SIM #2 REVIEW

A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure? Place actions in the correct order. - Lubricate 2-3 inches of distal NG tube. - Elevate head of bed to fowler's position. - Rotate catheter and advance into nasopharynx. - Measure distal NG tube from nose tip to earlobe to xiphoid process. - Insert NG tube into unobstructed naris. - Have patient swallow ice as NG tube advances into stomach. - Advance NG tube upward and backward until resistance is met. - Secure NG tube.

- Elevate head of bed to fowler's position. - Measure distal NG tube from nose tip to earlobe to xiphoid process. - Lubricate 2-3 inches of distal NG tube. - Insert NG tube into unobstructed naris. - Advance NG tube upward and backward until resistance is met. - Rotate catheter and advance into nasopharynx. - Have patient swallow ice as NG tube advances into stomach. - Secure NG tube. First, elevate the client's head of bed to Fowler's position. Second, measure the distal NG tube from the nose tip to the earlobe to the xiphoid process. Third, lubricate 2-3 inches of the distal NG tube. Fourth, insert the NG tube into unobstructed naris. Fifth, advance NG tube upward and backward until resistance is met. Sixth, rotate catheter and advance into oropharynx. Seventh, have client swallow ice to pass the NG tube into the stomach. Eighth, secure the NG tube. The core issue of the question is knowledge of the insertion procedure for a nasogastric tube. Use nursing knowledge to sequence the steps that the nurse needs to take. Visualize the procedure to aid in answering the question.

A client diagnosed with pancreatitis becomes increasingly restless, confused and has pulled out the NG tube and IV catheter. HR-128/min, BP 96/62. Oxygen saturation = 90%. Skin is cool and clammy to touch. Prioritize the actions that the nurse should take. - Insert another IV line. - Repeat vital sign checks. - Initiate oxygen. - Insert NG tube. - Obtain blood sugar level.

- Initiate oxygen. - Insert another IV line. - Obtain blood sugar level. - Insert NG tube. - Repeat vital sign checks. First, initiate oxygen. The client is anxious and has tachycardia, signs of hypoxia. The BP is also low, so the client might be bleeding internally. If there is a decreased circulating blood volume then there is less hemoglobin to carry oxygen, so increasing the available oxygen will help the client until the problem is corrected. Second, get the IV started so fluid resuscitation can continue.This increased volume will improve the blood pressure. More volume, more pressure. The IV will also provide a port for needed medications. Third, check the client's blood sugar. Since the pancreas is sick, insulin production can be decreased so glucose can go up. This is next in the priority line of the available options. You have addressed air and circulation, so blood glucose would be next. Fourth, insert the NG tube so that the client can be kept empty and dry and you can prevent aspiration if the client starts vomiting. Last, recheck vital signs to assess effectiveness of your nursing actions.

Which assignment would be most appropriate for the charge nurse to assign to the LPN/VN in the Labor, Delivery, Recovery and Postpartum Unit (LDRP)? Select all that apply. 1. Primipara needing assistance with breastfeeding. 2. Multipara reporting a headache and epigastric discomfort. 3. Primipara who is two days post op cesarean section. 4. Primipara who is preeclamptic in active labor. 5. Multipara post op cesarean section with a PCA pump.

1. & 3. Correct: These are stable clients whose care is within the scope of practice of an LPN/VN. 2. Incorrect: This client is high risk because she is exhibiting symptoms of postpartum onset preeclampsia. 4. Incorrect: This client is considered to be at high risk since she is in labor and exhibiting symptoms of preeclampsia. This is an unstable client whose care is not within the scope of the LPN. 5. Incorrect: This client has an IV narcotic infusing which cannot be assigned to an LPN. IV narcotics are within the scope of the RN only.

The nurse is caring for a client with hyperparathyroidism. The nurse will monitor the client for which complications? Select all that apply. 1. Kidney stones 2. Diarrhea 3. Osteoporosis 4. Tetany 5. Fluid volume deficit

1. & 3. Correct: Yes, because too much calcium in the blood equals too much calcium in the urine and increased risk of kidney stones. Increased parathyroid hormone (PTH) is pulling the calcium from the bones, leaving them weak. 2. Incorrect: A clinical manifestation of hyperpararthyroidism is constipation. Diarrhea is not a clinical manifestation of hyperparathyroidism. 4. Incorrect: Tetany is a clinical manifestation of hypoparathyroidism. 5. Incorrect: Fluid volume deficit (FVD) is not a clinical manifestation of hyperparathyroidism.

What is the best instruction the nurse should provide when administering acetylsalicylic acid 81 mg to a client experiencing severe, crushing chest pain radiating up the left jaw? 1. Chew the acetylsalicylic acid prior to swallowing. 2. Place the acetylsalicylic acid under the tongue so that it can dissolve. 3. Swallow the acetylsalicylic acid tablet. 4. Insert the acetylsalicylic acid between the cheek and gum for greater absorption.

1. Correct: Acetylsalicylic acid has been shown to decrease mortality and re-infarction rates after MI. The fastest way to get the aspirin into the circulatory system is to have the client chew the acetylsalicylic acid prior to swallowing. 2. Incorrect: Nitroglycerin is administered sublingual (SL) or buccal. Initially acetylsalicylic acid is administered by chewing the tablet or swallowing the tablet. 3. Incorrect: If a solid dose pill is prescribed, the pill should be chewed. Faster absorption is obtained from chewing, rather than swallowing acetylsalicylic acid. 4. Incorrect: Nitroglycerin is administered SL or buccal. Initially acetylsalicylic acid would be chewed to increase the absorption rate.

