ICD generator. 4) CORRECT - Rough activities, such as contact sports, may cause ICD electrodes to become dislodged. 5) CORRECT - Nausea, fainting, and weakness indicate low cardiac output and must be reported to the health care provider.

The nurse provides care to a client with a peripherally inserted central catheter (PICC) for treatment of metastatic cancer. Which findings will the nurse expect 4 days after the catheter placement? (Select all that apply.) 1. Feels no resistance when flushing the catheter with saline. 2. Observes dried blood at the insertion site under the transparent dressing. 3. Notes the insertion site is on the client's left chest. 4. Measures the exposed (nontunneled) portion of the catheter as being 18 cm for the past 2 days. 5. Notes a vesicant medication is prescribed to be administered through the catheter. 6. Learns during hand-off communication that the client showered for morning care.

1) CORRECT - Feeling no resistance when flushing the catheter is a normal finding. 4) CORRECT - A PICC can be up to 60 cm in length, including the tunneled portion. The nurse should measure the exposed length each shift to ensure the catheter has not migrated. 5) CORRECT - Irritating and vesicant medications may be infused through a PICC. 6) CORRECT - The insertion site and dressing may be covered with a transparent semipermeable dressing during bathing. If the sterile dressing becomes loose or damp during the shower, a new dressing should be applied.

The nurse provides care for a client 2 days after admission for an acetaminophen overdose. It is most important for the nurse to monitor which laboratory results? 1. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST). 2. Blood glucose levels. 3. Blood urea nitrogen (BUN) and creatinine. 4. Hemoglobin and hematocrit.

1) CORRECT - Hepatic toxicity is a serious complication resulting from an acute acetaminophen overdose that manifests approximately 1 to 3 days after initial ingestion. Signs of hepatic toxicity include an increase in the serum transaminase liver enzymes, ALT and AST. The prothrombin time should also be monitored, as acetaminophen overdose prolongs it.

The nurse provides care to a client who is scheduled to undergo a craniotomy the following day. Which client data does the nurse recognize as being an indication for insertion of an indwelling urinary catheter? (Select all that apply.) 1. The client is diagnosed with severe urinary retention. 2. The client requires evaluation of residual urine volume. 3. The client is scheduled for a lengthy surgical procedure. 4. The client is at risk for developing a pressure injury. 5. The client requires strict monitoring of intake and output.

1) CORRECT - Indications for insertion of an indwelling urinary catheter include treatment of urinary retention, as urinary retention may cause health alterations including urinary tract infection (UTI) and kidney stones. 3) CORRECT - Lengthy surgical procedures performed under anesthesia may be an indication for insertion of an indwelling urinary catheter. 5) CORRECT - Indications for indwelling urinary catheter include when accurate intake and output are necessary to closely monitor fluid volume status.

The nurse plans staff assignments. Which clients are appropriate to assign to the LPN/LVN? (Select all that apply.) 1. A client who is 48 hours post-operative and requires heparin 5,000 units SQ every 8 hours. 2. A client who fell yesterday in the long-term care facility and sustained an orbital fracture. 3. A client who sustained a gunshot injury and has a chest tube to water-seal drainage. 4. A client who was admitted with a bowel obstruction and is now passing soft, formed stools. 5. A client who is 1 day post-laminectomy and is receiving morphine sulfate via a PCA pump.

1) CORRECT - Post-operative thrombosis prophylaxis, stable client, and unchanging prescriptions is a good assignment for the LPN/LVN. 4) CORRECT - The client with a resolved bowel obstruction and unchanging prescriptions is a stable client and may be assigned to the LPN/LVN.

The nurse develops a client teaching brochure on health promotion. Which interventions will the nurse include as examples of primary health promotion? (Select all that apply.) 1. Attending a stress management class. 2. Performing a testicular self-examination. 3. Determining glycated hemoglobin (HbA1C) level. 4. Taking an analgesic for a headache. 5. Determining foods low in cholesterol.

1) CORRECT - Primary prevention aimed at health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. 5) CORRECT - Primary prevention aimed at health promotion includes health education programs, immunizations, and physical and nutritional fitness activities.

The nurse provides care for a client in the emergency department (ED) who is shaking and crying after witnessing a friend being shot with a gun. The nurse observes the client to be severely anxious. Which interventions does the nurse include in the client's plan of care? (Select all that apply.) 1. Remain with the client. 2. Contact the police to interview the client. 3. Administer prescribed lorazepam 1 mg orally. 4. Encourage client to describe the incident. 5. Provide privacy for the client. 6. Write down important information.

1) CORRECT - Since the client is severely anxious, the nurse should remain with the client. Through use of therapeutic communication, the nurse should assist the client to clarify thoughts and feelings. 3) CORRECT - Administering the prescribed lorazepam, an anti-anxiety medication, will help the client cope with the anxiety. intervention to include in the client's care plan. 5) CORRECT - Since the client is anxious, it is important to provide privacy from the activities in the ED, which may overstimulate the client. 6) CORRECT - The client may have difficulty listening to and understanding information if anxiety is severe. Therefore, it is important for the nurse to write down essential information.

The nurse observes the unlicensed assistive personnel (UAP) providing care for a client diagnosed with shingles. Which UAP action requires the nurse to intervene? (Select all that apply.) 1. Ambulating the client to the nurses station. 2. Donning gowns and gloves prior to entering the client 's room. 3. Refusing to enter the client 's room due to a personal positive titer. 4. Performing hand hygiene upon entering the client 's room. 5. Using the unit equipment to monitor the client 's vital signs.

1) CORRECT - The client diagnosed with herpes zoster is placed in isolation; therefore, ambulating the client to the nurses station increases the risk for infection to others who may not be immune. 3) CORRECT - The UAP is immune to varicella (chickenpox) based on the positive titer, and the nurse will discuss this with the UAP. 4) CORRECT - Hand hygiene will be done prior to entering a contact precaution room. 5) CORRECT - Isolation rooms must have dedicated equipment to prevent hospital acquired infections and cross-contamination of clients.

The nurse provides care to a client with nuchal rigidity and photophobia. Which action will the nurse take first? 1. Implement droplet precautions. 2. Monitor for increased intracranial pressure. 3. Prepare for a lumbar puncture. 4. Implement seizure precautions.

1) CORRECT - The client has symptoms of meningitis. This illness is caused by Haemophilus influenzae or Neisseria meningitidis and requires droplet precautions. The client should be placed on droplet precautions until the diagnosis is confirmed or eliminated to protect other clients and staff.

The nurse teaches an adolescent male client how to perform a testicular self-exam. Which client statement indicates to the nurse that the teaching was successful? 1. "I will perform the exam when I get out of the shower." 2. "I will remember to examine myself every 3 months." 3. "I will examine each testicle by gently rolling it between my middle and index fingers. 4. "I will remember the pea size lump on the side of my testicles is the epididymis."

1) CORRECT - The client should examine testicles monthly immediately after a bath or a shower, when scrotal skin is relaxed.

The nurse provides discharge instructions to an adult client diagnosed with infectious diarrhea. In which situation does the nurse advise the client to call a health care provider immediately? (Select all that apply.) 1. Development of dry skin. 2. Pulse rate exceeding 100 beats per minute. 3. Lower abdominal cramping. 4. Cold extremities. 5. Increased thirst.

1) CORRECT - The development of dry skin suggests increasing mild to moderate dehydration. The nurse needs to advise the client to notify the health care provider of this situation. 2) CORRECT - A pulse rate that exceeds 100 beats per minute suggests possible severe dehydration. The nurse needs to advise the client to notify the health care provider of this situation. 4) CORRECT - Cold extremities suggest severe dehydration. The nurse needs to advise the client to notify the health care provider of this situation. 5) CORRECT - Increased thirst suggests mild to moderate dehydration. The nurse needs to advise the client to notify the health care provider of this situation.

The novice nurse administers RBCs to a client. Which actions by the novice nurse are deemed safe by the nurse preceptor? (Select all that apply.) 1. Priming the intravenous tubing with 0.9% sodium chloride. 2. Setting the infusion rate to deliver the blood within 6 hours. 3. Inserting a 26-gauge peripheral IV catheter. 4. Staying with the client for the first 10 minutes after starting the transfusion. 5. Obtaining and documenting a full set of baseline vital signs. 6. Verifying blood compatibility with the unlicensed assistive personnel (UAP).

1) CORRECT - The nurse primes the tubing with 0.9% sodium chloride to reduce hemolysis. 5) CORRECT - Obtaining baseline vital signs allows the nurse to determine when changes in vital signs occur as a result of a transfusion reaction.

The nurse provides care for clients in the emergency department. The nurse assesses a client following a motor vehicle accident. Which observation most warrants the nurse remaining with this client? 1. Client is disoriented to person, place, and time. 2. Client's vital signs are irregular and client is hostile. 3. Client is agitated with a rapid respiratory rate. 4. Client's blood pressure is elevated and client is apprehensive.

1) CORRECT - The nurse should remain with this client. This client is at risk of self-injury, such as falls, and disorientation may be a sign of serious head trauma or shock.

The nurse provides care for a client diagnosed with pneumonia and acute respiratory distress syndrome (ARDS). The client asks about the benefits of pulmonary rehabilitation. Which results of the rehabilitation program will the nurse include in the teaching? (Select all that apply.) 1. Improved exercise capacity. 2. Decreased anxiety. 3. Decreased depression. 4. Increased oxygen needs. 5. Decreased hospitalizations.

1) CORRECT - The program will help improve endurance and oxygenation. 2) CORRECT - Decreased anxiety is one of the major anticipated goals of the program. 3) CORRECT - Decreased depression is one of the major anticipated goals of the program. 5) CORRECT - Decreased hospitalizations is one of the major anticipated goals of the program.

The nurse provides cares for a client who sustained a T5 spinal cord injury four weeks ago. The nurse observes that the client is diaphoretic, nauseated, and reports a severe headache. Which action does the nurse take first? 1. Place the client in a sitting position. 2. Assist the client to empty the bladder. 3. Examine the client's rectum. 4. Administer hydralazine as prescribed.

1) CORRECT - These symptoms reflect autonomic dysreflexia, which is a life-threatening condition that can occur with spinal cord injuries above T6. Causes include visceral distension and noxious stimuli, such as skin pressure and temperature extremes. A primary symptom, and of most major concern, is severe and rapid-onset hypertension. Another symptom includes bradycardia. Placing the client in a sitting position should be done immediately to help reduce intracranial pressure and prevent cerebral hemorrhage and seizures.

The home health nurse visits a client with cancer undergoing anti-cancer treatment. The nurse asks how the client is coping, and the client cries and with an angry voice says, "Nobody understands. I am hanging on, trying to take one day at a time, but it is all I can do to get up in the morning." How does the nurse best respond? 1. "What kind of support do you think would be most helpful to you at this time?" 2. "I would be upset too if the people around me didn't act like they cared." 3. "Dealing with family is a challenge, even for people who are feeling healthy." 4. "Why don't you attend a support group for women who are going through the same thing?"

1) CORRECT - This is an open-ended question that focuses in on the client's underlying message, encourages discussion and problem-solving, and implies that some support will be offered directly by the nurse once the client's needs are known.

The nurse delegates tasks to the unlicensed assistive personnel (UAP). For which UAP action does the nurse intervene? (Select all that apply.) 1. Decreases the flow rate of oxygen from 4 L/minute to 2 L/minute for a client being titrated off oxygen therapy. 2. Reapplies the nasal cannula for a client who displaces the oxygen tubing. 3. Reports a decrease in a client's systolic blood pressure to the health care provider. 4. Reports an abnormal capillary blood glucose value to the nurse. 5. Assists a healthy, multiparous, postpartum client to the bathroom for the first time following childbirth.

1) CORRECT - Titrating an oxygen flow rate requires the nurse to assess the client's tolerance to a lower amount of oxygen. This action should only be done by the nurse. 3) CORRECT - Only the nurse should report a change in client status to the health care provider (HCP). The HCP may want to provide new prescriptions, which the UAP cannot accept, since this is beyond the scope of practice. 5) CORRECT - Since the client has just delivered, the nurse may need to provide teaching such as perineal cleansing. The nurse should assist the client to the bathroom to assess tolerance to activity and urine output. This task is not appropriate to delegate to the UAP.

The nurse provides care for a client diagnosed with moderate flail chest. Which interventions will the nurse anticipate including on the care plan? (Select all that apply.) 1. Monitor client 's vital signs. 2. Maintain closed-chest drainage system. 3. Administer pain medication. 4. Maintain mechanical ventilation. 5. Monitor arterial blood gases (ABGs).

1) CORRECT - Vital signs need to be assessed frequently to determine if the client is experiencing shock. The nurse needs to anticipate including this intervention on the care plan. 3) CORRECT - Flail chest is caused by blunt chest trauma and is extremely painful. The nurse needs to anticipate that administering pain medications will be included on the client 's care plan. 4) CORRECT - Mechanical ventilation helps to maintain adequate gas exchange. The nurse needs to anticipate including this intervention on the care plan. 5) CORRECT - Monitoring ABGs is essential for it assesses for hypoxemia and hypercapnia. The nurse needs to anticipate that this intervention will be included on the care plan.

The nurse prepares to administer the Haemophilus influenzae type b (Hib) vaccine to a 4-month-old infant. The nurse teaches the infant's parent about the vaccine. Which information does the nurse include in the teaching? 1. "Monitor your child for signs of allergic reaction for a few hours after the vaccine." 2. "Your child will receive 1 or 2 doses of the vaccine, depending on the vaccine used." 3. "Immediately notify the health care provider of a low-grade fever." 4. "This vaccine cannot be given at the same time as other vaccines."

1) CORRECT -Signs of allergic reaction to the Hib vaccine include hives, facial and airway edema, difficulty breathing, tachycardia, dizziness, and weakness. These typically begin a few minutes to a few hours after the child receives the vaccine.

The nurse receives several telephone messages when performing triage. Which client will the nurse direct to come to the health facility immediately? 1. Multipara client at four weeks' gestation reporting unilateral, dull abdominal pain. 2. Primigravida client at five weeks' gestation having vaginal spotting and some cramping. 3. Multigravida client at six weeks' gestation reporting frank, red vaginal bleeding with moderate cramps. 4. Primipara client at seven weeks' gestation reporting an increase in whitish vaginal secretions.

1) CORRECT -The client reporting unilateral dull abdominal pain needs to be evaluated immediately for an ectopic pregnancy.

The nurse prepares to administer amikacin to a client diagnosed with an enterococcal infection. Which client findings cause the nurse to question administration of the medication? (Select all that apply.) 1. Reports nausea and diarrhea. 2. Has an activated partial thromboplastin time (aPTT) value of 28 seconds. 3. Receives warfarin for atrial fibrillation. 4. Smokes one pack of cigarettes a day. 5. Receives hemodialysis three times weekly.

1) CORRECT — Anti-infective medications can eradicate normal intestinal flora and lead to superinfection of the gastrointestinal and genitourinary tracts. Nausea and diarrhea are signs of superinfection. Therefore, the nurse questions the administration of this medication. 3) CORRECT — Anti-infective medications can eradicate normal flora, reducing the amount of vitamin K produced by these bacteria. Amikacin is an aminoglycoside and can potentiate the action of warfarin. The nurse questions the administration of this medication based on this data. 5) CORRECT — Aminoglycosides are nephrotoxic and are contraindicated in clients diagnosed with kidney impairment because toxic levels are reached rapidly. The nurse questions the administration of this medication based on this data.

A client is to undergo an electroencephalogram (EEG) the following day as part of the workup for evaluation of seizure activity. Which statement is approrpiate for the nurse to include when preparing the client for the test? 1. "Avoid drinking coffee, tea, or caffeinated beverages before the test." 2. "You will need to wash your hair after the test, so do not bother washing it beforehand." 3. "Be careful not to eat or drink anything for at least 6 hours before the test." 4. "There will be harmless pricking sensations during the test as the electricity enters your brain." View Explanation

1) CORRECT — Caffeine intake may alter the results of the test, as caffeine is a stimulant. The client should avoid caffeine-containing beverages or foods for 24 to 48 hours prior to the test.

The client is admitted with extreme fatigue, shortness of breath, anxiety, and chest pressure. Which intervention does the nurse implement? (Select all that apply.) 1. Place the client on bed rest. 2. Administer supplemental oxygen. 3. Administer ketorolac for pain. 4. Assess serum troponin level. 5. Monitor intake and output. View Explanation

1) CORRECT — The client is experiencing the symptoms of a myocardial infarction. Bed rest decreases stress on the heart by decreasing muscle metabolism and therefore oxygen demand. 2) CORRECT — In a myocardial infarction, administering oxygen is a priority action as this client is experiencing poor oxygenation to the heart muscle. 4) CORRECT — The troponin level is sensitive to cardiac damage and can confirm that the client is having a myocardial infarction. 5) CORRECT — The nurse should monitor intake and output to assess for fluid overload. The client is at high risk to experience heart failure due to death of myocardial tissue.

A client is scheduled for a colonoscopy, and the nurse is completing teaching regarding the procedure. Which client statement indicates to the nurse an appropriate understanding of the procedure? 1. "I need to not eat or drink anything by mouth 8 hours before the procedure." 2. "I need to begin a liquid diet 2 days before the procedure." 3. "I need to stop taking my oral hypoglycemic agent the day before the procedure" 4. "I need to let my health care provider know that I am allergic to iodine before the procedure."

1) CORRECT — The client needs to be NPO 8 hours before a colonoscopy. This statement indicates understanding of the procedure.