The unit charge nurse is responsible for reporting all healthcare associated infections. Which client condition needs to be reported? 1. A client diagnosed with Clostridium Difficile while receiving intravenous (IV) antibiotics. 2. A client admitted with Methicillin-Resistant Staphylococcus aureus (MRSA) in a wound. 3. A client with ulcerative colitis exhibiting diarrhea. 4. A client with a fever of 99.1º F (37.2° C) two days post gastrectomy.

1. Correct: Clostridium Difficile is a spore forming bacterium that has significant healthcare associated infections (HAI) potential. Clients with intravenous catheters are at a higher risk for HAI. 2. Incorrect: This client was admitted with MRSA already present which indicates that this is a community acquired infection. The client did not acquire a healthcare associated infection. 3. Incorrect: Clients with ulcerative colitis have diarrhea. Diarrhea in this instance does not indicate a possible healthcare associated infection. 4. Incorrect: Low grade fever may occur after surgery. The temperature of 99.1°​ F (37.2° C) does not indicate a HAI at this time.

A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. EGD, colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the symptoms. The client tells the nurse, "The doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad some times that I can't function!" What is the nurse's most appropriate response? 1. "The pain you feel is real." 2. "The primary healthcare provider is right. Your pain is not real." 3. "Let me get you an appointment with the psychiatrist." 4. "Don't worry. Everything will be ok."

1. Correct: Pain is real even if it is psychological pain. The client is experiencing anxiety, or stress through stomach pain. The nurse should use therapeutic communication technique that is client centered and empowers the client. 2. Incorrect: This is a example of nontherapeutic communication. The response is confrontational and does not address how the client feels. 3. Incorrect: This nontherapeutic communication of changing the subject ignores the client's feelings. This action invalidates the client. 4. Incorrect: This is a nontherapeutic communication technique, because the response is trite, with false reassurance. The nurse can not know if everything will be ok for the client.

A homebound client lives alone, has a history of poorly controlled diabetes, and has an open wound on the left heel. The home health nurse is concerned about the client's condition and the possible need for a referral. Which intervention should the nurse initiate for this client? 1. Ask the primary healthcare provider to prescribe a diabetes educator consult. 2. Increase home health visits to monitor the healing process of the open wound. 3. Suggest nursing home placement to the family until wound has healed. 4. Suggest that the client's family hire sitters to assist with hygiene care.

1. Correct: Referrals to appropriate agencies or departments are often made by the home care nurse. Client needs must be met in the most efficient way while utilizing appropriate expertise. This client has poorly controlled diabetes resulting in a wound. A diabetes educator can help develop a plan to prevent further complications of diabetes. 2. Incorrect: The home care nurse has identified an immediate need which must be met. Increasing the number of visits may be part of the nurse educators plan but the total care of this client needs to be assessed. Healing is not the primary problem, poorly controlled diabetes is the problem. 3. Incorrect: Nursing home placement may or may not be needed. Other disciplines may need to be involved in the care of the client before suggesting alternate placement. Remember to fix the problem and the nurse educator will fix the poorly controlled diabetes. 4. Incorrect: Bringing in sitters for hygiene needs will not fix the problem. The problem is poorly controlled diabetes and this poor control has resulted in an open wound.

A new mother brings her infant to the clinic for a well-baby checkup. While at the clinic, the mother asks the nurse if there are any reasons why her infant should not have the measles, mumps, rubella (MMR) vaccine. The nurse's response is based on evidence that the MMR vaccine is contraindicated under which condition? 1. A known allergy to gelatin. 2. A family history of autism. 3. In infants with diarrhea. 4. A known allergy to sulfonamides.

1. Correct: The MMR vaccine is grown using chicken embryos and manufactured with the use of gelatin. Known allergies to gelatin would be a contraindication for administration. 2. Incorrect: The Centers for Disease Control does not recognize a link between the administration of the MMR vaccine and the development of autism. 3. Incorrect: Diarrhea is not a contraindication specifically for the MMR vaccine. Diarrhea may result in hypovolumia and electrolyte imbalance which need to be addressed. 4. Incorrect: Sulfonamides are not used in the development of the MMR vaccine. Neomycin is used in the development of the MMR vaccine. Neomycin is the only antibiotic allergy that would contraindicate the administration of the MMR vaccine.

Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection? Select all that apply. 1. Cleans perineum from front to back after newborn soils diaper. 2. Makes certain the umbilical cord remains dry with each diaper change. 3. Places the top of the diaper just above the umbilicus. 4. Wraps sterile petroleum gauze around umbilical cord. 5. Submerges newborn in warm water up to the chest for first bath.

1., & 2. Correct: Cleaning from front to back will decrease the risk of infection by reducing the number of microorganisms at the urethral meatus. Keeping the umbilical cord clean and dry will decrease the risk of infection and will allow it to fall off. 3. Incorrect: The top of the diaper should be placed just below the umbilicus to prevent exposure to body waste and moisture. Placing the diaper above the umbilical cord will cause the diaper to rub the umbilicus, which will increase the risk of infection. 4. Incorrect: This would keep the umbilical cord moist and could lead to infection. Also a sterile dressing is not warranted. The umbilical cord needs to be kept dry so it will fall off. 5. Incorrect: The newborn should not be placed in water until after the umbilical cord falls off. Water submersion keeps the cord moist and at risk for infection. The umbilical cord should be kept dry so that it will fall off.

The nurse is planning health promotion strategies for a single parent of young children who is trying to increase personal physical activity level but expresses a lack of time. Which interventions would help the client get more regular physical activity into the day? Select all that apply. 1. Suggest walking up and down steps at home several times each morning and evening. 2. Suggest parking further away from the grocery store and work. 3. Walk with the children in the evening instead of watching TV with them. 4. Suggest waking one hour earlier in the morning to go to the gym. 5. Suggest walking for 30 minutes with a buddy each afternoon before leaving work.

1., 2. & 3. Correct: This plan will allow the parent to stay home without adding further time demands to the day. Parking farther away is one plan to get more steps into the day without increasing time demands drastically. Walking with the children allows the parent to spend quality time with the children as well as offers them a good example. 4. Incorrect: Being a single parent, this plan would not be feasible. The demands of getting the children out earlier could impact the time schedule for the day in a negative way. 5. Incorrect: This plan would only increase time demands and possibly financial demands if the children have to be cared for by someone else at an extra charge each day.

Which interventions should the nurse include when planning care for a client diagnosed with paranoid personality? Select all that apply. 1. Develop a trusting relationship. 2. Be honest when communicating with the client. 3. Encourage the client to participate in group therapy. 4. Encourage the client to clean the day room daily. 5. Give clear explanations of procedures before hand.Select all that apply.

1., 2. & 5. Correct: This disorder is characterized by distrust and suspicion towards others. The nurse should use open communication techniques to increase the client's trust in the nurse. Clear explanations of procedures will decrease the anxiety of the client. 3. Incorrect: The client with paranoid personality is reluctant to share personal information with other people. They suspect everyone of causing problems for them. Group therapy would not be appropriate for this client. 4. Incorrect: The client with paranoid personality feels that others are using or exploiting them. The client may perceive that they are being exploited if they clean the dayroom.

What should the nurse teach a pregnant client who comes to the clinic reporting hemorrhoids and constipation? Select all that apply. 1. Increased rectal pressure from the gravid uterus may result in hemorrhoids. 2. Hormones decrease maternal GI motility, resulting in constipation. 3. The client needs more fiber in the diet. 4. A mild laxative is recommended to alleviate constipation. 5. The client needs to increase fluid intake.

1., 2., 3. & 5. Correct: As pregnancy progresses, the enlarging uterus increases abdominal and rectal pressure. GI motility slows due to hormonal influences. Pregnant clients may benefit significantly from dietary changes including adequate hydration and increased fiber intake. 4. Incorrect: Medications, including laxatives, should not be taken by pregnant women unless prescribed by the primary healthcare provider. If needed, the primary healthcare provider may prescribe a stool softener but rarely a laxative because of possible fluid and electrolyte shifts.

A nurse is planning to provide an education class on preconception health care to a group of young women wishing to become pregnant. What points should the nurse include in this class? Select all that apply. 1. Attain a healthy weight. 2. Make sure immunizations are up to date. 3. Avoid drinking alcohol. 4. Learn family health history. 5. Maintain folic acid intake at 200 micrograms/day.

1., 2., 3., & 4. Correct: All of these actions are needed to promote the birth of a healthy baby. A preconception care visit or class can help women take steps for a safe and healthy pregnancy before they get pregnant. 5. Incorrect: Folic acid intake should be 400 micrograms per day in order to reduce neural tube defects by 70%.

A client arrives at the emergency department after sustaining partial and full-thickness burns over the anterior neck, chest, and right arm. Which interventions will the nurse initiate? Select all that apply. 1. Administer oxgen 2. Start two intravenous lines 3. Remove necklace 4. Elevate right arm 5. Debride wounds

1., 2., 3., & 4. Correct: Burns over the anterior neck and chest mean that the client is likely to have inhalation burns, putting him/her at high risk for impaired gas exchange. The inhalation will cause edema of the airway. It goes back to Maslow's Hierarchy of Needs. Administer oxygen and start two IVs so that fluid resuscitation can begin. Metal continues to burn and swelling will occur, so remove the necklace or any jewelry. Elevate the arm to decrease swelling. 5. Incorrect: Debridement of the wound occurs in the acute/intermediate phase. This phase starts 48-72 hours after the burn accident has happened.

A nurse has just inserted an indwelling urinary catheter in a client scheduled for surgery. What should the nurse document? Select all that apply. 1. Perineal skin assessment 2. Client teaching 3. Color of urine 4. Date and time of insertion 5. Type catheter inserted 6. Infusing rate of IV fluid

1., 2., 3., 4., & 5. Correct: Perineal skin assessment should be assessed prior to insertion of the indwelling catheter. The following documentation is appropriate after inserting an indwelling catheter: Client teaching, color of the urine, date and time of the insertion and the type of catheter inserted. 6. Incorrect: Documenting the IV rate is not relevant to inserting the catheter. The infusion rate may need to be documented, but the question is asking about the documentation of the insertion of the indwelling catheter.