A pediatric client presents with flushed skin, generalized itching, nausea, wheezes, and inspiratory stridor after being stung by a bee. Which medication prescriptions will the nurse expect to implement for this client? (Select all that apply.) 1. IM epinephrine. 2. IV diphenhydramine. 3. IV bolus of lactated Ringer solution. 4. IV methylprednisolone. 5. Nebulized albuterol treatment.

1) CORRECT — The nurse expects to implement this medication prescription. Intramuscular (IM) epinephrine is appropriate for anaphylactic shock because it causes peripheral vasoconstriction and bronchodilation. 2) CORRECT — The nurse expects to implement this medication prescription. Intravenous (IV) diphenhydramine is appropriate for anaphylactic shock because it blocks histamine release. 4) CORRECT — The nurse expects to implement this medication prescription. Intravenous (IV) methylprednisolone is appropriate for anaphylactic shock because it treats inflammation and elevates blood pressure if needed. 5) CORRECT — The nurse expects to implement this medication prescription. A nebulized albuterol treatment is appropriate for anaphylactic shock because it opens the airways and promotes oxygenation.

The unlicensed assistive personnel (UAP) reports to the nurse that four clients are vomiting. Which client does the nurse see first? 1. A client with a nasogastric (NG) tube attached to low suction. 2. A client diagnosed with cirrhosis of the liver who has extensive ascites. 3. A client diagnosed with lung cancer who is undergoing chemotherapy. 4. An older adult client diagnosed with irritable bowel syndrome (IBS).

1) CORRECT- Assess for patency of the NG tube first. Clients should not vomit around an NG tube. The tube is there to maintain decompression of gastrointestinal pressure and continuous removal of contents. The nurse must assess the client and the NG system and suction to ensure patency and rule out emergent needs.

A client receiving parenteral nutrition is to receive an intravenous fat emulsion infusion. Which action will the nurse take when administering the fat emulsion? 1. Administer it through separate tubing. 2. Provide it as intravenous boluses. 3. Wrap the infusion container in aluminum foil. 4. Infuse it through a central line.

1) CORRECT- Fat emulsions are infused through a separate peripheral or central line using a Y-connector.

While performing abdominal thrusts to remove a foreign body, the client becomes unconscious. Which actions are appropriate for the nurse to implement at this time? (Select all that apply.) 1. Begin chest compressions. 2. Look in the client 's mouth for a foreign body. 3. Insert an oropharyngeal airway. 4. Open the client 's airway using a head tilt-chin lift maneuver. 5. Activate the emergency response system.

1) CORRECT- If the client with a foreign body airway obstruction becomes unresponsive and is not breathing, the nurse should begin chest compressions. 2) CORRECT- Before delivering ventilations, the nurse should look into the client 's mouth. If the nurse sees a foreign body that can be easily removed, the nurse should remove it. 4) CORRECT- The nurse should open the client 's airway using the head tilt-chin lift maneuver. 5) CORRECT- The nurse should call for nearby help to activate the emergency response system, so help is available to aid resuscitation efforts.

The nurse assesses a client in the emergency department. Which symptoms cause the nurse to suspect that the client is experiencing a panic attack? 1. Decreased perceptual field, diaphoresis, fear of going crazy, and palpitations. 2. Decreased blood pressure, chest pain, choking feeling. 3. Increased blood pressure, bradycardia, shortness of breath. 4. Increased respiratory rate, increased perceptual field, increased concentration ability.

1) CORRECT- Panic disorders are characterized by recurrent, unpredictable attacks of intense apprehension or terror that can render a client unable to control a situation or to perform simple task. The client can experience palpitations, diaphoresis, a decrease in perceptual field, and a fear of "losing it" or going crazy.

The nurse teaches a client who experiences persistent tachycardia. Which instruction does the nurse include in teaching the client about tachycardia? (Select all that apply.) 1. Avoid becoming overheated while outdoors. 2. Regular propranolol use causes bradycardia. 3. Seek counseling as needed for anxiety management. 4. Use prescribed medications to control asthma. 5. Rest as much as possible and avoid strenuous work.

1) CORRECT- The body responds to hyperthermia by increasing the heart rate to meet metabolic demand to cool off. The client should drink cool liquids, limit time in the sun, and take other reasonable measures to avoid becoming too hot. 3) CORRECT - Anxiety causes increase in heart rate, and should be managed to prevent this. If the client needs counseling or medication to accomplish this, then they should seek that treatment. 4) CORRECT- An asthma exacerbation causes an increase in heart rate and should be prevented with daily medications as prescribed. Medications such as albuterol may be avoided in this client with an abnormal rhythm. However, even this treatment is preferable to the cardiac strain of an asthma attack.

A female client reports that she discovered a lump in her breast about 4 months ago, and the lump seems to be getting larger. Which action is most important for the nurse to take? 1. Notify the health care provider to schedule a mammogram. 2. Ask the client if she is taking oral contraceptives. 3. Ask the client the date of her last period. 4. Instruct the client to discontinue any hormones.

1) CORRECT— A mammogram is an x-ray of the breast, which screens for breast cancer. It is the first step to determine whether the lump is malignant or benign. This is the priority action.

e nurse provides care for clients in an inpatient setting. Which client does the nurse determine is at the highest risk to develop a healthcare-associated infection (HAI)? 1. A client with full-thickness burns who has a nasogastric tube and a urinary catheter. 2. A client who has a history of gastric ulcer and is recovering from an appendectomy. 3. A client diagnosed with type 1 diabetes mellitus admitted for evaluation of peripheral neuropathy and cardiac palpitation. 4. A client with a history of migraine headaches who is diagnosed with alcohol abuse and admitted for alcohol detoxification.

1) CORRECT— An HAI results from care being delivered in the health care setting. Burns, an NG tube, and a urinary catheter all are risk factors for organisms entering the body. Follow strict standard precautions to prevent HAIs.

An adolescent client sustains a spinal cord injury at the level of L1 in a motor vehicle accident (MVA). The adolescent returns to school after rehabilitation and tells the school nurse, "I am determined to lead a normal life. " To assist the adolescent to achieve this goal, which action by the school nurse is most appropriate? 1. Reinforce teaching about the Cred é maneuver. 2. Provide privacy for the adolescent to change protective undergarments. 3. Refer the adolescent to school counselor. 4. Procure urinary catheter trays.

1) CORRECT— Applying manual pressure to the bladder aids in emptying the bladder completely and helps reduce risk for infection. Performing the Cred é maneuver at the same times every day can result in bladder control.

The nurse supervises a team of LPN/LVNs. Which actions by an LPN/LVN will cause the nurse to take action? (Select all that apply.) 1. An LPN/LVN prepares to administer carvedilol to a client with a documented allergy to nadolol. 2. An LPN/LVN prepares to administer hydralazine to a client with a documented allergy to hydroxyzine. 3. An LPN/LVN prepares to administer thioridazine to a client with a documented allergy to promethazine. 4. An LPN/LVN prepares to administer ciprofloxacin to a client with a documented allergy to azithromycin. 5. An LPN/LVN prepares to administer ceftriaxone to a client with a documented allergy to cefazolin.

1) CORRECT— Carvedilol and nadolol are beta-blocker medications. An allergy to one type of beta-blocker likely means the client will be allergic to all beta-blockers. 3) CORRECT— Thioridazine and promethazine are phenothiazine medications and should not be administered to a client who has a documented allergic reaction to promethazine. 5) CORRECT — Ceftriaxone and cefazolin are cephalosporin medications. A documented allergic reaction to any cephalosporin dictates that no medications in this classification should be prescribed or administered to the client.

A client recovering from surgery is alert and stable but requests pain medication. Vital signs are BP 98/62 mm Hg and pulse 120 beat/min. Which response is the best for the nurse to make to the nursing assistive personnel (NAP) who questions giving pain medication because of a low blood pressure? 1. "The rapid heartbeat related to pain causes hypotension. " 2. "You don 't need to worry about that. " 3. "I think there is another client light on. " 4. "Did you check on the client in the next bed? "

1) CORRECT— Explaining how the rapid heart rate affects the blood pressure addresses the NAP 's question. Pain medication may cause the heart rate to slow and conversely increase the client 's blood pressure.

The nurse provides discharge teaching to a young adult client diagnosed with HIV and AIDS. Which client statement indicates the nurse's discharge teaching is effective? 1. "I should not share a razor with anyone else." 2. "I should have a private bathroom that no one else uses." 3. "I should not eat my meals at the same table as my family members." 4. "I should wash my laundry separately from my family members' clothing."

1) CORRECT— HIV is transmitted through exposure to contaminated blood and body fluids. Sharing a razor may promote disease transmission if the blade is contaminated with blood that contains HIV.

The nurse in the critical care unit reviews postoperative care for a client after a supratentorial craniotomy. Which instruction is important for the nurse to communicate to the unlicensed assistive personnel (UAP)? 1. "Put an ice pack on the client's eyes and a cool compress on the forehead." 2. "Determine how much pain the client is experiencing on a scale of 1 to 10, and report back to me." 3. "Keep the head of the bed flat, with the client lying on the back." 4. "If the client starts to have a seizure, place a padded tongue blade in the mouth right away and call for help."

1) CORRECT— It is appropriate to delegate the application of heat or cold to a closed inflamed or painful area to the unlicensed assistive personnel (UAP). The client may have periorbital edema and burning after the surgery. Ice will cause vasoconstriction and decrease the edema. The cool compress is a comfort measure.

The nurse is preparing the client for a C3 to C4 laminectomy. Which client statement indicates to the nurse the client requires further instruction? (Select all that apply.) 1. "My pain will be completely gone when I wake up. " 2. "I should not twist my back right after surgery. " 3. "I will probably be incontinent after the surgery. " 4. "I do not smoke so there will not be complications. " 5. "It does not matter if I take herbal supplements. "

1) CORRECT— Postoperative pain is common. This client requires further instruction regarding this common phenomenon. 3) CORRECT— Bowel or bladder incontinence would be an unexpected complication that might indicate spinal cord injury. This statement indicates the need for further instruction. 4) CORRECT— The client may still have complications, although the risks for many complications are reduced. This statement indicates the need for further instruction. 5) CORRECT— The use of herbal supplements should be shared with the health care team as some herbs interfere with other treatments and medications. This statement indicates the need for further instruction.

The nurse admits an older adult client to the unit. The client demonstrates decreased ability to problem-solve, psychomotor deficits, and social isolation. Which nursing action is most appropriate? 1. Prepare a schedule of activities and monitor the client's participation in the activities. 2. Encourage the client to choose the client's own activities. 3. Allow the client time to get acclimated to the milieu before scheduling activities. 4. Allow the client to rest quietly to restore energy level.

1) CORRECT— The client displays symptoms of depression. For the client with depression, a regular daily routine of scheduled activities provides structure and decreases the amount of problem solving required. Participating in activities will increase self-esteem and assist the client to engage with others.

A client diagnosed with terminal cancer asks the nurse's opinion about complementary therapy. The nurse notices that the client has stopped taking fluorouracil. Which response by the nurse is appropriate? 1. "Tell me more about the complementary therapy that interests you." 2. "The only thing that is going to help you is the chemotherapy." 3. "How did you hear about the complementary therapy?" 4. "Is the chemotherapy causing side effects?"

1) CORRECT— The client has the right to choose the treatment modality for the cancer. The nurse should obtain more information about what the client is taking and ensure that the client understands the benefits and drawbacks of utilizing complementary therapy.

The nurse reinforces principles of asepsis to the LPN/LVN. Which action by the LPN/LVN will prompt the nurse to intervene? (Select all that apply.) 1. Allowing clean gloves to touch the sterile tip of a syringe. 2. Talking to the assisting nurse over a sterile field. 3. Placing sterile instruments on the edge of an opened sterile package. 4. Holding sterile objects below waist level. 5. Performing hand hygiene prior to donning sterile gloves. 6. Touching the outside of a sterile glove.

1) CORRECT— The nurse should intervene because the tip of the syringe is now contaminated. 2) CORRECT— The nurse should intervene because no one should talk, laugh, sneeze, or cough over a sterile field due to the risk of contamination by microorganisms traveling by droplets through the air. 3) CORRECT — The nurse should intervene because after a sterile package is opened, the edges are considered unsterile. 4) CORRECT— The nurse should intervene because any object held below waist level is considered contaminated because the LPN/LVN cannot view it at all times. 6)The nurse should intervene. An LPN/LVN should touch only the inside of the sterile glove to avoid contamination.

The nurse prepares a client for diagnostic testing to determine if the client has cancer. The client seems to have difficulty concentrating, is tense, and restless. Which response by the nurse is best? 1. "You seem to be anxious. Please share your thoughts with me." 2. "You will be less anxious if you understand the diagnostic tests." 3. "Why are you so restless? Your health care provider is very good." 4. "You seem worried about the tests. I'm sure everything will be fine."

1) CORRECT— This open-ended response acknowledges the client's concerns and allows the client to verbalize feelings.

The nurse manager is informed that a client on the unit has developed a central line-associated bloodstream infection (CLABSI). The nurse manager collaborates with the risk manager during an investigation of the incident. Which actions are appropriate for the nurse to take in this situation? (Select all that apply.) 1. Determine if lack of supplies was a contributing factor. 2. Review nursing documentation prior to the CLABSI. 3. Determine the method by which nurses access central lines. 4. Reassure the client and family that the CLABSI was unavoidable. 5. Instruct the nurses who cared for the client to obtain legal counsel.

1) CORRECT— Those individuals participating in the investigation will determine whether appropriate supplies, such as chlorhexidine/silver sulfadiazine-impregnated catheters and occlusive dressings, were available. 2) CORRECT— Nursing documentation is reviewed to determine the frequency of dressing changes and how frequently catheter insertion sites were changed. 3) CORRECT— Those individuals participating in the investigation will determine the exact technique that nursing staff uses when accessing central lines to determine whether faulty nursing actions increase the risk of CLABSI.

A client is admitted to the hospital with a diagnosis of hepatitis B. On which factors will the nurse base the plan of care? 1. Blood and body fluids of an infected individual can be contagious. 2. Client should not receive any blood or blood products during the hospitalization. 3. Client should not have blood drawn during the hospitalization. 4. Client has increased susceptibility to other viruses because of the hepatitis B. View Explanation

1) CORRECT— Transmission of the virus is through parenteral drug abuse, sexual contact, and blood and body fluids. High risk groups include immigrants from endemic areas, drug addicts, fetuses from infected mothers, unprotected sexual contact between multiple partners, transfusion clients, and health care workers.

The nurse provides teaching for a client diagnosed with herpes zoster. Which client statements indicate to the nurse a correct understanding of the information presented? (Select all that apply.) 1. "I will take antibiotics for the infection." 2. "I should expect only one side of my face to hurt." 3. "I caught this from my partner." 4. "This pain may linger for months." 5. "I will try not to scratch the lesions."

1) INCORRECT - Antivirals, not antibiotics, are used to treat viral infections such as herpes zoster (shingles). 2) CORRECT— Herpes zoster follows dermatomes on one-half of the body. 3) INCORRECT - It is not possible to catch shingles from another person. However, varicella zoster virus can be spread from someone with shingles to someone who has never had chickenpox. This person would develop chickenpox, not shingles. 4) CORRECT— Herpes zoster may lead to post-herpetic neuralgia, a nerve pain that persists for days to months after the infection is cleared. 5) CORRECT — Lesions are known to cause itching as well as pain. The client is advised not to scratch primarily to avoid secondary bacterial infection.

The nurse provides care for a client diagnosed with malignant melanoma. Which finding does the nurse expect to observe when assessing the client? 1. An irregularly shaped lesion. 2. A pearly papule with a waxy border. 3. A small papule with rough dry scale. 4. A firm, nodular lesion covered by a crust.

11) CORRECT — Malignant melanoma is expected to be an irregluarly shaped lesion. This type of lesion may also be a pigmented papule with red, white, or blue color.

The nurse provides dietary teaching to a client with advanced stage liver cirrhosis. Which client statements require intervention by the nurse? (Select all that apply.) 1. "I will increase the number of calories in my diet. " 2. "I will increase the amount of fat in my diet. " 3. "I will increase the amount of sodium in my diet. " 4. "I will increase the number of B complex vitamins in my diet. " 5. "I will increase the amount of fluids in my diet. "

2) CORRECT - A client with liver cirrhosis should decrease the amount of fat, and increase the amount of carbohydrates, in the diet. 3) CORRECT- The client with liver cirrhosis should decrease the amount of sodium in the diet to prevent or manage ascites. 5) CORRECT- A client with liver cirrhosis should decrease the amount of fluids in the diet to help prevent or manage ascites.

The nurse provides care to a client who is diagnosed with chronic cirrhosis due to long-term alcohol abuse. Which nursing assessment finding leads the nurse to suspect the client may also be experiencing early-stage hepatic encephalopathy? 1. Abdominal distention with umbilical protrusion. 2. Alternating periods of euphoria and lethargy. 3. Flaccidity of the arms and legs. 4. Absence of deep tendon reflexes.

2) CORRECT - Alternating periods of euphoria and lethargy are consistent with early-stage hepatic encephalopathy. Other manifestations of early-stage hepatic encephalopathy include a normal level of consciousness and reversal of day-night sleep patterns.

A client seeks medical attention after having bleach splashed in the eyes. Which action will the nurse perform first? 1. Ask the unit secretary to gather demographic data. 2. Irrigate the client's face and eyes. 3. Perform a comprehensive physical assessment. 4. Place the client on a stretcher and cover with a blanket.

2) CORRECT - Bleach is an alkaline substance that can penetrate the scleral membrane and cause permanent eye damage. The alkaline should be immediately removed to limit the amount of damage to the eye.

The nurse provides care for clients in a senior citizens center. The client tells the nurse, "I had pneumonia once, and I do not want to get it again." Which question is most important for the nurse to ask? 1. "How often do you cough and deep breathe?" 2. "Have you received a flu shot this year?" 3. "Do you attempt to avoid crowds?" 4. "How much sleep do you receive each night?"

2) CORRECT - Community-acquired pneumonia (most common form of pneumonia) often follows viral infections or influenza. The nurse should also ask the client about the pneumococcal vaccine.

An older adult client takes dexamethasone 1.5 mg by mouth three times a day. Which client statement causes the nurse concern? 1. "I take my medication with meals." 2. "I have this little sore on my leg that won't go away." 3. "I should take a brisk walk several times a week." 4. "I avoid public places during the flu season."

2) CORRECT - Dexamethasone, a cortiosteroid, suppresses the immune response. A non-healing sore should be reported to the health care provider and further assessed.

A client who received an intravenous dose of penicillin G develops restlessness, wheezing, and swelling of the lips and tongue. After applying oxygen via nonrebreather face mask, which action will the nurse take next? 1. Initiate an intravenous infusion of warmed 0.9% sodium chloride. 2. Administer epinephrine 1:1000 intravenous push. 3. Give subcutaneous diphenhydramine. 4. Insert an indwelling urinary catheter.

2) CORRECT - The client is exhibiting symptoms of an anaphylactic reaction. The next action the nurse should take is to administer 0.3 to 0.5 mL of epinephrine 1:1000, by the subcutaneous, intramuscular, or intravenous route, which the nurse can repeat in 20 to 30 minutes if there is an indication. Epinephrine is the medication of choice for anaphylaxis as it can activate three types of adrenergic receptors and thus reverse the reaction to the antigen. This leads to increased blood pressure, decreased epiglottal edema, and decreased bronchoconstriction.

The nurse overhears the unlicensed assistive personnel (UAP) discuss a client who is hospitalized under an alias after being injured while committing a crime. Which statement will the nurse make to the NAP? (Select all that apply.) 1. "As long as we don't talk to anyone else, it's fine to gossip among ourselves." 2. "We treat all of our clients the same, regardless of what they may have done." 3. "We can discuss the client's situation only with others involved in the care." 4. "I will tell you what crime was committed after I ask the client." 5. "The discussion violates the client's confidentiality. Please stop the conversation immediately."

2) CORRECT - Ethical client care means that all clients are treated the same, regardless of the illness or circumstances. This supports the client's right to ethical care. 3) CORRECT - The UAP should only discuss the client's care needs with those who are involved with the care. 5) CORRECT - The Health Insurance Portability and Accountability Act (HIPAA) includes information about client confidentiality. The UAP talking about the client violates HIPAA and should be stopped immediately.

The charge nurse on the medical unit reviews the health care provider's prescriptions for four newly admitted clients. Which prescription does the nurse question? 1. A computed tomography (CT) scan for a client who has suspected intracranial bleeding. 2. A bone imaging study for a client diagnosed with multiple myeloma. 3. A chest x-ray for a client who has a positive tuberculin skin test. 4. An upper GI tract endoscopy for a client diagnosed with cirrhosis.

2) CORRECT - Every contrast medium has a risk for causing reactions, so the benefit versus risk of harm to the client should be considered. Multiple myeloma involves overproduction of plasma cells, with resultant destruction of bone and of bone marrow products. If a bone scan is done, false-negative results will occur. This means that the client would be exposed to potential harm with no benefit. Multiple myeloma is unique as a neoplastic condition in that it is better detected with a plain radiograph than with a nuclear scan.

The nurse provides care to infant and toddler clients in a day care facility that has experienced an outbreak of hepatitis A. To control disease transmission and prevent a future outbreak of hepatitis A, the nurse prioritizes the implementation of which intervention? 1. Restricting contact with children who have symptoms of hepatitis A. 2. Educating staff and clients about proper hand hygiene protocols. 3. Advising staff and clients to request administration of immune globulin (IG) from their health care providers. 4. Recommending mandatory hepatitis A screening of all potential staff members.

2) CORRECT - Following proper hand hygiene protocols is the most effective measure to prevent or control an outbreak of hepatitis A. Restricting contact with individuals who have symptoms of hepatitis A is not an effective strategy for controlling disease transmission, as the disease may be transmitted before symptoms appear. Immune globulin (IG) is effective against hepatitis if administered within 2 weeks of exposure. Because of the cost of blood tests used to screen for hepatitis A, routine screening is not recommended.

The nurse provides care to a male client. The health care provider (HCP) prescribes IV infusion of 1000 mL 0.9% sodium chloride (NaCl) over 8 hours. Which assessment findings cause the nurse to hold administration of the IV fluid and clarify the HCP's prescription? (Select all that apply.) 1. Blood urea nitrogen (BUN) is 18 mg/dL (6.43 mmol/L). 2. Hematocrit is 38% (0.38 Proportion of 1.0). 3. Urine output is 2200 mL/day. 4. Urine specific gravity is 1.008. 5. Serum sodium (Na +) is 139 mEq/L (139 mmol/L).

2) CORRECT - Normal hematocrit is 42 to 52% (0.42 to 0.52 Proportion of 1.0) in men, and 35 to 47% (0.35 to 0.47 Proportion of 1.0) in women. In the absence of bleeding, decreased hematocrit may indicate fluid volume excess. Further evaluation is needed prior to administering additional fluid. 3) CORRECT - Normal adult urine output is 800 to 2000 mL/day. Excessive urine production may indicate fluid volume overload. Administration of additional fluid should be questioned. 4) CORRECT - Normal urine specific gravity is 1.010 to 1.030. A decrease in urine specific gravity is reflective of dilute urine and may indicate excess fluid volume is present. Administration of additional fluid should be questioned.

The nurse provides care to an infant client who is 4 months of age with meningitis. Which assessment finding indicates increased intracranial pressure (ICP)? 1. Positive Babinski reflex. 2. High-pitched cry. 3. Bulging posterior fontanelle. 4. Pinpoint pupils.

2) CORRECT - One of the first signs of increased intracranial pressure in an infant is a high-pitched cry. Other signs include irritability, poor feeding, and increased frontal occipital circumference.

The nurse supervises the unlicensed assistive personnel (UAP) who provides care for a client diagnosed with a cervical spinal cord injury (C7-C8). Which action by the UAP requires intervention by the nurse? 1. The UAP elevates the head of the bed 30 degrees when assisting with meals. 2. The UAP firmly massages the client's lower back and buttocks with lotion. 3. The UAP instructs the client to shift weight every 15 minutes when sitting. 4. The UAP positions the client in a 30-degree lateral turn position in bed.

2) CORRECT - Providing a firm massage can damage tissue, increasing the risk for skin breakdown. This client is already at risk for skin breakdown due to immobility. This action requires immediate intervention by the nurse.

The nurse instructs a client receiving acyclovir. Which client statement indicates that teaching is effective? 1. "The medication will cure my disease." 2. "I should drink extra fluids while taking this medication." 3. "I am glad that I only have to take this once a day." 4. "I can apply lotion on the lesions if they begin to hurt."

2) CORRECT — Acyclovir may cause or contribute to renal failure. The client should drink additional fluids while taking the medication and report any decrease in urination to the health care provider.

A client is discharged from the emergency department after evaluation for a concussion with loss of consciousness. Which statement by the client's spouse indicates to the nurse that further teaching is necessary? 1. "I will wake my spouse up every 3 hours when he is sleeping and ask him his name, my name, and where he is." 2. "If my spouse reports a headache and needs aspirin, I will give it to him no more than every 4 hours." 3. "If my spouse complains of blurry vision or has difficulty walking, I will bring him to the emergency department." 4. "I will talk to my spouse's friend about doing the coaching for the soccer team tomorrow.

2) CORRECT - The client should not receive aspirin, as it can prolong any bleeding that might occur. Acetaminophen every 4 hours as needed is what should be given for pain.

The nurse teaches the spouse of a client about changing the dressing on a central venous catheter (CVC). The spouse asks, "What is that round foam disc for?" Which response by the nurse is accurate? 1. "The disc ensures that the insertion site stays clean and dry." 2. "The disc has anti-microbial properties to help prevent infection." 3. "The disc serves as an anchor to hold the catheter in place." 4. "The disc helps to keep the line from clotting."

2) CORRECT - The disc is impregnated with an anti-microbial product intended to help prevent infections at the insertion site.

The nurse instructs a client who is requesting information on breast self-examination (BSE). Which information is accurate for the nurse to provide during this teaching? 1. "Firmly press the palm of your hand over the entire breast, rotating it in a circular motion." 2. "Using the pads of your middle three fingers, press the breast against the chest wall in a circular motion." 3. "Gently squeeze the breast between the thumb and the index and middle fingers, moving from the base of the breast to the nipple." 4. "Compress the breast between the palms of both hands, applying moderate pressure."

2) CORRECT - The nurse should instruct on the use of a gentle rotating motion with the palmar surfaces of the middle three fingers. These fingers are used to press the breast tissue against the chest wall. Palpation begins in the upper lateral quadrant, moves from the periphery to the areola, and moves around the breast in a counterclockwise direction.

The charge nurse assists a new nurse in learning client care management and delegation. The charge nurse counsels the new nurse when which actions are observed? (Select all that apply.) 1. The new nurse asks the charge nurse to assist with the insertion of an IV catheter after two failed attempts. 2. The new nurse asks the unlicensed assistive personnel (UAP) to obtain the blood glucose on a client newly diagnosed with diabetes mellitus who was just admitted to the unit. 3. The new nurse asks the unlicensed assistive personnel (UAP) to perform a complete bed bath on a bedbound client with a tracheostomy. 4. The new nurse asks the unlicensed assistive personnel (UAP) to obtain vital signs on a client who just returned from a cardiac catheterization. 5. The new nurse asks the unlicensed assistive personnel (UAP) to assist a newly admitted client with myasthenia gravis with the first meal.

2) CORRECT - This client is both newly diagnosed with diabetes mellitus and is a new admit. The new nurse should obtain the initial blood glucose, for there is a high likelihood of an abnormal result that requires immediate treatment. The charge nurse needs to counsel this new nurse on tasks that are appropriate to delegate. 4) CORRECT - The client just returned from an invasive procedure, and obtaining vital signs are part of the assessment after a cardiac catheterization. This task should not be delegated. The charge nurse needs to counsel this new nurse on tasks that are appropriate to delegate. 5) CORRECT - This client may be unstable and require additional assessment by the nurse, including a swallow assessment. The charge nurse needs to counsel this new nurse on tasks that are appropriate to delegate.

A client diagnosed with leukemia has a platelet count of 100×10 3/µL (100×10 9/L). The client is scheduled to receive a platelet transfusion. The novice nurse reviews the transfusion plan with the nurse preceptor. Which statement, made by the novice nurse, requires the nurse preceptor to intervene? 1. "I will stop the intravenous amphotericin B while the transfusion is taking place." 2. "I will be sure to have a standard transfusion set ready before I call the blood bank." 3. "I will have normal saline intravenous solution available for use with the transfusion." 4. "I will monitor the client closely for the first 15 to 30 minutes, especially for a fever."

2) CORRECT - This requires an intervention. All equipment should be ready before blood is requested from the blood bank. However, standard transfusion sets are not used for platelet administration because the filter traps the platelets and there is increased adherence of platelets to the lumen of the longer tubing. An administration set particularly designed for platelets must be used, as it has a smaller filter and shorter tubing.

The nurse monitors a client for the early signs and symptoms of dumping syndrome. Which assessment findings indicate to the nurse that this complication has occurred? (Select all that apply.) 1. Abdominal cramping. 2. Vertigo. 3. Tachycardia. 4. Profuse sweating. 5. Pallor.

2) CORRECT - Vertigo is an early manifestation that occurs 5 to 30 minutes after eating. 3) CORRECT -Tachycardia is an early manifestation that occurs 5 to 30 minutes after eating. 4) CORRECT - Profuse sweating is an early manifestation that occurs within 5 to 30 minutes after eating. 5) CORRECT - Pallor is an early manifestation that occurs 5 to 30 minutes after eating. 1)Abdominal cramps are a late sign

The nurse provides care to an adult client who sustained a T3 spinal cord injury 2 days ago. The nurse suspects a developing emergency based on which assessment finding? (Select all that apply.) 1. Respiratory rate of 18 breaths/min. 2. Warm, dry, flushed skin. 3. Absence of sensation in lower extremities. 4. Blood pressure of 88/42 mm Hg. 5. Heart rate of 88 beats/min.

2) CORRECT - Warm, dry skin and skin flushing may be manifestations of neurogenic shock. With neurogenic shock, changes in skin color and temperature occur as a result of loss of vascular tone, which causes peripheral vasodilation. 4) CORRECT - Classic manifestations of neurogenic shock include hypotension and warm, dry skin. Bradycardia may or may not be present with neurogenic shock.

A community experiences a prolonged heat wave. The emergency department has several clients admitted from a construction project. Which indications will alert the nurse to the diagnosis for heat stroke? 1. Elevated temperature, diaphoresis, nystagmus. 2. Hypotension, tachypnea, tachycardia. 3. Hemiplegia, diplopia, dysarthria. 4. Headache, hot dry skin, hypertension. View Explanation

2) CORRECT — A client will have a temperature of 105°F (40.6°C) or above with skin that is hot and dry. A client's behavior may be bizarre, with confusion or delirium, or the client may be comatose.

A nurse prepares to perform blood pressure screenings at a health fair in the local community center. Which part of the preparation receives the most attention? 1. Ensure that there will be several quiet rooms near the main gathering area. 2. Collect blood pressure cuffs of varied sizes. 3. Arrange low-cholesterol snacks for participants. 4. Procure booklets that explain hypertension in simple language. View Explanation

2) CORRECT — Having blood pressure cuffs of varied sizes is essential to ensure accurate blood pressure readings. People attending the fair almost certainly will vary in arm size. A cuff that is too small will produce a falsely high reading, while a cuff that is too large will produce a falsely low reading. The nurse will ensure the ability to obtain accurate readings.

The nurse on the medical unit reviews laboratory results on four clients. Which result causes the nurse to notify the health care provider? 1. Theophylline level 15 mcg/mL (82.25 µmol/L ) for a client diagnosed with emphysema. 2. Digoxin level 2.5 ng/mL (3.2 nmol/L) for a client diagnosed with heart failure. 3. International normalized ratio (INR) 2.5 for a client who takes warfarin. 4. Lithium level of 1.2 mEq/L (1.2 mmol/L) for a client diagnosed with bipolar disorder.

2) CORRECT — The normal therapeutic level of digoxin in the blood is between 0.5 and 2 ng/mL (0.6 to 2.6 nmol/L). The client with a digoxin level of 2.5 ng/mL (3.2 nmol/L) has digoxin toxicity, and this should be reported to the health care provider. Digoxin is a cardiac glycoside and a positive inotrope.

The nurse presents a program at the community center about risk factors for colorectal cancer. Which client does the nurse identify as being at risk for colorectal cancer? 1. An 18-year-old client who exercises five times weekly. 2. A 54-year-old client who eats a diet high in fat. 3. A 35-year-old client whose cousin was diagnosed with colorectal cancer at age 32. 4. A 45-year-old client who had an appendectomy during the teen years.

2) CORRECT — This client has two risk factors. Those include age (over 50 years) and a high-fat diet. A diet high in fat or low in fiber is a risk for colorectal cancer.

The nurse in the outpatient clinic counsels a client diagnosed with genital herpes. The client states, "I do not know how I keep getting reinfected because I am really careful." Which response by the nurse is best? 1. "What do you mean, ' I am really careful'?" 2. "The virus remains in your body in a dormant state." 3. "Are you sure that you protect yourself adequately?" 4. "Have you notified all of your sexual contacts?"

2) CORRECT — This response provides the client with objective information to directly respond to the concern raised. The client should not engage in sexual activity while the lesions are present. To prevent spread, the client should either abstain from sex or use a condom.

A client is brought to the emergency department by a family member who reports that the client experienced a sudden onset of decreased level of consciousness, blurred vision, headache, and slurred speech. Which action does the nurse take? 1. Elevate the head of the bed 90 degrees. 2. Obtain a finger-stick blood glucose level. 3. Pad the side rails of the client 's bed. 4. Obtain a urine specimen from the client.

2) CORRECT- Assessment of other possible underlying causes that can be quickly and easily corrected should be ruled out first. These include hypoglycemia, which may present with similar symptoms. The client's symptoms are suggestive of a possible TIA or CVA.

The nurse prepares a solution of parenteral nutrition (PN) to infuse through a client's central line. Which piece of equipment is most important for the nurse to obtain before starting the infusion? 1. Glucose monitor. 2. Electronic infusion pump. 3. Pulse oximeter. 4. Urine glucose strips.

2) CORRECT- Because of the high glucose content, use of an infusion pump is necessary to ensure that the solution does not infuse too rapidly or fall behind.

The school nurse assesses four school-age clients. Which client's parents will be contacted to pick up the child from school? 1. Child with a red rash on the cheeks that makes the face look like it has been slapped. 2. Child with a fever reporting headache, malaise, anorexia, and an earache when chewing. 3. Child with allergies whose conjunctiva are inflamed with swollen eyelids and watery drainage. 4. Child with clusters of small, erythematous, intensely pruritic papules in the antecubital space.

2) CORRECT- The child with a fever, headache malaise, anorexia, and ear pain with chewing indicates probable mumps. The child is most communicable immediately before and after the swelling begins.