A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions for at risk clients. What steps should the QA manager include in this evaluation? Select all that apply. 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Poll staff to identify what fall precautions are implemented for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.

1., 2., 4 & 5. Correct: The QA manager is responsible for evaluating performance improvement plans to ensure that staff are providing appropriate care. The QA manager can do chart reviews to see if staff are documenting fall precaution for a client. Direct observation of unit staff will let the QA manager know if staff are performing proper precautions while caring for clients. The first step is to identify what clients are at risk for falls and then see if the staff have identified these clients as at risk as well. Monitoring should be at unpredictable intervals, so staff do not comply just for a scheduled evaluation. 3. Incorrect: Asking the staff does not ensure that they follow through.

The nurse is teaching the client about benzodiazepines. Which comments by the client indicate adequate understanding of the drug effects/side effects? Select all that apply. 1. I should not drive my car until I see how the medication affects me. 2. I can expect my reaction time to be slowed in the beginning. 3. I may need to double the dose if I continue to be anxious. 4. I must be careful to take the medication for a limited time. 5. There is a risk for dependence on this medication.

1., 2., 4. & 5. Correct: Benzodiazepines slow reaction time and may affect general alertness. The client should not operate machinery until effects of the medication are observed, and client can drive safely. Benzodiazepine medications are usually prescribed for short periods of time. Benzodiazepines are frequently abused. Clients develop tolerance and dependence on the drugs. 3. Incorrect: The client should not self-regulate dosage. There is a potential for tolerance and dependence to develop. Dosage should be monitored carefully by the primary healthcare provider.

The home care nurse visits a client who has moderate cognitive impairment and whose family provides care for the client. Which suggestions would be helpful for this family to reduce the risk of injury? Select all that apply. 1. Suggest that the family lock up medications and poisons and keep the keys. 2. Encourage the family to place locks high on the door frame to make it difficult for the client to leave. 3. Suggest that the family talk with the client weekly about safety issues around the house. 4. Suggest that the family remove knobs from stove when not in use. 5. Keep fire extinguishers present and in working order.

1., 2., 4. & 5. Correct: Clients with cognitive impairment may forget that they have taken their medicines and take them again. They may also confuse harmful substances with other substances. Locks in places that are not normally expected will make it more difficult for the client with a cognitive impairment to find and open. This is especially useful if the client wanders. The client may turn the stove on and be burned or cause a fire. If the knobs are removed, the home is safer for everyone. Fires are a hazard for people with cognitive impairment; therefore, the presence of a working fire extinguisher could prevent damage from a fire. 3. Incorrect: A client with moderate cognitive impairment will need to be continually supervised to decrease their risk of injury. The retention of information this client has is too short for weekly discussions.

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

1., 2., 4., & 5. Correct: An alternating pressure mattress will help to prevent pressure ulcers. A hospital bed is needed so that the head of the client's bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. The unresponsive client may need suction equipment for suctioning if unable to clear secretions from the oropharynx. The client at the end stages of liver disease will be hypoxemic, so oxygen therapy is provided. 3. Incorrect: The unresponsive client will not need a walker.

What statements by a client diagnosed with a hiatal hernia would indicate to the nurse that the discharge teaching was effective? Select all that apply. 1. "I should eat six small meals a day." 2. "Sitting up for an hour after I eat will decrease symptoms." 3. "Eating a grapefruit for breakfast will help digest the rest of my food." 4. "Ten inch blocks need to be placed under the head of my bed." 5. "I will get assistance for lifting heavy objects." 6. "I will avoid using laxatives."

1., 2., 4., & 5. Correct: Clients with a hiatal hernia should eat small frequent meals, because large meals cause them to be symptomatic with heartburn and other symptoms. Sitting up after eating will keep the stomach down as much as possible. If they lie down, the stomach will go upward and cause regurgitation, heartburn, nausea, and fullness. Placing blocks under the bed also helps keep the stomach downward and reduces symptoms when the client sleeps. One of the major causes and aggravating actions for a hiatal hernia is straining. Therefore, the clients do not need to be lifting heavy objects. 3. Incorrect: Since grapefruits are acidic, they can increase the amount of acid backing up into the esophagus. Eating grapefruits should be avoided. 6. Incorrect: Straining should be avoided so use of laxatives may be advised. Straining to have a bowel movement will cause increased abdominal pressure which may cause pressure on the hiatal hernia.

An elderly client arrives in the emergency department (ED) after a fall. What assessment findings would lead the nurse to suspect that the client has a fractured right hip? Select all that apply. 1. Severe pain in the right hip and groin. 2. Inability to bear weight on the right leg. 3. Right leg slightly longer in length than the left leg. 4. External rotation of right lower leg. 5. Bruising and swelling around the right hip.

1., 2., 4., & 5. Correct: Pain in the affected hip, often severe, is one of the main signs of a hip fracture. This pain may radiate to the groin area. The pain and bone injury generally prevent the client from being able to bear weight on the affected leg. The client will often assume a position in which the leg on the injured side is held in a still and externally rotated position (the foot and knee turns outward). Discoloration and swelling can be an indication of a hip fracture in some clients. 3. Incorrect: A client who has a hip fracture often appears to have shortening of the extremity on the affected side. This is a result of the location of the break and the positioning of the body in response to the injury and pain.