The nurse views the cardiac monitors for clients on the unit and notes the presence of elevated T waves. Which client is likely to have this appear on the ECG? (Select all that apply.) 1. A client with Cushing syndrome who has hypertension and a pathologic fracture of the spine. 2. A client with alcoholic liver cirrhosis who has severe ascites and shallow respirations. 3. A client who was in a house fire and suffered extensive burns on the arms, trunk, and face. 4. A client who reports severe vomiting for 3 days and shows symptoms of mild dehydration. 5. A client who has been on prednisone for 6 months.

2) CORRECT- Clients with liver failure may have an underproduction of bicarbonate, leading to metabolic acidosis. Ascites pushes on the lungs, decreasing lung capacity. Shallow respirations lead to buildup of CO2 and respiratory acidosis. Hyperkalemia is associated with acidosis. This client will likely have an elevated T wave. 3) CORRECT - There is a release of intracellular potassium because of cell destruction from the burns, which will increase serum potassium. This client will likely have an elevated T wave.

The charge nurse reviews potential client assignments for a team consisting of a nurse, the LPN/LVN, and the unlicensed assistive personnel (UAP). Which client will the nurse assign to the LPN/LVN? 1. Client with Alzheimer disease and diabetes mellitus who requires help with feeding. 2. Client with a stage 2 pressure injury requiring a sterile dressing change. 3. Client with Parkinson disease and osteoporosis who requires ambulation. 4. Client transferred from the hospital after admission for evaluation of a fall.

2) CORRECT- Completing a sterile dressing change is an appropriate assignment for the LPN/LVN, as this is within the scope of practice.

The nurse provides care for a client diagnosed with disseminated herpes zoster. Which observation by the nurse would require intervention? 1. The health care provider wears an N-95 mask when entering the client 's room. 2. The phlebotomist leaves the door open when exiting the room. 3. The client is placed in a room with negative air pressure. 4. The LPN/LVN removes the gown before leaving the client 's room.

2) CORRECT- Disseminated herpes zoster requires both airborne and contact precautions. The client must be placed in a negative air pressure room, which requires the door to be closed at all times. The nurse needs to intervene if the client 's door is left open.

The nurse sees four clients for an annual health assessment. To which of these clients does the nurse offer the meningococcal immunization? 1. A 60-year-old who works as an Licensed Practical Nurse in a skilled nursing facility. 2. A first-year college student who lives in a residence hall. 3. A 30-year-old who is sexually active, but human immunodeficiency virus (HIV) negative. 4. A retired military veteran who served combat duty.

2) CORRECT- Due to past outbreaks of bacterial meningitis in dormitories, first-year college students living in a residence hall should be immunized against bacterial meningitis.

The nurse leads a class for graduate nurses about immunizations. Which statement by the graduate nurse indicates an appropriate understanding of immunizations? 1. "The influenza vaccine is contraindicated if the client is allergic to pork. " 2. "The pneumococcal and influenza vaccine can be administered at the same time. " 3. "The pneumococcal vaccine prevents any complications from a chronic illness. " 4. "Vaccinations have not been shown to decrease the hospitalizations for older adults. "

2) CORRECT- Flu and pneumonia vaccines can be administered at the same time in different sites.

The nurse provides care for a client diagnosed with septic shock who has a BP of 70/46 mm Hg, HR of 136 beats/min, RR of 32 breaths/min, a temperature 104.0°F (40°C), and a blood glucose of 296 mg/dL (16.43 mmol/L). Which health care provider's prescription does the nurse implement first? 1. Start an insulin drip to maintain the blood glucose at 140 to 180. 2. Administer normal saline (NS) at 500 mL/hour. 3. Start norepinephrine to keep the mean arterial pressure (MAP) at 65 to 70 mm Hg. 4. Obtain blood and sputum cultures.

2) CORRECT- Fluid volume resuscitation is the priority in order to improve the client's hemodynamic status.

The nurse provides care to a client who just underwent left modified radical mastectomy. When assisting the client with positioning, the nurse implements which action? 1. Extend the client's left arm flat along the affected side. 2. Elevate the client's left arm on a pillow. 3. Rest the client's left arm across her chest. 4. Place the client's left arm below the level of her torso.

2) CORRECT- Following modified radical mastectomy, the client should be placed in semi-Fowler position. To promote lymphatic drainage without compromising circulation, the arm on the affected side should be elevated on a pillow. Elbow flexion or dependent positioning of the arm may impede lymphatic drainage and compromise circulation.

The nurse provides care to a client admitted with mild hyponatremia secondary to excessive water consumption. Which intervention does the nurse anticipate including in the client's plan of care? 1. Administering 0.45% sodium chloride IV. 2. Restricting fluid intake. 3. Administering 3% sodium chloride IV. 4. Encouraging frequent ambulation. View Explanation

2) CORRECT- For treatment of hyponatremia secondary to hypervolemia, restriction of fluid intake is an appropriate intervention.

The nurse provides care for a client who is on therapeutic hypothermia and is being considered for rewarming. Which outcome is the most appropriate to establish? 1. Turn and reposition the client every 2 hours. 2. Rewarm at a rate of 0.45°F. (0.5°C) per hour. 3. Restore the body temperature to 98.6°F. (37°C) in 2 hours. 4. Assess the sedation level every hour.

2) CORRECT- Gradual rewarming is important, keeping the rate of increase at 0.45°F. (0.5°C) per hour. This will safely rewarm the client without untoward effects.

When assessing an older adult client who is diagnosed with dehydration, the nurse expects to observe which clinical manifestations? (Select all that apply.) 1. Weight gain. 2. Tachycardia. 3. Moist mucous membranes. 4. Cold hands or feet. 5. Flattened neck veins.

2) CORRECT- Tachycardia (heart rate greater than 100 beats/minute) is a sign of dehydration secondary to hypovolemia. 4) CORRECT- For the client who is dehydrated, peripheral vasoconstriction may cause the hands and feet to feel cold. 5) CORRECT- Flattened neck veins are a sign of hypovolemia and dehydration. By contrast, hypervolemia causes neck vein distention.

While performing hourly rounds for a client diagnosed with sepsis, the nurse finds that the client is very lethargic, but has a pulse. Which nursing action is the priority for the client? 1. Start a normal saline IV through a large bore needle. 2. Establish airway patency and call for a Rapid Response Team (RRT). 3. Call for a "code" and start chest compressions. 4. Obtain a lactic acid level and apply 100% oxygen.

2) CORRECT- The situation warrants a call for the RRT, while making sure the client's airway is patent.

The nurse is feeding a resident in the dining room of a long-term care facility. Suddenly, the resident starts to choke and becomes cyanotic. Which is the best action for the nurse to take? 1. Stand behind the resident and deliver a quick blow to the middle of the back with the palm of the hand. 2. Embrace the resident from behind and, with a fist, quickly thrust upward into the abdomen. 3. Check the resident 's mouth and throat for food, and perform a finger sweep. 4. Lay the resident on the floor and prepare to initiate cardiopulmonary resuscitation.

2) CORRECT- This describes the Heimlich maneuver, which expels the remaining air in victim 's lungs, along with the foreign body.

When caring for a client receiving internal radiation therapy, which action by the nurse will prevent accidental exposure? 1. Instruct visitor who is pregnant to wear a lead apron. 2. Wear lead gloves and apron when possible. 3. Maintain a 2-foot distance from client when providing care. 4. Place client's room next to the nurse's station.

2) CORRECT-When caring for a client receiving internal radiation therapy, the nurse needs to wear lead gloves and apron whenever possible. When the nurse wears lead gloves and an apron, this shields the nurse from the radiation

The nurse plans discharge care for the client diagnosed with recurrent cancer and lymphedema. Which client statements alert the nurse to a need for home health services? (Select all that apply.) 1. "I use this magnifying glass when I need to read small print. " 2. "Sometimes I don 't get to the bathroom in time. " 3. "My hands always shake when I try to pick things up. " 4. "My dentures don 't fit so I don 't wear them, but I eat just fine. " 5. "I can 't feel a thing in my feet. It 's been that way for a while. " 6. "I 'm not able to get in the bathtub anymore. "

2) CORRECT— A home health referral could benefit this client by assessing for durable medical equipment that might assist the client in using the bathroom. If incontinence is a problem, the client may need assistance with personal care. 3) CORRECT— This client may need assistance preparing meals, and managing medication administration. Home health care can provide accurately assess and provide appropriate referrals. 4) CORRECT— Although the client says, "I eat just fine, " a dietary referral will ensure the client has the home resources and ability to eat a balanced diet. The fact that the dentures don 't fit may indicate the client has lost significant weight. 5) CORRECT— A home health referral will determine if this client has safety needs in the home because of numbness in the feet. Slippery or uneven surfaces could be dangerous for this client.

The nurse manager on the oncology unit makes rounds during the day shift. Which observation by the manager requires an immediate intervention? 1. Wearing gloves, the nurse firmly seals all four edges of the sterile gauze dressing at an IV catheter insertion site with tape. 2. Using a marking pen, the nurse labels an IV fluid bag with the date and time the IV was initiated and the nurse's initials. 3. The nurse secures aluminum foil around a hanging IV solution of nitroprusside. 4. The nurse wears a cap, mask, gown, and gloves when initiating a peripherally inserted central catheter (PICC) line.

2) CORRECT— A marking pen should not be used to label an IV bag, especially directly on the plastic IV bag. Ink can penetrate the plastic and diffuse into the solution, posing a risk to the client. Labeling should be done on a label or tape using a regular pen and then placed on the IV bag.

The nurse prepares to administer medications to a newly admitted client. Which intervention by the nurse is most likely to prevent complications for the client? 1. Encourage the client to report any new or unusual symptoms to the nurse or health care provider immediately. 2. Obtain information regarding the client 's allergies, document the information in the chart, and apply an allergy armband. 3. Monitor the client 's response to prescribed medications and document the information in the chart. 4. Offer the client information regarding medications before administration.

2) CORRECT— Accurate history taking and documentation of allergies are the first line of defense in preventing unnecessary reactions in medication administration. This nursing action is most likely to prevent client complications.

The nurse provides care to oncology clients. Which clients require further intervention from the nurse? (Select all that apply.) 1. The client receiving chemotherapy treatment for breast cancer who reports "always feeling tired." 2. The client receiving a chemotherapeutic alkylating agent intravenously via an implanted port with redness on the chest. 3. The client with bladder cancer reporting that "nothing tastes good" and who drinks four cans of nutritional supplement daily. 4. The client receiving radiation for lymphoma who reports there are handfuls of hair on the pillow every morning. 5. The client diagnosed with bone cancer who is receiving chemotherapy and is afebrile but has a productive cough. 6. The client who reports frequent bouts of diarrhea but states the nausea is manageable with occasional sips of fluid.

2) CORRECT— Alkylating agents can cause tissue necrosis if extravasation occurs. This client needs immediate intervention. 5) CORRECT — Clients receiving chemotherapy may not have fever even though they are ill because of bone marrow depression. This client needs immediate intervention. 6) CORRECT— This client is at great risk for dehydration due to frequent diarrhea and reduced oral intake. The nurse will intervene immediately.

The nurse admits a client with a diagnosis of cancer of the larynx to the surgical unit. A total laryngectomy is scheduled. How does the nurse assess laryngeal nerve function? 1. Assess the extent of the client's neck edema. 2. Check the client 's ability to swallow. 3. Observe for excessive drooling. 4. Tap side of face and observe for facial twitching.

2) CORRECT— Assessing the client's ability to swallow is a method of assessing the function of the glossopharyngeal and vagus nerves, which innervate the larynx.

The nurse provides care for a client who is diagnosed with a transection of the spinal cord at T-5 after a motor vehicle crash (MVC). Which client statement most concerns the nurse? 1. "I had a bowel movement last night." 2. "I emptied my bladder 7 hours ago." 3. "I smoke 2 packs of cigarettes per day." 4. "I am menstruating."

2) CORRECT— Bladder retention will cause autonomic dysreflexia, which results in a pounding headache, profuse sweating, nasal congestion, and hypertension due to a sharp elevation in intracranial pressure. The nurse should immediately scan the client's bladder and perform a catheterization to prevent this occurrence.

The nurse notes that an older adult client, receiving treatment in the intensive care unit for pneumonia, develops cognitive changes. Which situation will the nurse suspect first as the reason for this finding? 1. Intensive care unit psychosis. 2. Infection. 3. Hypertension. 4. Medication allergy.

2) CORRECT— Cognitive changes are often seen in older adults with infection. This occurs before fever, pain, or altered laboratory values.

The nurse instructs a client on how to collect a 24-hour urine specimen for a creatinine clearance test. Which statement by the client would cause the nurse to intervene? 1. "I will have to have my blood drawn during the test." 2. "I will go to the lab after I work out in the gym." 3. "I will drink at least 1 cup of water hourly." 4. "I will void and discard the urine before the test begins." View Explanation

2) CORRECT— Creatinine is a waste product of muscle breakdown. A client should not engage in strenuous exercise during, or just before, the test.

The nurse provides care for a client receiving doxycycline. The nurse is concerned if the client makes which statements? (Select all that apply.) 1. "I wear sunscreen when I work in the garden. " 2. "Currently I have a thick vaginal discharge. " 3. "I take the medication at 10:30 AM and 10:30 PM. " 4. "My husband and I use condoms for birth control. " 5. "Finishing all of the medication in the bottle is important. " 6. "I take an antacid immediately before going to bed. "

2) CORRECT— Doxcycline is an antibiotic, which can increase the risk for superinfection. Vaginal discharge may indicate a superinfection, which requires immediate treatment. 3) CORRECT— Medication is taken at regular intervals around the clock, but should not be taken within 1 hour of bedtime because it may cause esophageal irritation. The nurse should find out what time the client usually goes to bed. 6) CORRECT— The client should not take antacids within 1 -3 hours of taking doxcycline to avoid absorption interference.

The nurse supervises the care of a client receiving enteral feedings through an NG tube. Which observations indicate to the nurse that the care being provided by the unlicensed assistive personnel (UAP) is appropriate for this client? (Select all that apply.) 1. Aspirates and measures the amount of the gastric aspirate. 2. Elevates the head of the bed 30 degrees. 3. Warms the feeding to room temperature. 4. Measures the pH of the gastric aspirate. 5. Infuses the intermittent feeding in 20 minutes. 6. Clamps the proximal end of the feeding tube at the end of the feeding.

2) CORRECT— Elevating the head of the bed prevents aspiration and indicates appropriate care by the UAP. 3) CORRECT— Warming the feeding to room temperature prevents cramping and indicates appropriate care by the UAP. 6) CORRECT— Clamping the proximal end of the feeding tube at the end of the feeding prevents air from entering the stomach and indicates appropriate care by the UAP.

The nurse notices that a client who practices Judaism has a lunch tray containing beef, green beans, salad, vanilla pudding, and milk. Which action by the nurse is most appropriate? 1. Ask the client if the client would like a chicken entrée. 2. Inform the client that an alternate meal will be requested. 3. Ask the client if the beef is cooked appropriately. 4. Offer the client more vegetables.

2) CORRECT— For clients practicing Judaism, dietary laws based on biblical and rabbinical regulations forbid the consumption of dairy and meat products during the same meal. The nurse should obtain an alternate meal on a new tray.

The nurse provides care for a client diagnosed with an acute episode of pancreatitis. Which observation causes the nurse to intervene? 1. An unlicensed assistive personnel (UAP) obtains daily intake and output. 2. The spouse assists the client to ambulate in the hall. 3. The LPN/LVN maintains nasogastric suctioning. 4. A nurse administers intravenous fentanyl.

2) CORRECT— For the client with pancreatitis, bed rest is needed to decrease the metabolic rate and the secretion of pancreatic enzymes.

The hospice nurse is called to the home of a terminally ill client who is actively dying. Which action by the nurse is most important? 1. Encourage the family to discuss legal issues with the family attorney. 2. Encourage family to spend time together. 3. Sedate the client. 4. Ask the child to discourage visits by family and friends.

2) CORRECT— The goals of end-of-life care include controlling symptoms, promoting meaningful interactions between client and family, and facilitating a peaceful death. The nurse should be with the client and family to encourage expressions of grief.

The client diagnosed with dehydration is treated with IV normal saline (NS). Which client responses noted by the nurse demonstrate a therapeutic effect of the NS? (Select all that apply.) 1. Crackles noted in the lungs. 2. Blood pressure increases. 3. The pulse rate decreases. 4. Urine output increases. 5. Hematocrit (HCT) level increases.

2) CORRECT— Hypotension may indicate decreased fluid volume. An increase in blood pressure to normotensive is a therapeutic and expected response to the fluid infusion. 3) CORRECT— An increased pulse may indicate decreased fluid volume as the heart pumps faster to maintain homeostasis. A decrease of heart rate to the normal range indicates therapeutic effectiveness of the intervention. 4) CORRECT— Urine output decreases with hypovolemia. A client with adequate hydration replacement should experience increased urination.

The nurse provides care for a client diagnosed with Guillain-Barré syndrome. Which statement indicates to the nurse that the client's family member understands the diagnosis? (Select all that apply.) 1. "The syndrome only lasts one or two weeks." 2. "Intravenous immunoglobulins are often used for treatment." 3. "The cause of the syndrome may be a virus." 4. "This illness doesn't cause shortness of breath." 5. "My loved one's ability to walk will be affected." 6. "A feeding tube may be required for treatment."

2) CORRECT— Intravenous immunoglobulins (IVIG) decrease circulating antibody levels and reduce the amount of time the client is immobilized and can prevent the need for mechanical ventilation. This statement indicates correct understanding of the information presented. 3) CORRECT — A viral infection precipitates clinical presentation in approximately 60% to 70% of cases. This statement indicates correct understanding of the information presented. 5) CORRECT— Guillain-Barré syndrome is an autoimmune attack on the peripheral nerve myelin. This statement indicates correct understanding of the information presented. 6) CORRECT— If the client cannot swallow because of bulbar paralysis, a gastrostomy tube may be placed to administer nutrients. This statement indicates correct understanding of the information presented.

A client diagnosed with lung cancer gains 4.4 lb (2 kg) overnight and has a serum sodium of 122 mEq/L (122 mmol/L) and potassium of 4.5 mEq/L (4.5 mmol/L). Which intervention does the nurse expect to be prescribed for this client? 1. Desmopressin. 2. Furosemide 40 mg IV push. 3. Sodium polystyrene sulfonate. 4. IV normal saline to infuse at 125 mL/hr.

2) CORRECT— Lung cancer is a common cause of syndrome of inappropriate antidiuretic hormone (SIADH), which is an abnormal secretion of antidiuretic hormone. This health problem results in increased water absorption and dilutional hyponatremia. Diuretics are used to promote fluid loss.

The nurse supervises care on the medical-surgical unit. Which situation does the nurse attend to first? 1. The unlicensed assistive personnel (UAP) enters the room of the client diagnosed with Pneumocystis jiroveci pneumonia wearing gown, N95 mask, and gloves. 2. A client who returned to the unit after a right pneumonectomy is placed in a room with a client diagnosed with emphysema who is receiving IV antibiotics. 3. The family of a client reports that the toilet in the client's bathroom is overflowing. 4. A client diagnosed with tuberculosis is ready for discharge and waiting for discharge instructions.

2) CORRECT— Post-operative clients are considered "clean" or uncontaminated and should not be placed with the client who is considered contaminated. The client who is diagnosed with emphysema and receiving IV antibiotics is considered contaminated; therefore, this situation requires immediate intervention by the nurse.

During the height of the flu season, the nurse notes that several family members accompanying clients in the outpatient clinic are coughing and have runny noses. Which action will the nurse take first? 1. Inform family members to stay home if coughing. 2. Instruct those who are coughing to sit at least 3 feet way from others. 3. Post an alert at the entrance to the facility. 4. Provide tissues to the family members.

2) CORRECT— Since influenza is spread by droplets, the nurse should offer masks to people who are coughing, as well as enforce separation by directing them to sit at least 3 feet away from other people.

The nurse provides care to a client diagnosed with a blunt injury to the right temple. Which observation is most important for the nurse to make in this client? 1. Diarrhea. 2. Slowing of speech. 3. Nausea and vomiting. 4. Vertigo and insomnia.

2) CORRECT— Slowing of speech is an early indication of increasing intracranial pressure. Other indications include changes in level of consciousness, restlessness, and confusion.

The nurse enters a client's room after receiving the shift report. The nurse finds the client unresponsive. The client is not breathing and does not have a pulse. The nurse immediately calls out for help. Which action does the nurse take next? 1. Open the airway. 2. Start chest compressions. 3. Give the client oxygen. 4. Ventilate with a mouth-to-mask device.

2) CORRECT— Starting 30 compressions is the second step of the basic life support process, after calling for help. The airway is not opened until after the first 30 chest compressions.

The nurse teaches suctioning techniques to the spouse and client with a new laryngectomy. Which action indicates to the nurse that teaching is effective? 1. Spouse selects a tonsil tip catheter to suction the laryngectomy tube. 2. Client takes several deep breaths before the suction catheter is inserted. 3. Spouse applies suction while introducing the sterile catheter into the stoma. 4. Spouse suctions the client's mouth and then the laryngectomy tube.

2) CORRECT— Taking several deep breaths before being suctioned oxygenates the client and prevents hypoxia.

The nurse provides care for a client diagnosed with a malignant brain tumor located in the left frontal lobe. Which sign or symptom does the nurse expect the client to exhibit? 1. Unilateral hearing loss. 2. Personality changes. 3. Visual impairments. 4. Bowel and bladder incontinence.

2) CORRECT— The frontal lobe controls voluntary activity, executive function, personality, concentration, motivation, ability to plan, and problem solving.

The nursing team on a medical surgical floor consists of two nurses, one nursing assistive personnel (NAP), and one nurse reassigned from the postpartum unit. Which client will the charge nurse assign to the postpartum unit nurse? 1. A client diagnosed with spinal cord injury requiring assistance with meals. 2. A client diagnosed with a myocardial infarction reports burning on urination. 3. A client diagnosed with terminal cancer exhibiting Cheyne-Stokes respirations. 4. A client diagnosed with a head injury with a Glasgow coma score of 7.

2) CORRECT— The reassigned nurse is given the same type of clients as an LPN/LVN. The reassigned nurse should be assigned stable clients with expected outcomes.

The nurse provides care for a client with a head injury who is placed on a volume-cycled ventilator. Which action by the nurse best indicates an understanding of proper management of a client on a mechanical ventilator? 1. Water is added to the tubing to provide for humidification of inspired air. 2. The sigh setting on the ventilator is adjusted to occur every hour. 3. Ventilator settings are adjusted according to the client 's serum electrolytes. 4. A high concentration of oxygen is delivered to prevent tissue ischemia and necrosis.

2) CORRECT— The setting on the ventilator should be set for 1.5 times the tidal volume and adjustment should occur every 1 to 3 hours.

The nurse reviews medical records of clients seen at the clinic. The nurse schedules cancer screenings for which clients based on their increased risk? (Select all that apply.) 1. The client who used an intrauterine device for 15 years. 2. The client who is a seasoned construction worker with red hair and freckles. 3. The client who smoked a half-pack of cigarettes daily for 15 years. 4. The middle-aged client whose parent was diagnosed with colorectal cancer. 5. The retired client who worked as a receptionist in the radiology department for 25 years. 6. The overweight client who identifies as a "meat and potatoes person

2) CORRECT— This client should be screened for skin cancer regularly because of sun exposure related to the job and the additional risk to those with fair skin. A skin assessment and teaching is needed. 3) CORRECT— This client is at increased risk for lung and other cancers due to the carcinogenic and cancer-promoting effects of cigarette smoke. A CT scan of the chest is needed. 4) CORRECT— This client should be scheduled for a colonoscopy because of a possible inherited risk of colorectal cancer, even if the age of 50 has not been reached. 6) CORRECT— This client is at increased risk for colorectal cancer due to being overweight and eating a high-fat diet.

The nurse provides care for an adult client diagnosed with uterine cancer who is receiving chemotherapy. Which statement indicates to the nurse that the client has a realistic perception of the health status? 1. "I will be cured after my therapy is complete." 2. "I have started buying scarves of different colors." 3. "I will be carrying a full load of classes this semester." 4. "I must have done something to cause this illness."

2) CORRECT— This indicates that the client is realistic about what may happen because of chemotherapy. The client should be encouraged to obtains wig, scarves, or hats before losing hair.

A young adult is informed of the diagnosis of breast cancer by the health care provider. Which statement by the nurse is best? 1. "Do you have any questions about your diagnosis?" 2. "Tell me how you are feeling about what you have been told." 3. "I am sure you want to be alone for a few minutes." 4. "I will contact your minister."

2) CORRECT— This is an open-ended statement that allows the client to respond emotionally to the diagnosis.

The nurse provides care for a school-age client diagnosed with leukemia. The client asks the nurse, "Am I going to die?" Which response by the nurse is most appropriate? 1. "Let's talk about you getting well, okay?" 2. "What do you think is happening to you?" 3. "I really do not know the answer." 4. "Please ask your health care provider."

2) CORRECT— This open-ended question allows the client to express feelings, and allows the nurse to assess the client's understanding of the diagnosis and prognosis.

The home health nurse visits a client who is rehabilitating after colostomy surgery. The client says to the nurse, "Can you smell me?" Which response is best by the nurse? 1. "Are you having second thoughts about the surgery?" 2. "Tell me about your specific concerns." 3. "Are you having problems with gas?" 4. "I have a cold and can't smell anything."

2) CORRECT— This response uses therapeutic communication because it acknowledges the client's feelings and allows the client to express concerns about the colostomy.

The nurse provides care for the client diagnosed with acute pancreatitis. The nurse intervenes if the client makes which statement? (Select all that apply.) 1. "I may need to take antibiotics." 2. "After I get better, I need to eat a high fat diet." 3. "I'm glad I won't get sick like this again." 4. "I'm glad my blood sugar will not be affected." 5. "I should stop drinking alcohol." 6. "I cannot have anything to eat or drink."

2) CORRECT— This statement requires intervention by the nurse. Between acute attacks, the client needs a diet high in protein, high in carbohydrates, and low in fat. 3) CORRECT— This statement requires intervention by the nurse. The client may have flare-ups in the future or may develop chronic pancreatitis. 4) CORRECT— This statement requires intervention by the nurse. Transient hyperglycemia occurs in some clients with acute pancreatitis. If the damage from the pancreatitis episode is severe or recurrent, type 2 diabetes mellitus can occur.

The nurse instructs a client with a necrotizing spider bite how to perform dressing changes at home. Which statement indicates the client understands aseptic technique? 1. "I should buy sterile gloves to redress this wound." 2. "I should wash my hands before redressing my wound." 3. "I should keep the wound covered at all times." 4. "I should use an over-the-counter antimicrobial ointment."

2) CORRECT— Washing hands before changing the dressing indicates an understanding of aseptic technique as hand washing is a hallmark strategy.

The nurse instructs parents on ways to decrease the incidence of sudden infant death syndrome (SIDS). Which statements require the nurse to intervene? (Select all that apply.) 1. "I position my baby on the back for sleep. " 2. "My baby takes naps in the car seat. " 3. "My baby sleeps covered with one blanket from chest to feet. " 4. "My baby sleeps with one pillow under the head. " 5. "My baby sleeps best on the sofa. "

2) CORRECT—This statement requires immediate intervention. Infants should not routinely take naps in car seats, strollers, or swings. They may slump enough to obstruct the airway. 3) CORRECT—This statement requires immediate intervention. Infants should ideally be dressed warmly in pajamas, sleepers, or sleep sack instead of using blankets. If a blanket is used, it should be placed no higher than infant 's waist. The edges of the blanket should be tucked under the mattress to prevent blankets from covering the infant 's face. 4) CORRECT—This statement requires immediate intervention. Use of a pillow increases the risk for suffocation. 5) CORRECT—This statement requires immediate intervention. Infants should not sleep on soft surfaces like a sofa, armchair, soft mattress, or waterbed.

A client is prescribed 3000 mL of 5% dextrose in normal saline (D5NS) every 24 hours by gravity infusion. The administration set delivers 15 drops/mL. Which is the correct infusion rate/minute for this solution? 1. 21 drops/minute. 2. 31 drops/minute. 3. 50 drops/minute. 4. 96 drops/minute.

2). ) CORRECT bsp— The nurse will take the volume of solution (3000 mL) and multiply it by the drop factor (15 drops/mL). This will yield the total number of drops to be infused in 24 hours (45,000). The nurse will then divide the total number of drops (45,000) by 24 hours. This will yield the drops per hour (1875). Then the nurse will then divide the drops per hour by the number of minutes per hour (60 minutes/hour). The nurse can do this by cross-multiplying: 1875 drops/hour X 1 hour/60 minutes. This will result in 1875 drops/60 minutes. Once the nurse divides 1875 by 60, this will yield 31.25 drops/minute. Because the nurse cannot infuse fractions of a drop, the nurse will round to 31 drops/minute.

A nurse prepares to teach a health promotion class to a group of adult clients. Which recommendation does the nurse include regarding cancer screening? 1. Clients should have a colonoscopy every 10 years starting at age 40. 2. Clients should have a fecal occult blood test every year starting at age 30. 3. Women should have a Papanicolaou test every 3 years between 21 and 29 years of age. 4. Women should have a clinical breast examination every 5 years between 20 to 40 years of age.

3) CORRECT - According to the American Cancer Society, women should have a Papanicolaou (Pap) test every 3 years between the ages of 21 and 29 years.

The nurse provides care for clients in the intensive care unit (ICU). A client diagnosed with a head trauma needs to be admitted. There are no empty beds. Which client does the nurse anticipate as being the most stable for a transfer to the step-down neurological unit? 1. A client diagnosed with bacterial meningitis and Glasgow Coma Scale of 7. 2. A client 1 day postoperative after a transsphenoidal craniotomy with a possible cerebrospinal leak. 3. A client diagnosed with a stroke 4 days ago who is exhibiting confusion. 4. A client with a head injury who is having seizures.

3) CORRECT - After 4 days, the risk for this client having a second stroke is significantly reduced. Therefore, the focus of care is rehabilitation. This client can be transferred.

The nurse provides care to a client receiving packed RBCs to treat anemia. Which action does the nurse take? (Select all that apply.) 1. Uses a 22 gauge needle for the transfusion. 2. Selects standard IV tubing used with an IV pump. 3. Checks client name and blood product with second licensed nurse. 4. Administers 0.9% sodium chloride solution after the transfusion. 5. Ensures the transfusion completes within 5 hours. 6. Monitors for signs of transfusion reaction or fluid volume overload. View Explanation

3) CORRECT - Blood products are to be checked by two licensed care providers to ensure that the correct blood product is being provided to the correct client. 4) CORRECT - Intravenous normal saline is used during a blood transfusion. This solution is to flush the IV line after the transfusion is completed. 6) CORRECT - Clients receiving a blood product should be monitored for the first 15 minutes and then periodically thereafter. Since the client is being treated for anemia and may receive several units of red blood cells, there is a risk for fluid volume overload. The client should be monitored frequently.

The nurse notes that a client who received 1000 mL of parenteral nutrition over the past 24 hours has 200 mL remaining in the infusion bag. Which action will the nurse take when changing the solution? 1. Infuse the remaining solution over the next half-hour. 2. Infuse the remaining solution over the next 2 hours. 3. Change the infusion as scheduled. 4. Call the health care provider for further instructions.

3) CORRECT - Changing the infusion as scheduled decreases the chance of infection. Unused solution is always discarded. The dressing over the catheter insertion site, the tubing, and filters should all be changed according to the organization's policies.

The nurse provides postoperative care for a client after an ileal conduit procedure. Which observation most concerns the nurse? 1. There is bleeding from the stoma when the appliance is changed. 2. The skin under the ostomy pouch is irritated. 3. The client has abdominal pain and a temperature of 100.4°F (38°C). 4. Bowel sounds are absent in all four quadrants.

3) CORRECT - Fever, abdominal rigidity and pain are indications of peritonitis. Urine may have entered the peritoneal cavity from anastomosis site leakage or from separation of the ureter from the ileal segment (the conduit). The health care provider should be notified at once, as this requires immediate medical intervention. This poses the greatest risk of harm to the client and is the highest priority

The home care nurse visits a client diagnosed with acquired immune deficiency syndrome (AIDS). The nurse instructs the client's caregiver about how to prevent infection. Which is the most important instruction the nurse will give to the caregiver? 1. "Cover your nose and mouth when you sneeze or cough." 2. "Get rid of all pets in the home." 3. "Wash your hands frequently." 4. "Wash the client's dishes separately."

3) CORRECT - Hand hygiene is the single best way to kill germs. The caregiver should wash hands after going to the bathroom and before and after fixing food. The caregiver should also wash hands before and after caring for the client.

The nurse provides care for a client who requires neurological checks every 2 hours. The nurse identifies which components as part of the Glasgow Coma Scale (GCS)? (Select all that apply.) 1. Eye-opening response — partially. 2. Best motor response — unsteady gait. 3. Best verbal response — confused. 4. Eye-opening response — none. 5. Best verbal response — incomprehensible sounds. 6. Best motor response — localizes pain. View Explanation

3) CORRECT - The client would score a 4 on best verbal response. 4) CORRECT - The client would score a 1 on eye-opening response. 5) CORRECT - The client would score a 2 on best verbal response. 6) CORRECT - The client would score a 5 on best motor response.

The nurse teaches a group of nursing students about elder abuse. Which older adult client does the nurse list as most likely to be a victim of abuse? 1. A male diagnosed with moderate hypertension. 2. A male with newly diagnosed cataracts. 3. A female with advanced Parkinson disease. 4. A female diagnosed with early stage Lyme disease.

3) CORRECT - The typical abuse victim is a woman of advanced age with reduced social interaction and at least one physical or mental impairment.

The nurse prepares to administer medication via IV push into an established IV line. Which action does the nurse take? 1. Select the port farthest from the insertion site. 2. Ensure that the tubing above the injection port is patent. 3. Time the medication administration with a watch. 4. Explain the procedure to the client after completion.

3) CORRECT - Using a watch to time the administration ensures safe drug infusion. Ideally, the watch should have a second hand or digital readout. Many medications that are ordered as IV push or bolus need to be given slowly over several minutes.

The nurse provides care for a young adult client who became paraplegic after a swimming accident. The client experiences autonomic dysreflexia. Which response by the nurse is appropriate to further assess the client's current condition? 1. "Have you experienced runny stools today?" 2. "Are you drinking adequate amounts of fluid?" 3. "When was the last time you irrigated your indwelling catheter?" 4. "Are you experiencing symptoms of an upper respiratory infection?"

3) CORRECT — Bladder distension creates a noxious stimulus, which causes the potentially life-threatening complication experienced by victims of a spinal cord injury. The client's indwelling catheter should be assessed for obstruction and irrigated, if necessary to resolve the obstruction.

A nurse from the emergency department (ED) is floated to the surgical unit. Which clients will the charge nurse appropriately assign to the ED nurse? (Select all that apply.) 1. A client with a new diagnosis of heart failure to be discharged in 24 hours. 2. A client who had a cholecystectomy 6 hours ago. 3. A client who had a stroke 3 days ago and requires total care and enteral feedings. 4. A client admitted with pneumonia requiring IV antibiotics. 5. A client admitted with anemia requiring a blood transfusion.