Which tasks would be appropriate for the nurse to assign to an LPN/VN? Select all that apply. 1. Changing a colostomy bag. 2. Administer antibiotic via intravenous piggyback (IVPB). 3. Teach insulin self administration to a diabetic client. 4. Administer IV pain medication to a two day post op client. 5. Check for urinary retention. 6. Remove wound sutures.

1., 2., 5., & 6. Correct. These tasks are within the PNs practice scope. The PN can change a colostomy bag, administer antibiotics by IVPB, monitor for urinary retention and remove wound sutures. 3. Incorrect: The RN is responsible for teaching. The PN can reinforce teaching once taught by the RN. 4. Incorrect: The RN must give IV pain meds to clients. The PN can monitor the effectiveness of the medication after given by the RN and can report any problems if necessary.

The nurse is providing discharge education to a client after a concussion. What should the nurse emphasize to report to the primary healthcare provider? Select all that apply. 1. Difficulty waking up 2. Headache (3/10 on the pain scale) 3. Blurry vision 4. Achy feeling all over 5. Vomiting

1., 3. & 5. Correct: Increased intracranial pressure (ICP) is a result of increased pressure around the brain or blood in the brain. These are signs of increasing intracranial pressure (post-concussion syndrome). This is a medical emergency, and the PHP should be notified immediately. 2. Incorrect: A headache of 3/10 on the pain scale does not warrant notifying the primary healthcare provider. The primary healthcare provider should be notified if the pain intensity increases. 4. Incorrect: This is not related. This is not a symptom of increased ICP.

The primary healthcare provider is preparing to drain a large abdominal abscess. The client has dementia and moves about on the bed frequently. Which personal protective equipment (PPE) should the nurse wear while holding the client for the procedure? Select all that apply. 1. Face shield 2. Sterile Gloves 3. Gown 4. Mask 5. Regular exam gloves

1., 3., 4. & 5. Correct: The nurse should implement transmission based contact precautions. During drainage of an abscess, the nurse may come into direct and indirect contact of the contaminated body fluids. The nurse needs the protection of a gown, mask, face shield, and regular exam gloves. Since the nurse is not directly assisting with the wound care, regular exam gloves are appropriate. 2. Incorrect: Sterile gloves are not necessary since the nurse is holding the client and not directly assisting with the wound care procedure.

What should the nurse include in the post-op care of a client following the removal of the posterior pituitary gland? Select all that apply. 1. Monitor intake and output. 2. Restrict fluids to no more than 1500 ml/day. 3. Weigh daily. 4. Monitor urine specific gravity. 5. Assess the level of consciousness (LOC). 6. Instruct client to avoid blowing the nose forcefully.

1., 3., 4., 5., & 6. Correct: Removal of the pituitary gland can lead to diabetes insipidus (DI) as a result of the reduced production of antidiuretic hormone (ADH). The nurse should monitor I & O closely and watch for an increase in output which would indicate diuresis as part of DI. Daily weights are an important part of monitoring the client's fluid status. Monitoring the urine specific gravity is another good way of assessing the fluid status because, as the urinary output increases, the client's urine is becoming more dilute, which would result in a lower urine specific gravity. If the client's serum volume is decreasing from the excessive diuresis, the client can go into shock. The nurse should monitor for early signs of changes in the level of consciousness. To avoid disrupting the surgical site, the client should not blow the nose forcefully for at least one week post-op. 2. Incorrect: If the client is lacking ADH, the client may begin losing large amounts of fluid volume. Therefore, the fluid intake would need to be increased (not decreased) to avoid dehydration and shock.

A nurse is preparing to conduct a presentation on barriers to therapeutic communication with clients from a culture other than the nurse's culture. Which points should the nurse include in the presentation? Select all that apply. 1. Lack of knowledge about a client's culture is a major barrier to therapeutic communication. 2. Follow cultural beliefs when caring for all clients of that particular culture. 3. Ethnocentrism facilitates therapeutic communication. 4. Do not touch the client until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and preferences.

1., 4. & 5. Correct: Nurses must understand and take into consideration the cultural differences of their clients. Some cultures do not approve of touching or shaking hands. By assessing the client's culture preference, the nurse is able to provide individualized care. 2. Incorrect: Do not stereotype all clients of a certain culture. Ask questions. Allow for individuality. To provide culturally competent care, the nurse must recognize individual preferences within the client's culture. 3. Incorrect: Ethnocentrism is the belief that one's own culture and traditions are better than those of another. It blocks therapeutic communication by allowing the nurse's biases and prejudices to negatively influence the nursing care of the client.

A nurse is planning a health education seminar for a group of females who are age 45-54. What should the nurse recommend be done annually? Select all that apply. 1. Chest xray 2. Mammography 3. Influenza vaccine 4. Tuberculous (TB) skin test 5. Colonoscopy

2. & 3. Correct: It is recommended that women age 45-54 should have a mammogram annually. Women 55 or older should have a mammogram every 2 years. The influenza vaccination is recommended annually for persons 6 months and older. 1. Incorrect: Chest x-ray is not done routinely since that exposes the client to low doses of radiation. A chest x ray would be ordered as a diagnostic radiographic examination. 4. Incorrect: Tuberculosis (TB) skin test yearly is required for high risk individuals, such as those working in the healthcare field or in nursing homes or other close-contact areas. This test is not recommended annually at a specific age for low risk individuals. 5. Incorrect: Colonoscopy is recommended for clients beginning at age 50, but not annually (every 10 years with no problems) until the age of 75. A colonoscopy should be performed more frequently if there is a change in bowel habits, obvious or occult blood in the stool or abdominal pain.