3) CORRECT — Delegate stable clients with expected outcomes and routine tasks. The client with a stroke 3 days ago requiring enteral feedings is a stable client. 4) CORRECT — The client with pneumonia is stable with expected outcomes and a routine task of IV antibiotics. 5) CORRECT — Delegate stable clients, such as anemia, with expected outcomes, and the routine task of a blood transfusion.

The home care nurse receives a phone call from the caregiver for a client diagnosed with AIDS. The caregiver reports having the flu and is afraid of giving the client an infection. Which action does the nurse take first? 1. Instruct the caregiver to wear a well fitting surgical mask that covers the mouth and nose. 2. Assess whether the caregiver is washing hands frequently before providing care. 3. Determine if there is someone else available to provide care for the client. 4. Inform the caregiver to clean the client's bathroom daily.

3) CORRECT — The priority is to prevent the client's exposure to infection. The nurse should first determine whether another healthy caregiver can provide care in place of the caregiver with the flu. This will protect the client from exposure to the flu.

The nurse provides care to a client who is suspected of having a respiratory infection. When collecting a sputum sample for culture and sensitivity testing, which action does the nurse implement? 1. Ask the client to expectorate into a clean emesis basin. 2. Collect the specimen at night just before the client goes to sleep. 3. Use a sterile plastic container for obtaining the specimen. 4. Collect the specimen immediately after the client eats a meal.

3) CORRECT- A sterile container is used for sputum sample collection. The sputum culture and sensitivity test is used to identify the type of infectious organism(s) present, as well as to determine which antibiotics are ideal for use in treating the infection. Contamination of the sterile container may cause the test results to be invalid.

The nurse assesses a school-age child with suspected Hodgkin lymphoma. Which finding is most characteristic of this disease? 1. Fever and malaise. 2. Enlarged, painful inguinal lymph nodes. 3. Firm, painless, and movable adenopathy in the cervical area. 4. Anorexia and weight loss.

3) CORRECT- Firm, painless, and movable adenopathy of the cervical area is associated with this disease.

The nurse receives report on a group of clients at the beginning of the shift. Which client does the nurse assess first? 1. A client drinking contrast for an abdominal CT scan who reports nausea and abdominal pain. 2. A client with a respiratory rate of 24 breaths/min and an oxygen saturation of 93% on room air. 3. A client reporting frequent small amounts of watery diarrhea with abdominal cramping and nausea. 4. A client whose family member threatened to sue the hospital if the nurse does not talk with the family immediately.

3) CORRECT- Frequent and small amounts of diarrhea may indicate a possible bowel obstruction that can be life threatening if the bowel perforates. The nurse needs to assess this client so interventions can be implemented quickly.

The nurse assesses the client who is diagnosed with metastatic prostate cancer for complications related to hypercalcemia. The nurse understands that which assessment finding represents a late manifestation of hypercalcemia? 1. Restlessness. 2. Muscle weakness. 3. Heart block. 4. Constipation

3) CORRECT- Late manifestations of cancer-related hypercalcemia include a variety of cardiac complications, such as heart block, widened T waves, ventricular dysrrhythmias, and asystole. For the client with cancer, early signs and symptoms of hypercalcemia include restlessness, muscle weakness, and constipation.

The nurse preceptor supervises a new nurse change the dressing of a client with a newly inserted peritoneal dialysis catheter. After removing the old dressing, which new nurse action requires intervention by the preceptor nurse? 1. Cleans the catheter insertion site using a sterile cotton swab soaked in povidone-iodine. 2. Applies two sterile precut 4×4 gauze pads to the catheter insertion site. 3. Cleans the insertion site using a circular motion from the outer abdomen toward the insertion site. 4. Tapes the edges of the sterile dressing with paper tape.

3) CORRECT- The insertion site should be cleansed from the insertion site outward towards the outer abdomen.

A client with a previous history of transfusion-related acute lung injury (TRALI) requires another transfusion of red blood cells (RBCs). Which intervention will the nurse use to prevent a recurrence of TRALI? 1. Premedicate with intravenous diphenhydramine. 2. Transfuse the red blood cells over 4 hours. 3. Request for leukocyte-reduced red blood cells. 4. Give supplemental oxygen during the transfusion.

3) CORRECT- The reaction of anti-leukocyte antibodies between donor and recipient leads to TRALI. Leukocyte-reduced RBCs reduces the risk of TRALI recurrence.

The nurse provides care for a client diagnosed with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which data does the nurse expect upon assessment? 1. BP 150/90 mm Hg, P 64 beats/min, R 12 breaths/min. 2. Urinary output of 3000 mL in 24 hours. 3. Serum sodium of 115 mEq/L (115 mmol/L). 4. Urine specific gravity of 1.005.

3) CORRECT— Because of water retention, a dilutional hyponatremia occurs. The normal sodium is 135 -145 mEq/L (135-145 mmol/L). Treatment includes restricting fluid intake to 500 -600 mL/24 h, administering diuretics, daily weights, and an accurate intake and output.

The nurse reviews newly written prescriptions for clients who are on a telemetry unit. Which finding does the nurse report to the health care provider? 1. The client who has congestive heart failure (CHF) and has been prescribed intravenous (IV) morphine while receiving a continuous IV infusion of dopamine. 2. The client who has atrial fibrillation (AF) and renal insufficiency (RI) and has been prescribed a low-molecular-weight heparin. 3. The client who had coronary artery bypass graft surgery (CABG) 4 hours ago, has had 800 mL of serosanguineous chest tube drainage since surgery, and has been prescribed enoxaparin. 4. The client who has coronary artery disease (CAD) and has been prescribed warfarin while receiving a continuous IV infusion of heparin.

3) CORRECT— Chamber one of the chest tube drainage system collects the fluid draining from the client. This fluid is measured hourly during the first 24 hours. Notify the care provider if more than 100 mL/hr of drainage occurs. Since there is active bleeding, enoxaparin, a synthetic heparin, may be contraindicated.

A client sustained a crush injury to the trachea in a motor vehicle crash (MVC). In the emergency department (ED), a cuffed tracheostomy tube is inserted. Several hours after admission, the nurse enters the client's room and finds the client in respiratory distress. Which action does the nurse take first? 1. Observe the color of the client's mucous membranes. 2. Assess the client's level of consciousness (LOC). 3. Listen to the client's breath sounds. 4. Check the client for retractions.

3) CORRECT— Changes in breath sounds will help the nurse to identify what is causing the respiratory distress. The client may be experiencing tracheal edema that is occluding the tracheostomy tube cuff, the tube may be displaced, or the client may have previously unidentified respiratory injuries secondary to the accident.

The nurse teaches a client diagnosed with breast cancer about radiation therapy. Which client statement indicates additional teaching is required? 1. "I have to wait until my breast tissue heals to begin radiation therapy." 2. "Radiation therapy should help prevent my cancer from returning." 3. "I'm glad I won't feel tired as a result of my radiation treatments." 4. "I'll need to watch my skin for changes."

3) CORRECT— Clients commonly experience fatigue with external radiation therapy. This statement indicates the need for further teaching.

The nurse instructs a client diagnosed with diverticulosis. Which client statement indicates that further teaching is needed? 1. "I will eat fruits and vegetables with every meal. " 2. "I will select meats that are low in fat. " 3. "I will start weight lifting for strength. " 4. "I will work on losing some weight. "

3) CORRECT— Clients with diverticulosis should avoid weight lifting or excessive bending due to the stress placed on the abdomen.

The nurse provides care to an adult client diagnosed with leukopenia. The client requires protective isolation due to immunosuppression. Which observation prompts the nurse to intervene? 1. The client's spouse enters the client's room wearing a mask, gown, and gloves. 2. The client's food tray contains non-disposable eating utensils. 3. A basket of fresh fruit is delivered to the client's room. 4. A large card signed by the client's coworkers is delivered to the client's room.

3) CORRECT— Consumption of fresh fruit is contraindicated for the client who requires isolation precautions due to the potential for ingestion of microorganisms.

The nurse provides care for a client diagnosed with meningococcal pneumonia, admitted 2 hours ago. Which transmission-based precautions will the nurse implement? 1. Standard precautions. 2. Airborne precautions. 3. Droplet precautions. 4. Contact precautions.

3) CORRECT— Droplet precautions are implemented when pathogens are transmitted by infectious droplets. Meningococcal pneumonia requires the use of standard precautions plus droplet precautions. Droplet precautions are required until 24 hours after initiation of effective therapy.

The nurse provides care to a client with a pulse oximeter probe. Which situation requires intervention by the nurse? 1. Probe is on the ring finger and there is clear polish on the nail. 2. Emitting and receiving sensors of the probe are directly opposite each other. 3. Hand with the probe attached is directly beneath a procedure light to prevent chilling. 4. Oxygen saturation alarm is set at 95%.

3) CORRECT— Exposure of the probe to direct sunlight or strong light causes an inaccurate measurement. The probe should be covered with a dry washcloth and rotated every 4 hours to prevent skin irritation.

While irrigating the eyes of a client who was splashed with battery acid, the nurse is called to address another client emergency. Which direction is the most important for the nurse to give to the LPN/LVN who will care for the client with the eye injury? 1. "Wait here with the client until I can locate another nurse. " 2. "Cover the eye with a patch and tape a metal eye shield securely in place. " 3. "Continue to irrigate the eyes until the pH is within normal limits. " 4. "Notify the client 's boss that discharge from the emergency department will be delayed. "

3) CORRECT— It is imperative to remove the acid. Checking the pH helps verify if all of the chemical has been removed. This direction is appropriate to provide to the LPN/LVN who will be caring for the client and falls within the LPN/LVN 's scope of practice.

The client is admitted to the emergency department after a motor vehicle accident. The client does not recall the accident, is oriented to person, but does not know what city the hospital is in and is confused regarding the day. Pupils are equal in size and reactive to light. The client reports a severe headache and is restless. Which action does the nurse take first? 1. Continue to orient the client to the situation. 2. Apply soft wrist restraints or a vest restraint. 3. Perform a bedside neurological assessment. 4. Administer pain medications as prescribed.

3) CORRECT— Neurological checks are done initially and every 15 minutes thereafter for this symptomatic client. The client may be developing increased ICP. Confusion, restlessness, pupillary changes, and altered level of consciousness are the earliest signs of increased ICP.

The nurse instructs a client receiving furosemide and digoxin. The nurse determines that teaching is effective when the client selects which drink? 1. Whole milk. 2. Gatorade. 3. Orange juice. 4. Water.

3) CORRECT— Orange juice contains 496 mg of potassium per 8 ounces and helps restore potassium lost because of furosemide. Potassium must be maintained within normal limits to avoid digoxin toxicity.

The nurse provides care to a school-aged client diagnosed with terminal cancer. Which nursing action offers support to the family and client during the terminal stages of the illness? 1. Encourage the family to avoid any reference to death or dying. 2. Decrease the amount of time the client spends with siblings. 3. Assure the family that they will receive support after discharge. 4. Limit the information and explanations given to the client.

3) CORRECT— Palliative care requires a multidisciplinary approach to manage the care of the dying child. The team consists of social workers, chaplains, nurses, nursing assistants, and health care providers.

The nurse provides care to a client with a tracheostomy who is receiving oxygen. Which action is considered negligence by the nurse? 1. Wears goggles when changing the tracheostomy dressing. 2. Applies cream on the feet and legs after a bath. 3. Sprinkles powder on the chest after a bath. 4. Places a pre-cut gauze dressing around the tracheostomy.

3) CORRECT— Powder should not be used on a client with a tracheostomy because it could occlude or irritate the airway.

The nurse provides an infant with routine immunizations. Which side effect will the nurse instruct the client's mother may occur? 1. Vomiting and diarrhea. 2. Swelling of the lymph nodes and conjunctivitis. 3. Low-grade fever and irritability. 4. Anorexia and nystagmus.

3) CORRECT— Slight elevation of temperature, localized response at the injection site, and increased irritability are anticipated responses after an immunization. This usually occurs within a few hours or days after receiving the immunization. More serious side effects include continuous screaming, convulsions, high fever, and loss of consciousness. The immunization should not be given if there is a past history of a serious reaction.

The nurse evaluates tasks delegated to the staff. Which observation indicates that the care provided to a client who is positive for human immunocompromised virus (HIV) is appropriate? 1. LPN/LVN applies a gown when entering the room. 2. Nursing assistive personnel uses sterile linen to make the bed. 3. Nursing staff wear gloves when exposed to secretions. 4. Family members wear gown, gloves, and mask when entering the room.

3) CORRECT— Standard precautions are used when caring for this client. This observation indicates appropriate care.

The nurse observes a group of children at play. Which type of play does the nurse identify as typical for toddlers? 1. Four children playing dodge ball. 2. Three children playing tag. 3. Two children in the sandbox building castles side by side. 4. One child digging a hole, another child blowing bubbles.

3) CORRECT— The children in the sandbox are engaged in parallel play. This type of play is seen with toddlers and is described as playing alongside but not with others.

The nurse instructs a client about the care of a new colostomy. Which information does the nurse include? (Select all that apply.) 1. Change the ostomy appliance following a meal. 2. Use a moisturizing soap to clean skin around stoma. 3. Place tissue on stoma when changing the appliance. 4. Cut the skin barrier 1/8 inch larger than the stoma. 5. Empty the pouch of stool before removing the appliance. 6. Check stoma for color, size, and shape.

3) CORRECT— The client should place tissue on the stoma when changing the appliance, for this will absorb stool and prevent stool from contacting the skin. 4) CORRECT— The client needs to cut the skin barrier no more than 1/8 inch larger than the stoma. This will allow the stoma to expand and prevent stool from contacting peristomal skin. 5) CORRECT— The client needs to empty the pouch of stool before removing the appliance. This will prevent contact of stool to the client's skin. 6) CORRECT— The client needs to check the stoma for color, size, and shape. This will ensure adequate blood flow to the stoma.

The nurse receives hand-off communication from the nurse who provided care to a group of clients during the previous shift. Which client does the nurse see first? 1. A client with dementia who is at risk for falling. 2. A client with an intravenous (IV) infusion 1 day post-operative. 3. A client with pneumonia reporting shortness of breath. 4. A client with a hip fracture reporting 9/10 on a pain scale.

3) CORRECT— The nurse sees the client with physiological needs first. Of the clients with physiological needs, the nurse first addresses the client with pneumonia who reports shortness of breath because airway, breathing, and circulation take priority.

The nurse in the emergency department (ED) is notified that multiple workers in a local plant have been exposed to radioactive materials and will be arriving shortly. Which action does the nurse take first? 1. Set up decontamination stations outside of the emergency department. 2. Locate the nuclear exposure immediate reaction kit. 3. Notify the Director of Nursing of the incident. 4. Obtain official verification that the incident has occurred.

3) CORRECT— The nurse should first contact administration to initiate the disaster plan.

The nurse prepares to discharge a client diagnosed with acquired immune deficiency syndrome (AIDS). The client is going to live with the parents so that they can assist with care. Which action does the nurse take first? 1. Refer the client for home care. 2. Assess if the client and parents understand the dosing schedule and side effects of the medication. 3. Ask the client about what kind of help is needed from the parents. 4. Encourage the parents to join a support group.

3) CORRECT— The nurse should first determine the client's needs and then assess whether the parents are able to meet the client's needs. After assessment is complete, the nurse can begin implementation.

An ice storm paralyzes a community during the night. The two nurses on a 24-bed medical/surgical unit learn that it will be 12-15 hours before they can expect the next shift to arrive. Which action do the nurses take first? 1. Each nurse takes a shower while the other nurse cares for all of the clients. 2. Instruct the nursing assistive personnel (NAP) to begin morning care at 0400. 3. Make a list of all of the clients' breathing treatments and intravenous medications for the next 12-15 hours. 4. Plan to administer all of the clients' as needed pain medication before they ask for it.

3) CORRECT— The priority is to determine treatments and medications that are vital to the well-being of the clients.

The nurse supervises the care provided by a nursing assistive personnel (NAP) to a client being treated with a radioactive implant for vaginal cancer. Which situation requires the nurse to intervene? 1. The NAP spends a half hour in the client's room helping with morning care. 2. The NAP places all the equipment needed for morning care on the bedside table. 3. The NAP stands behind the portable bedside shield placed at the foot of the client's bed. 4. The NAP stands 6 feet away when talking with the client.

3) CORRECT— The shield should be placed on the hallway side of client's bed to protect caregivers and visitors who enter the client's room. They should not stand at the foot of bed.

The client receives supplemental feeding via an NG tube. Upon entering the room, the nurse notes the client has a weak, nonproductive cough and dusky lips. Which actions are appropriate for the nurse to take based on the current data? (Select all that apply.) 1. Continue the infusion as prescribed. 2. Assess posterior lung sounds only. 3. Discontinue the tube feeding. 4. Contact the health care provider. 5. Suction the client 's airway.

3) CORRECT— The tube feeding should be stopped as assessment data indicate possible aspiration. 4) CORRECT— The health care provider should be notified as assessment data indicate possible aspiration. 5) CORRECT— The nurse suctions the client 's airway to clear any possible obstruction.

An influx of clients arrives at an emergency department. The nurse is correct in triaging which clients as critical? (Select all that apply.) 1. The client with facial asymmetry and pulse 112 beats/min. 2. The client with chest pain and blood pressure 140/100 mm Hg. 3. The client with generalized weakness and dizziness and pulse 30 beats/min. 4. The client with copious amounts of diarrhea and blood pressure 118/72 mm Hg. 5. The client with an oxygen saturation of 79% on room air. 6. The client with confusion and blood glucose 42 mg/dL (2.33 mmol/L).