The charge nurse is evaluating knowledge of tracheostomy suctioning of a new nurse prior to that procedure being performed. Which statement by the new nurse would indicate to the charge nurse that additional education is needed? 1. "Prior to suctioning, I will hyper-oxygenate the client." 2. "I will instill normal saline bullets to liquefy secretions." 3. "I will allow at least 20 seconds between suctioning passes." 4. "Suctioning will be limited to a maximum of three catheter passes."

2. Correct. The best ways to liquefy secretions are to humidify secretions and hydrate the patient. Do not use normal saline solution or normal saline bullets routinely to loosen tracheal secretions because this practice may reach only limited areas, may flush particles into the lower respiratory tract, may lead to decreased post-suctioning oxygen saturation, increases bacterial colonization, and damages bronchial surfactant. 1. Incorrect. This is a true statement. Prior to suctioning, the client should be hyper-oxygenated. Suctioning a client will cause a decrease in the clients oxygen level. 3. Incorrect. This is a true statement. This allows the client to get oxygen between passes. The nurse should wait at least 20 seconds before suctioning the client again. This allows the oxygenation of the client to increase. 4. Incorrect. This is a true statement. Each session of suctioning should be limited to no more than 3 passes this will allow the client proper oxygenation and to prevent tissue damage during repeated suctioning.

Which finding should a nurse expect when assessing a healthy 65 year old client? 1. Anomia 2. Presbyopia 3. BP 156/88 4. Apraxia

2. Correct: As the lens becomes less flexible, the near point of focus gets further away. This condition, presbyopia, usually begins in the 40s. Reading glasses to magnify objects are required. 1. Incorrect: Anomia (cannot name objects) is an early sign of Alzheimer's disease. Anomia is not a normal assessment of a 65 year old client. 3. Incorrect: Blood pressure (BP) reading of 156/88 is not within normal BP range. The normal blood pressure range for the 65 to 79 year old is 140/90 or less. 4. Incorrect: Apraxia means client cannot perform purposeful movement. We would not expect to assess this in a healthy 65 year old.

The nurse is administering the prescribed Mantoux tuberculin skin test to a client. The nurse does not observe the tense blister-like formation at the injection site. Which action should the nurse take? 1. Chart the injection site response as the only action. 2. Administer another Mantoux tuberculin skin test at a different site. 3. Circle the area, wait 48 to 72 hours, and assess for a reaction. 4. Call the primary healthcare provider.

2. Correct: If there is not a wheal of at least 6 mm in diameter after the solution is injected , the test should be administered again. The nurse would need to administer another Mantoux tuberculin skin test in another area about 5-6 cm from the original injection site. 1. Incorrect: The Mantoux tuberculin skin test is an intradermal injection. The expected outcome after the injection of the medication is a tense blister-like formation at the injection site. The absence of the tense blister-like formation is an indicator that the injection was given too deep. 3. Incorrect: The Mantoux tuberculin skin test was not administered correctly. A wheal of 5-6 cm did not occur after injection was given. The test would need to be done again. 4. Incorrect: There is no need to call the primary healthcare provider. The primary healthcare provider prescribed the test. The injection should be administered to create a 5-6 cm wheal.

The nurse in the outpatient clinic performs an assessment on a client who takes propranolol for management of palpitations associated with mitral valve prolapse. Which statement by the client should be reported immediately to the primary healthcare provider? 1. "My resting pulse was 60 this morning." 2. "I feel a little short of breath when walking." 3. "I have lost 5 pounds in the last 2 weeks." 4. "My blood pressure (BP) was lower this visit than last time."

2. Correct: Propranolol is a non-selective beta blocker so it blocks sites in the heart and in the lungs. The shortness of breath could be the result of the adverse reactions of bronchospams or heart failure. This statement requires immediate investigation by the primary healthcare provider. 1. Incorrect: A side effect of propranolol is bradycardia. The client should be taught to contact their primary healthcare provider if their pulse is <50 beats per minute (bpm). A pulse rate of 60 bpm is acceptable. 3. Incorrect: Losing weight is not a side effect of propranolol. Weight loss regimen may be encouraged for hypertension. Losing 5 pounds in 2 weeks is within the acceptable range. 4. Incorrect: The therapeutic effect of propranolol is to reduce BP. If the client is asymptomatic, decreased BP is no big deal.

An elderly client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200 mL/hr via pump. What is the priority nursing action? 1. Intake and output every shift. 2. Lung assessments every 2-4 hours. 3. Vital signs every shift. 4. IV site assessment every 2-4 hours.

2. Correct: The IV is infusing at 200 mL/hr which is a rapid infusion rate for an elderly client. The lungs should be assessed every 2-4 hours to evaluate for potential fluid volume excess (FVE). 1. Incorrect: Input and Output (I&O) are important, but are a less priority than lung assessment in the elderly client. 3. Incorrect: Vital signs should probably be more frequent than every shift on the elderly client with dehydration. In addition, the cliet's IV rate is 200 mL/hr which may result in FVE. 4. Incorrect: The site should be monitored but will not be priority over lung assessment in the elderly client.

A client who has developed hypovolemic shock is receiving albumin. What assessment finding by the nurse indicates that the albumin has been effective? 1. Swelling in the legs 2. Increase in uninary output 3. Proteinuria 4. Increase in waist measurement

2. Correct: The action of albumin is to increase the serum albumin level. When the albumin level increases there is a shift of fluid from extracellular to intracellular. This action will result in an increase in urinary output. 1. Incorrect: This is a symptom of hypoalbuminemia. There is a shift in the fluid from intracellular to extracellular. This results in the swelling of the legs. 3. Incorrect: Hypoalbuminemia may cause damage to the kidneys. Proteinuria is indicative of renal disease or damage. 4. Incorrect: There may be a increased accumulation of fluid in the abdomen. The ascites is due to the decreased albumin level in the vascular space, which also causes damage to the liver.

A client has been admitted with a diagnosis of septic shock and has been successfully intubated. The nurse performs and documents a rapid assessment. Which information from the assessment requires the most immediate action by the nurse? EXHIBIT: - Vital Signs: Blood pressure 90/40 mm Hg Heart rate 112 beats/min Respiratory rate 32 breaths/min Temperature 103deg;F (39.4deg;C) axillary O2 saturation 94% - Nursing Notes: Heart rate irregular. Face flushed and warm. Extremities cool and mottled. Radial pulses faintly palpable. Pedal pulses non-palpable. Denies chest pain. Breath sounds audible bilaterally with adventitious sounds noted to left lung base. Grimaces with light abdominal palpation over pelvic bone. Urine amber and cloudy with red streaks. 100 mL urine output in urinary drainage system. Opens eyes and moves to command. Pupils equal, round, and react to light. 1. Lung assessment finding. 2. Blood pressure reading. 3. Elevated temperature 4. Urine description and output.

2. Correct: The low blood pressure indicates that systemic tissue perfusion will not be adequate. The blood pressure needs to be improved rapidly. 1. Incorrect: The oxygen sat is 94%, so the adventitious lung sounds do not need immediate intervention. 3. Incorrect: The second priority is to treat the infection that is a likely cause of the temperature elevation and hypotension. 4. Incorrect: This is the likely cause of the sepsis, but the priority is to improve the BP. The second priority is to treat the infection.

A client has been admitted to the medical unit and placed on airborne precautions for suspected pulmonary tuberculosis (TB). The nurse will assess for which signs and symptoms? Select all that apply. 1. Weight gain 2. Fatigue 3. Hemoptysis 4. Diaphoresis during sleep 5. Anorexia

2., 3., 4. & 5. Correct: Feeling tired all the time, loss of appetite, fever, coughing up blood, and night sweats are the most common signs and symptoms of active TB. 1. Incorrect: A symptom of TB is a decreased desire for food. This will result in weight loss rather than weight gain.

Which nursing tasks can the RN delegate to an unlicensed assistive personnel (UAP)? Select all that apply. 1. Tell a female client who has recurrent urinary tract infections how to wipe after urinating. 2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 3. Collects a urine specimen from an indwelling catheter tubing. 4. Document the intake and output of a client in acute renal failure. 5. Irrigate the foley catheter of a client who has had transurethral resection of the prostate (TURP). 6. Perform perineal care of a client who has urinary incontinence.

2., 4., & 6. Correct: These are all tasks that can be performed by the UAP. The UAP has received training for completing these tasks. 1. Incorrect: The UAP cannot provide teaching; that is planned and implemented by the RN. 3. Incorrect: This is out of the scope of practice for the UAP as it is requires entering a sterile system using sterile technique. 5. Incorrect: The UAP does not have the knowledge and skill to irrigate catheters of any kind. This is a skilled procedure.

Which findings would indicate to the nurse that a client with Addison's disease has received too much glucocorticoid replacement? Select all that apply. 1. Dry skin and hair 2. Hypotension 3. Rapid weight gain 4. Decreased blood glucose level 5. Increased cholesterol

3, & 5. Correct: Excessive drug therapy with glucocorticoids will cause rapid weight gain, round face, and fluid retention. Cholesterol and triglycerides in the blood are also increased by glucocorticoids. Long term use of high steroid doses can lead to symptoms such as thinning skin, easy bruising, changes in the shape or location of body fat (especially in your face, neck, back, and waist), increased acne or facial hair, menstrual problems, impotence, or loss of interest in sex. 1. Incorrect: Dry skin and hair would be seen with a decrease in sex hormones, not with a increase in glucocorticoids. An increase in glucocorticoids will result in an increase in oil production in the skin. 2. Incorrect: Hypotension is a sign of Addison's disease. The client loses sodium and water, causing the client's blood pressure to drop. This loss of sodium and water would come from a decrease in mineralocorticoids. This would have nothing to do with glucocorticoids. 4. Incorrect: An increase in glucocorticoids will result in glucose intolerance. The client will become resistive to insulin production. This will result in an increase in the serum blood glucose.