3) CORRECT— This client should be triaged as critical due to the signs and symptoms of hypoperfusion (e.g., weakness, dizziness, and bradycardia). 5) CORRECT— This client should be triaged as critical as the oxygen saturation is critically low. 6) CORRECT— This client should be triaged as critical due to symptomatic hypoglycemia. This client will progress to death without intervention.

A newly hired nurse is being screened for vaccination history by employee health. The newly hired nurse reports to the employee health nurse that hepatitis B immunity was established with a previous employer. Which response by the employee health nurse is most appropriate? 1. "You must repeat the hepatitis immunity screen." 2. "Would you like to verify your immunity to hepatitis B with a blood test?" 3. "Do you have a copy of the results of your hepatitis screening?" 4. "Did you receive the hepatitis vaccine in the deltoid?"

3) CORRECT— This enables the employee health nurse to confirm immunity.

The Suicide Prevention Hotline nurse receives a call from a client who reports the intention to commit suicide. Which question is most important for the nurse to ask? 1. "Do you really want to die?" 2. "When did you start to feel this way?" 3. "How do you plan to kill yourself?" 4. "What has happened to cause this?"

3) CORRECT— This lets the nurse prioritize interventions to assure the client's safety. Clients with a suicide plan have the highest lethality.

The nurse reviews the laboratory results of an older adult client diagnosed with a bacterial infection. Which result does the nurse expect to find? 1. Severe thrombocytopenia. 2. Elevated hematocrit. 3. Decreased hemoglobin. 4. Minimal leukocytosis.

4) CORRECT - Leukocytosis refers to an increase in the number of white blood cells (WBCs). Although a bacterial infection typically triggers an increase in the WBC count, up to 40% of older adults with serious infections may not develop leukocytosis. As a result, absence of leukocytosis in an older adult does not necessarily rule out an infectious process.

The school nurse notes that an 8-year-old child experiences stomach aches that are relieved after the nurse contacts the parents at work. Which action is the most important for the nurse to take? 1. Ask the child what is eaten for breakfast and dinner. 2. Ask the child to describe life at home. 3. Report this event to social services. 4. Ask the parents how the child behaves prior to school.

4) CORRECT - The nurse needs to validate anxiety, especially separation anxiety. The child may be worrying about the parents and is relieved when the nurse talks to the parents

The nurse notes that a health care provider prescribed D 5W 100 mL with 80 mEq KCl to infuse in 30 minutes. Which action does the nurse take first? 1. Assess the client's urinary output. 2. Ensure the patency of the client's IV. 3. Request a prescription for IV lidocaine. 4. Contact the health care provider.

4) CORRECT - The rate of IV administration should be no faster than 10 mEq/hr (20 mEq to 30 mEq per hour in highly specialized settings and only through a central venous line). The nurse first contacts the health care provider to clarify this prescribed dose.

The nurse evaluates comprehension of teaching provided to a client scheduled for surgery. Which client response is the most important for the nurse to report to the health care provider? 1. "Sometimes I feel so claustrophobic I want to run." 2. "I have heard about near-death experiences occurring in the operating room. Have you heard about it?" 3. "I had my will finalized last week just in case anything happens." 4. "I hope they keep the operating room cool. My grandfather died during surgery when he got very hot." View Explanation

4) CORRECT - The statement about keeping the operating room cool may indicate a risk for malignant hyperthermia, which is a genetic predisposition disorder transmitted as an autosomal dominate trait. It is a life-threatening complication of general anesthesia. Symptoms include tachycardia, dysrhythmias, tachypnea, hyperthermia, and hypotension. It is treated with dantrolene sodium.

A pediatric client is admitted to the cardiology unit after experiencing sudden chest pain and dizziness. A diagnosis of supraventricular tachycardia (SVT) is made. If the client experiences another episode of chest pain and dizziness, which action does the nurse implement? 1. Place the client in a supine position with arms to the side, and elevate the foot of the bed. 2. Instruct the client to assume a squatting position with the arms wrapped around the legs. 3. Encourage the client to lie on the side and picture walking through a meadow, breathing in slowly through the nose and out through the mouth. 4. Ask the client to stick the thumb in the mouth, close the mouth around it, and then blow on the thumb as if it were a trumpet.

4) CORRECT - This is a form of the vagal or Valsalva maneuver, which can stop SVT. Blowing should occur for 30 to 60 seconds. Other possible vagal maneuvers include ice to the face, holding the breath and then bearing down, or massaging the carotid artery on only one side of the neck. If vagal maneuvers do not work, intravenous adenosine, an anti-dysrhythmic agent, may be given.

The nurse observes a nursing student attempt to measure a client's blood pressure with a cuff that is too small for that client. Which instruction does the nurse give to the student about this observation? 1. Fails to show reliable changes in blood pressure. 2. Produces a false-low measurement. 3. Causes sciatic nerve damage. 4. Produces a false-high measurement.

4) CORRECT — Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff cannot record brachial artery measurements unless it is excessively inflated.

The nurse discovers an older adult client on the floor of the waiting room in the outpatient clinic. The client is unconscious and not breathing, but has a pulse. Which action does the nurse implement next? 1. Lift the back of the client's neck and check the airway. 2. Move the lower jaw backward and push the tongue to the side. 3. Turn the client's head to one side and shake the client firmly. 4. Tilt the client's head back and lift the chin. View Explanation

4) CORRECT - This opens the airway. The nurse should place a hand on the client's forehead, applying backward pressure. The nurse should place the fingers of the other hand under the client's chin and lift forward.

The nurse assists the anesthesia health care provider with the insertion of a central venous catheter. During the insertion, the nurse notes that the tip of the device brushes the underside of the sterile field. Which action is correct? 1. Wipe the tip with alcohol before connecting to the system. 2. Notify the primary health care provider of the occurrence. 3. Back-flush the catheter for several seconds before connecting. 4. Obtain a new device and prepare for a second attempt.

4) CORRECT - When equipment becomes contaminated during a sterile procedure, obtain new equipment.

The nurse teaches a client diagnosed with neutropenia about the condition. Which client statement indicates to the nurse an understanding of the instructions? 1. "I will use a soft toothbrush." 2. "I have to wear a mask at all times." 3. "My grandchildren may get an infection from me." 4. "I will call my health care provider if I develop a fever."

4) CORRECT - With neutropenia, the client has an increased risk for acquiring infections. Therefore, the client should notify the health care provider immediately if an increased temperature or chills occur.

The nurse assesses a client who received a blunt head injury from a motorcycle crash. Which finding indicates a basal skull fracture? 1. Periorbital edema. 2. Epistaxis. 3. Purulent drainage from the auditory canal. 4. Bloody or clear drainage from the auditory canal.

4) CORRECT — Bloody or clear drainage from the auditory canal indicates a cerebrospinal fluid leak following trauma and suggests a basal skull fracture.

The nurse provides care for an adult client on a mechanical ventilator. Which finding most concerns the nurse? 1. The client's Babinski response is negative. 2. The client's pulse changes from 80 bpm to 70 bpm. 3. The client's extremities are twitching. 4. The client is moving about restlessly in bed. View Explanation

4) CORRECT — Confusion, agitation and restlessness suggest hypoxemia. The nurse should assess for hypoxemia and manually ventilate the client with 100% oxygen. This is a breathing concern that represents an immediate risk of harm to the client. This is the priority concern.

The nurse provides care for a client who had an open reduction internal fixation (ORIF) of the left femur 18 hours ago. Which finding requires the nurse to follow up with the health care provider? 1. The client has had an oral temperature of 97.4°F (36.3°C) for the past 4 hours. 2. The client has 600 mL of urine in the indwelling ureteral catheter bag. 3. The client reports incisional pain of 7 on a scale of 0 (no pain) to 10 (severe pain). 4. The client is apprehensive and has developed petechiae over the upper arms.

4) CORRECT — Fat embolism syndrome (FES) is a serious complication in which fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury. FES usually results from long bone fractures or fracture repair. Petechiae are seen on the chest 50% to 60% of the time. Early recognition of FES is crucial to prevent a potentially lethal course.

A client is prescribed pentamidine isethionate by the health care provider. Which observation best indicates to the nurse that the medication is effective? 1. Increased T-cell count. 2. Increased deep tendon reflexes. 3. Decreased bleeding and bruising. 4. Decreased crackles and dyspnea.

4) CORRECT — Pentamidine is an anti-protozoal agent used to prevent or treat Pneumocystis jiroveci pneumonia, a common opportunistic infection in immunocompromised clients. The manifestations usually include coughing, fever, dyspnea, fatigue, and weight loss, and crackles are heard in the lungs.

The nurse provides care for a client with suspected scabies. The nurse expects which assessment finding? 1. Small circular patches of redness on the top of the head. 2. Vesicles or pustules with thick honey-colored crust. 3. Small pink bumps with a raised surface on the chest and limbs. 4. Several wavy or straight thread-like lines beneath the skin.

4) CORRECT — Several wavy or straight thread-like lines beneath the skin are caused by the female mite that burrows beneath the skin to lay eggs.

The nurse plans care for a client with a head injury. Which interventions will the nurse select to minimize the risk of increasing intracranial pressure (ICP)? 1. Maintain a liquid diet, perform frequent tracheal suctioning, and turn the client every 2 hours. 2. Keep the head of the bed flat, turn the client every 2 hours, and perform nasotracheal suctioning every hour. 3. Keep the head of the bed elevated 90 degrees, keep the room dark and quiet, and place the call light within easy reach. 4. Keep the client's head from flexing or rotating, elevate the head of the bed 30 degrees, and avoid frequent suctioning.

4) CORRECT — The objective is to increase venous return and decrease cerebral edema. This is best accomplished by preventing the head from flexing or rotating, elevating the head of the bed at a 30-degree angle, and not suctioning the client.

The nurse provides care to a client who underwent a bone marrow biopsy. During the post-procedure period, the nurse implements which action? 1. Measure abdominal girth at the level of the umbilicus. 2. Assist the client to a right side-lying position. 3. Observe for changes in the client's cough and sputum. 4. Assess for bleeding and hematoma formation.

4) CORRECT- A bone marrow biopsy involves deep penetration soft tissue and large bones, such as the sternum and iliac crest, that can result in bleeding. After a bone marrow biopsy, the client should be monitored for bleeding and hematoma formation at the procedure site.

The nurse provides care for clients on the medical and surgical unit. Which observation requires intervention by the nurse? 1. The health care provider prepares to insert the needle for a lumbar puncture at the level of the posterior iliac crest. 2. As the nurse leaves the client 's room, the nurse removes gloves and then the gown, folding the gown inside out. 3. The unlicensed assistive personnel (UAP) feeds a client while the client 's neck and head are flexed slightly forward. 4. The LPN/LVN repositions a client in Buck traction by first removing the traction weights.

4) CORRECT- Skeletal traction weights should never be removed without a health care provider prescription to do so, including when repositioning the client. Such an action would be painful for the client and would interrupt the line of pull.

The nurse reviews the importance of receiving an annual influenza vaccination with a client. Which statement indicates to the nurse that the client requires further instruction? 1. "I will get the shot since I am 69 years old." 2. "I had bronchitis twice last year, so I will get the shot." 3. "I volunteer at a preschool, so I will get the shot." 4. "I live with two large dogs, so I will get the shot."

4) CORRECT- The client is not at risk for getting influenza from a dog. Therefore, this client statement indicates the need for further education

The nurse provides care for clients in the emergency department. Which client does the nurse see first? 1. A preschool age client with a temperature of 101 °F (38 °C). 2. A young adult client with asthma and a productive cough. 3. An adult client with nausea and vomiting for several hours. 4. An older adult client with one episode of fainting.

4) CORRECT- The fainting episode may be the result of an irregular cardiac rhythm or rate change, and this requires an immediate cardiac evaluation to prevent cardiac and respiratory arrest.

The nurse performs a physical assessment on a client to assess cranial nerve function. Which actions will the nurse take to assess the client's trigeminal nerve? (Select all that apply.) 1. Check the client's six cardinal positions of gaze. 2. Palpate the temporal and masseter muscles while the client clenches teeth. 3. Ask the client to stick out tongue. 4. Use a cotton swab on the client's face to test light touch. 5. Place a vibrating tuning fork in the midline of the client's skull.

4) CORRECT- The nurse should check for light touch on the forehead, maxillary area and chin on both sides of the face to assess the sensory function of the trigeminal nerve. The nurse should note for decreased or unequal sensation. 2) CORRECT- Checking the strength of the temporal and masseter muscles allows the nurse to assess the motor function of the trigeminal nerve (cranial nerve V). The nurse should check for equality of strength on both sides.

A client receiving continuous enteral feedings is prescribed to receive medications through the nasogastric tube. Which action will the nurse take when administering the medications to the client? 1. Flush the tube with 60 mL of warm sterile water after each medication. 2. Add the three medications directly to the enteral feeding. 3. Aspirate gastric contents to check that the pH value is greater than 6. 4. Clamp the tube for 30 minutes after administering the medications.

4) CORRECT-The nurse should clamp the tube for 30 minutes after administering the medications to enhance absorption and prevent interactions with the enteral feeding.

The nurse provides teaching for a client diagnosed with liver cirrhosis. Which statements by the client cause the nurse to determine that teaching is effective? (Select all that apply.) 1. "I will use a medium- or hard-bristle toothbrush." 2. "I will limit myself to one serving of alcohol per day." 3. "I will eat no more than 1200 calories per day." 4. "I will apply calamine lotion to my dry, itchy skin." 5. "I will immediately report melena to my health care provider." View Explanation

4) CORRECT— Applying calamine lotion is an appropriate action. The client may have pruritus accompanied by jaundice, which makes the skin dry and itchy. 5) CORRECT— Melena (black, tarry stools) should be reported to the health care provider immediately as it can indicate bleeding esophageal varices.

The nursing assistive personnel (NAP) reports to work on the oncology unit with a cough, a runny nose, and has an elevated temperature. The NAP reports having no sick leave and being the breadwinner of the family. Which response by the nurse is most appropriate? 1. "Did you take a flu shot?" 2. "Can you work at the desk and help the unit secretary with the charts?" 3. "I will call one of the other units where clients are less vulnerable." 4. "I'm sorry, but you will have to go home."

4) CORRECT— During community outbreaks of the flu, it is responsible management to exclude staff with febrile infections from caring for high-risk clients.

A client comes to the outpatient clinic for evaluation of a possible basal cell carcinoma of the nose. Which client statement most concerns the nurse? 1. "I am a meat cutter at the local packing plant." 2. "My hobby is raising thoroughbred Great Danes." 3. "My parents immigrated from Sicily when I was born." 4. "I spend nearly every weekend sailing with my family."

4) CORRECT— Exposure to the sun increases the risk of skin cancer. The nurse should urge the client to use sunscreen with SPF (solar protection factor) to block harmful rays and reapply sunscreen every 2 hours or after swimming. The client should also use lip balm with sunscreen protection and avoid sun exposure during peak sun hours.

The nurse prepares a client for a barium enema. Which instruction is most important for the nurse to include? 1. "Your stool will be light colored for 2 to 3 days after the test. " 2. "Once the test is over and you go to the toilet, you will be able to resume normal activities. " 3. "The x-ray table will be tilted so you can assume various positions. " 4. "During the test, it is crucial that you take slow, deep breaths through your mouth. "

4) CORRECT— For the test to be successful, a client must retain the barium. As barium is introduced, a client may have the urge to defecate. Slow, deep breathing will help ease the discomfort and urge to defecate.

The nurse provides care for clients diagnosed with dementia in a long-term care facility. A client's family member is trying to explain a financial issue to the client and expresses frustration to the nurse about the client's lack of insight into the problem. Which is the best response by the nurse? 1. "People with dementia are more confused at night. You should try to have this conversation in the morning." 2. "People with dementia take longer processing ideas. You need to explain more slowly and use pictures." 3. "Why are you talking to the client about the issue? Let me get the social worker to help you." 4. "That sounds frustrating. Poor judgment and memory deficits are part of the disease process."

4) CORRECT— In this response, the nurse first provides empathy and then provides objective information on the disease process

A nursing assistive personnel (NAP) reports to the nurse that a comatose client receiving oxygen through a tracheostomy has "lots of water in the tubing." Which action does the nurse take? 1. Ask the NAP to clarify "lots of water." 2. Instruct the NAP to empty the fluid. 3. Contact respiratory therapy to evaluate the tubing. 4. Empty the fluid from the tubing and assess the client.

4) CORRECT— This client is at risk for aspiration. Caring for the tracheostomy is within the scope of nursing practice.

A client with a history of hypertension experiences a subarachnoid hemorrhage, head laceration, and ulnar fracture from a motor vehicle crash. Which finding indicates to the nurse that the client's condition is deteriorating? (Select all that apply.) A. Urine output 5000 mL in 24 hours. B. Pink drainage on laceration dressing. C. Radial and apical pulse 120 beats per minute. D. Diminished pupillary response. E. Glasgow Coma Scale score of 15.

A, C, D A head injury can cause diabetes insipidus. A urine output of 5000 mL is extremely high, which is characteristic of diabetes insipidus. A rapid heart rate may indicate a hemorrhage. A decreased pupil response is a finding associated with increased intracranial pressure.

The nurse administers an immunization to an adult client. Which observations made after the injection cause the nurse to immediately intervene? (Select all that apply.) A. The client is clearing the throat and coughing. B. The client has nasal drainage and sneezing. C. The client is anxious and exhibits rapid breathing. D. The client is feverish and sweating profusely. E. The client reports dizziness upon standing. F. The client has a diffuse rash across the trunk.

A, C, E An anaphylactic reaction may begin with the client clearing the throat and coughing due to swelling in the airway. The nurse should assess the client for other signs of anaphylaxis and be prepared to intervene. Tachypnea and feelings of impending doom occur with anaphylaxis. This client needs immediate assessment and care. Dizziness upon standing may be indicative of hypotension, which occurs with anaphylaxis and shock. The nurse should immediately assess this client's vital signs.

The nurse provides care for a client who is on therapeutic hypothermia and is being considered for rewarming. Which outcome is the most appropriate to establish? A. Turn and reposition the client every 2 hours. B. Rewarm at a rate of 0.45°F. (0.5°C) per hour. C. Restore the body temperature to 98.6°F. (37°C) in 2 hours. D. Assess the sedation level every hour.

B Gradual rewarming is important, keeping the rate of increase at 0.45°F. (0.5°C) per hour. This will safely rewarm the client without untoward effects.

The nurse witnesses a neighbor fall from the roof of a house. The nurse goes to the victim and determines the need to open the airway. Which procedure does the nurse use to open the airway in this victim? A. Flexed position. B. Jaw thrust. C. Head-tilt, chin-lift. D. Modified head-tilt, chin-lift.

B If a cervical spine injury is suspected, this is the maneuver used to open the airway to prevent further injury.

A client diagnosed with lung cancer gains 4.4 lb (2 kg) overnight and has a serum sodium of 122 mEq/L (122 mmol/L) and potassium of 4.5 mEq/L (4.5 mmol/L). Which intervention does the nurse expect to be prescribed for this client? A. Desmopressin. B. Furosemide 40 mg IV push. C. Sodium polystyrene sulfonate. D. IV normal saline to infuse at 125 mL/hr.

B Lung cancer is a common cause of syndrome of inappropriate antidiuretic hormone (SIADH), which is an abnormal secretion of antidiuretic hormone. This health problem results in increased water absorption and dilutional hyponatremia. Diuretics are used to promote fluid loss.

The nurse provides care to a client who is diagnosed with chronic cirrhosis due to long-term alcohol abuse. Which nursing assessment finding leads the nurse to suspect the client may also be experiencing early-stage hepatic encephalopathy? A. Abdominal distention with umbilical protrusion. B. Alternating periods of euphoria and lethargy. C. Flaccidity of the arms and legs. D. Absence of deep tendon reflexes.

B Alternating periods of euphoria and lethargy are consistent with early-stage hepatic encephalopathy. Other manifestations of early-stage hepatic encephalopathy include a normal level of consciousness and reversal of day-night sleep patterns.

The nurse notes that an older adult client, receiving treatment in the intensive care unit for pneumonia, develops cognitive changes. Which situation will the nurse suspect first as the reason for this finding? A. Intensive care unit psychosis. B. Infection. C. Hypertension. D. Medication allergy.

B Cognitive changes are often seen in older adults with infection. This occurs before fever, pain, or altered laboratory values.

The nurse provides care to a client who just underwent left modified radical mastectomy. When assisting the client with positioning, the nurse implements which action? A. Extend the client's left arm flat along the affected side. B. Elevate the client's left arm on a pillow. C. Rest the client's left arm across her chest. D. Place the client's left arm below the level of her torso.

B Following modified radical mastectomy, the client should be placed in semi-Fowler position. To promote lymphatic drainage without compromising circulation, the arm on the affected side should be elevated on a pillow. Elbow flexion or dependent positioning of the arm may impede lymphatic drainage and compromise circulation.

The nurse provides care to a client admitted with mild hyponatremia secondary to excessive water consumption. Which intervention does the nurse anticipate including in the client's plan of care? A. Administering 0.45% sodium chloride IV. B. Restricting fluid intake. C. Administering 3% sodium chloride IV. D. Encouraging frequent ambulation.

B For treatment of hyponatremia secondary to hypervolemia, restriction of fluid intake is an appropriate intervention.

A client diagnosed with a seizure disorder asks what needs to be done when having to travel for work. Which teaching does the nurse emphasize with this client? A. "Travel with a person experienced in handling health problems. " B. "Place your medication in a carry-on bag. " C. "Ask for hotel rooms on the first floor. " D. "Avoid flashing lights. "

B The client should carry prescribed medication because luggage can get lost. The client needs to take medication as prescribed to keep drug levels constant to prevent seizures.

An older client with a history of smoking one pack per day for 50 years and consuming three beers per day demonstrates right middle lobe wheezing associated with a nonproductive cough, shortness of breath, and chest discomfort. Which prescription will the nurse implement first? A. Sputum culture. B. Chest X-ray. C. Echocardiogram. D. Pulmonary function tests.

B The client's symptoms suggest lung cancer and the wheezing is consistent with the associated constrictive airways.

The nurse provides care for a client with a head injury who is placed on a volume-cycled ventilator. Which action by the nurse best indicates an understanding of proper management of a client on a mechanical ventilator? A. Water is added to the tubing to provide for humidification of inspired air. B. The sigh setting on the ventilator is adjusted to occur every hour. C. Ventilator settings are adjusted according to the client 's serum electrolytes. D. A high concentration of oxygen is delivered to prevent tissue ischemia and necrosis.

B The setting on the ventilator should be set for 1.5 times the tidal volume and adjustment should occur every 1 to 3 hours.

The nurse provides care to an adult client who sustained a T3 spinal cord injury 2 days ago. The nurse suspects a developing emergency based on which assessment finding? (Select all that apply.) A. Respiratory rate of 18 breaths/min. B. Warm, dry, flushed skin. C. Absence of sensation in lower extremities. D. Blood pressure of 88/42 mm Hg. E. Heart rate of 88 beats/min.

B, D Warm, dry skin and skin flushing may be manifestations of neurogenic shock. With neurogenic shock, changes in skin color and temperature occur as a result of loss of vascular tone, which causes peripheral vasodilation. Classic manifestations of neurogenic shock include hypotension and warm, dry skin. Bradycardia may or may not be present with neurogenic shock.

The nurse provides care for a client in acute respiratory distress. The health care provider initiates mechanical ventilation. Which parameter is most important for the nurse to assess after initiation of mechanical ventilation? 1. The respiratory rate. 2. The heart rate. 3. The blood pressure. 4. The oxygen alarm on the ventilator.

3) CORRECT— A client may experience hypotension from decreased cardiac output. The blood pressure is monitored closely.

The nurse assists the health care provider in performing a paracentesis. Which position does the nurse assist the client to assume for the procedure? 1. Right-lying. 2. Left-lying 3. Supine 4. Upright.

4) CORRECT- The upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion.

The perioperative nurse is evaluating a group of clients for risk factors that may lead to postoperative complications. Which clients are at high risk for developing respiratory complications following surgery? (Select all that apply.) 1. A 76-year-old nonsmoker who underwent an open cholecystectomy one day ago. 2. A 34-year-old smoker who underwent a left ankle repair 2 days ago. 3. A 60-year-old nonsmoker who underwent carpal tunnel surgery 3 hours ago. 4. A 48-year-old nonsmoker who had coronary artery bypass graft (CABG) surgery 48 hours ago. 5. A 42-year-old nonsmoker who had a chest tube removed 2 hours ago.

1) CORRECT - Aging increases the risk for respiratory complications, as mucociliary clearance ability diminishes with age. Following abdominal surgery, splinting and pain also may lead to shallow breathing, atelectasis, and decreased mucociliary clearance. 2) CORRECT - Smoking increases the risk for postoperative complications, including respiratory problems, due to impaired mucociliary clearance. 4) CORRECT - Thoracic surgery leads to a decreased ability to cough and inhale deeply, and decreased mucociliary clearance. 5) CORRECT - Lung trauma, including trauma due to procedures or surgery, increases the risk for developing respiratory complications.

The home care nurse provides care to a client with alcoholic cirrhosis. Which caregiver statement requires intervention by the nurse? (Select all that apply.) 1. "I will give the low dose aspirin with breakfast." 2. "Elastic-waist pants are more comfortable for my client." 3. "I'm trying to prepare more salads and leafy green vegetables." 4. "We often have to wake the client to eat meals." 5. "Sometimes the client doesn't get to the commode in time." 6. "The client's appetite is not good, so I'm glad to see a weight gain."

1) CORRECT — Bleeding esophageal varices are the most life-threatening complication of cirrhosis. The client should not receive even low dose aspirin regularly. 4) CORRECT — Encephalopathy from cirrhosis is caused by increasing ammonia levels, and it causes changes in consciousness, including lethargy. This requires follow-up. 6) CORRECT — Weight gain may be due to fluid retention and ascites, because it is clearly not from nutritional intake. This requires follow-up.

After insertion of a central venous catheter (CVC), a client suddenly starts coughing. The nurse observes that the client is pale and dyspneic, and has tachycardia. Which action does the nurse take first? 1. Turn the client to the left side and lower the head of the bed. 2. Notify the health care provider. 3. Administer oxygen. 4. Instruct the client to do the Valsalva maneuver.

1) CORRECT — The client's symptoms are consistent with an air embolism, which can occur with CVC insertion. Placing the client in the left lateral position prevents the air embolism from entering the right atrium and pulmonary artery, which would create a right ventricular outflow obstruction (air lock) and stop the heart. The client should be kept in this position for 20-30 minutes.

The nurse notes that a client recovering from spinal anesthesia can feel the lower extremities, wiggle the toes, and move the legs. Which action will the nurse take next? 1. Assess blood pressure. 2. Auscultate bowel sounds. 3. Assess skin temperature. 4. Auscultate breath sounds.

1) CORRECT- The ability to feel and move the toes and legs indicates motor blockade from the anesthetic is wearing off. However, blockage of the autonomic nervous system may still be present and cause hypotension. The nurse should assess the client for hypotension and gradually elevate the head of the client's bed.

The cardiac monitor of a client who is awake and alert and has a peripheral pulse shows ventricular tachycardia with a rate of 160 beats/min. Which actions are appropriate for the nurse to implement? (Select all that apply.) 1. Defibrillate using 200 joules. 2. Monitor blood pressure. 3. Alert the rapid response team. 4. Prepare to administer adenosine by slow IV push. 5. Obtain a 12-lead electrocardiogram as prescribed.

2) CORRECT— The nurse should monitor the client's blood pressure to determine whether the client is tolerating the rhythm. 3) CORRECT— The nurse should alert the rapid response team to assist with the client's care. Evidence shows that rapid response teams help improve client outcomes when changes in condition occur. 5) CORRECT— The nurse should obtain a 12-lead ECG, as prescribed, to evaluate the client's cardiac conduction.

A client arrives at the emergency department experiencing tingling and weakness in the lower extremities that started when getting out of bed. The client reports the symptoms seem to be progressing upward. Which statement by the client is most important for the nurse to pursue during the assessment process? 1. "My grandfather had polio when he was young." 2. "I have been a vegetarian for several months now." 3. "Things have been stressful at work lately." 4. "We have been in the final preparations for a trip overseas."

4) CORRECT - This needs immediate further investigation. Immunizations may have been given in preparation for this trip and an immunization could trigger the onset of the neurologic symptoms of Guillain-Barré syndrome. The symptom onset in Guillain-Barré is usually abrupt and can progress rapidly. Symptoms often, but not always, progress in an ascending direction (from feet toward head). It is an emergency condition. The most immediate concern is potential respiratory compromise from respiratory muscle weakness.

The nurse provides care for a client undergoing a thoracentesis. The nurse assists the health care provider during the procedure. Which action is most appropriate for the nurse to perform? 1. Administer pain medication. 2. Instruct the unlicensed assistive personnel (UAP) to monitor vital signs. 3. Position the client in a seated position with elbows on the overbed table. 4. Place the client supine in the Trendelenburg position.

3) CORRECT - This position safely facilitates the procedure for the client. With the client leaning forward and supported, it will allow the ribs to separate for exposure of the site.

The nurse assesses a dark-skinned client for the presence of cyanosis. Which body area does the nurse use for the assessment? 1. Back of the hands. 2. Earlobes. 3. Palms of the hands. 4. Sacrum.

3) CORRECT — In a dark-skinned client with cyanosis, the palms of the hands will have a bluish tinge or be ashen gray, which is acrocyanosis. If experiencing central cyanosis, a bluish or gray tint to the mucous membranes and conjunctiva is expected.

The nurse provides care for a client after a thoracotomy. The client has a chest tube drainage system in place. Which observation most concerns the nurse? 1. The water in the suction control chamber bubbles constantly. 2. There is 700 mL of drainage in the collection chamber. 3. The level of the fluid in the water-seal chamber does not move. 4. There are air bubbles in the water-seal chamber when the client exhales.

3) CORRECT — The fluid in the water-seal chamber should fluctuate with the respirations of the client, rising with inspiration and falling with expiration. The absence of fluctuation indicates either that the lung has re-expanded (which is desired) or that there is an obstruction of the chest drainage tubes (which is not desired). The most common cause of tubing obstruction is the client lying on the tubing. Other causes are kinking, dependent loops, clots, or fibrin.

A client had a permanent pacemaker implanted 1 year ago and returns to the outpatient clinic because of not feeling well. Which question is important for the nurse to ask? 1. "Have you experienced abdominal pain?" 2. "Are you having wheezing on exertion?" 3. "Have you noticed shortness of breath and dizziness?" 4. "Have you had any headaches?"

3) CORRECT — This question assesses symptoms of decreased cardiac output, which occurs with pacemaker battery failure.

The nurse provides care for a client diagnosed with pneumonia. The client has a history of type 2 diabetes. The client is an older adult and is malnourished. For which type of shock does the nurse monitor the client? 1. Anaphylactic. 2. Cardiogenic. 3. Septic. 4. Neurogenic.

3) CORRECT- Older adults with chronic diseases who are malnourished or debilitated are at great risk for septic shock.

The clinic nurse instructs a client about an ambulatory electrocardiogram (ECG). Which client statements indicate to the nurse a need for additional education? (Select all that apply.) 1. "I will have to use a safety razor while the monitor is in place." 2. "I will keep a log of all of my activities during monitoring." 3. "I will wrap the device with plastic wrap before taking a shower." 4. "I will contact the health care provider if I experience lightheadedness." 5. "I will decrease my fiber during the monitoring."

3) CORRECT - The monitor cannot get wet so the client needs to avoid taking a bath or shower during monitoring. The nurse needs to provide additional education based on this statement. 4) CORRECT - If the client experiences dizziness, the client needs to document it in the event log along with pushing the event-marker button on the monitor. The client does not need to call the health care provider. This statement indicates that additional education is needed. 5) CORRECT - There is no reason to change diet while being monitored. This statement indicates that additional education is needed.

The nurse provides care for a client who had a lower gastrointestinal (GI) series. The client reports weakness. Which nursing concern is priority in planning the client's care? 1. Insufficient nutritional intake. 2. Alteration in sensation-perception, gustatory. 3. Potential for hypovolemia. 4. Constipation.

3) CORRECT - The preparation for the test is a clear liquid or low-residue diet for 2 days, nothing by mouth after midnight before the test, enemas and laxatives to prepare for the test. These preparations can result in dehydration. In addition, the laxatives posttest to remove the barium further increase the risk of dehydration.

A client receives epoetin alfa for chemotherapy-induced anemia. For which medication complication will the nurse closely assess this client? 1. Chronic kidney disease. 2. Hyperkalemia. 3. Hypotension. 4. Deep vein thrombosis.

4) CORRECT- It is important for the nurse to assess the client closely for signs of deep vein thrombosis or swelling, pain, and erythema of an affected limb as these are all adverse reactions associated with epoetin alfa therapy.

The nurse provides care to several clients receiving chemotherapy. Which clients require immediate follow up by the nurse? (Select all that apply.) 1. Client with lung cancer reporting clumps of hair on the pillow this morning. 2. Client with pancreatic cancer and who was unable to complete a physical therapy session due to fatigue. 3. Client with bladder cancer reporting moderate pain. 4. Client with stomach cancer with a blood pressure of 132/80 mm Hg, pulse 96 beats per minute, respirations 20 breaths per minute, and temperature 100.4°F (38°C). 5. Client with prostate cancer who is vomiting and has decreased urinary output. 6. Client with breast cancer with new onset of facial swelling.

4) CORRECT - The client with stomach cancer has an elevated temperature and should be assessed and the health care provider notified immediately. Neutropenia is a common adverse effect of chemotherapy and puts the client at risk for a life-threatening infection. 5) CORRECT - The client with prostate cancer is showing signs of dehydration, and vomiting will only exacerbate the problem. The nurse should assess the client and notify the health care provider immediately. 6) CORRECT - Swelling of the face and eyes and distention of neck and chest veins are signs of superior vena cava syndrome. The nurse should assess for this obstructive emergency and notify the health care provider immediately.

The nursing assistive personnel (NAP) reports that a client scheduled for surgery has a temperature of 102.5 °F (39.1 °C). Which action will the nurse take first? 1. Document the finding in the medical record. 2. Notify the health care provider immediately. 3. Administer acetaminophen per rectum, as prescribed. 4. Verify the temperature measurement.

4) CORRECT- The nurse should first verify the client's temperature to ensure accuracy before intervening. By doing so, the nurse prevents unnecessary intervention should the reported finding be in error.

The nurse assesses a client in the outpatient clinic reporting repeated severe headaches. Which action does the nurse take first? 1. Obtain a description of the headache. 2. Determine how the client usually relieves headaches. 3. Ask how long the client has been having headaches. 4. Obtain a list of medication the client is currently taking

1) CORRECT— The nurse should ask the client to describe the headache in the client's own words. Headache is usually a symptom and not a disease, and can be a result of neurological disease, vasodilation, or skeletal muscle tension. The description of the headache will assist the nurse to determine what course of action is best.