The primary healthcare provider suspects the client has tuberculosis (TB) and prescribes a Mantoux test. What precautions should the nurse take when administering the Mantoux test? Select all that apply. 1. Don sterile gloves. 2. Place the client on reverse isolation. 3. Wear a particulate respirator 4. Obtain a consent form. 5. Initiate airborne precautions.

3. & 5. Correct: A disposable particulate respirator that fits snugly around the face is needed. The client needs to be on acid-fast bacilli (AFB) isolation precautions, not reverse isolation. Airborne precautions include a private room with negative pressure and a minimum of 6 air exchanges per hour. Ultraviolet lamps and high efficiency particulate air filters are also needed. 1. Incorrect: Sterile gloves are not needed. Standard precautions indicate clean gloves. 2. Incorrect: The client needs to be on airborne isolation precautions, not reverse isolation. Airborne precautions include a private room with negative pressure and a minimum of 6 air exchanges per hour. Ultraviolet lamps and high efficiency particulate air filters are also needed. 4. Incorrect: A consent is not necessary.

The nurse is caring for a client with pneumococcal pneumonia. Which nursing observations would indicate a therapeutic response to the treatment regime for the infection? Select all that apply. 1. Dyspnea on exersion with nonproductive cough 2. Tachypnea with use of accessory muscles 3. Expectorating moderate amounts of thin, white sputum 4. White blood cell count of 18,000 cells per mcL 5. Crackles clearing with cough

3. & 5. Correct: The client has no signs of active infection. A cough with thin, white sputum is expected for a while, but it is infection free. Crackles clearing with cough are signs of an effective cough effort. 1. Incorrect: The client still has signs of active infection and complaints of dyspnea. The client should not have a nonproductive cough on exertion. 2. Incorrect: The client still has signs of active infection, such as tachypnea with use of accessory muscles. The respiration rate for an adult is 12-20 per minute with no use of accessory muscles. 4. Incorrect: The white cell count is still too high. A normal range for white blood count is between 4,500 and 10,000 mcL. This is not a therapeutic response to the treatment.

A client arrives in the emergency department with fever, nuchal rigidity, and seizures. What action should the nurse take first? 1. Administer Penicillin IVPB. 2. Obtain blood cultures from two sites. 3. Place on droplet precautions. 4. Set up for lumbar puncture.

3. Correct. When bacterial meningitis is suspected, the nurse should place the client on droplet precautions at once. Transmission can occur by the droplet/close contact route for up to 24 hours even after starting effective antibiotic therapy. The Centers for Disease Control and Prevention (CDC) recommends droplet precautions in addition to Standard Precautions for bacterial meningitis. 1. Incorrect. Penicillin is the drug of choice but would be initiated after blood cultures and other cultures are obtained. The client would be placed in isolation prior to starting penicillin. 2. Incorrect. Lumbar puncture is done to obtain cultures for diagnosis but would be done after placing in isolation. Blood cultures are obtained from the lumbar puncture and cultures may be obtained from blood, nasopharynx, urine, or skin lesions. The client would be placed in isolation first. 4. Incorrect. A lumbar puncture and cerebrospinal examination are needed to confirm a diagnosis. The lumbar puncture should be performed after placing the client in droplet precautions.

A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What statement made by the client indicates that teaching has been effective regarding safe needle disposal? 1. "I should wrap the needle in a paper towel and place in the trash." 2. "I should use a hospital issued biohazard container for all needles." 3. "I may use any hard plastic container with a screw-on cap." 4. "I should take my needles to the nearest hospital for disposal. "

3. Correct: At home, an FDA approved sharps container is not needed, however, needles, syringes, and sharps may be disposed of in a hard plastic container. Clients should follow their community guidelines for sharps container disposal. This protects the sanitation engineers from injury by the sharps. 1. Incorrect: Syringes must be placed in a safe container in order to protect others from becoming injured by sharps. Wrapping the needle in a paper towel and placing in the trash increases the possibility of injury to someone. 2. Incorrect: The hospital is not involved in sharps disposal in the home. A hard plastic container with a screw on cap is an acceptable container to dispose of needles. 4. Incorrect: The hospital is not involved in sharps disposal in the home. The client can dispose of needles safely at home in a hard plastic container with a screw on cap. The needle should not be brought to the hospital for disposal.

A client at 36 weeks gestation is receiving magnesium sulfate for treatment of pre-eclampsia. Which finding by the nurse requires immediate action? 1. Respiratory rate of 12 2. Deep tendon reflexes (DTR) of 3+ 3. Urinary output (UOP) of 100cc/4hours 4. Fetal heart rate (FHR) of 120

3. Correct: Magnesium sulfate is a potent central nervous system depressant that is excreted through the kidneys. Adequate kidney function is vital to prevent magnesium toxicity. A urinary output of at least 30 mL/hr is the minimum standard to evaluate adequate kidney function. 1. Incorrect: A respiratory rate of 12 is within the acceptable range for the client. Magnesium sulfate can cause bradycardia, tachycardia, or irregular rhythm. 2. Incorrect: Magnesium sulfate causes decreased DTRs. A 3+ DTR is a very brisk response and does not reflect a symptom of magnesium sulfate toxicity. 4. Incorrect: Fetal heart rate of 120 is within the normal range of 110-160 bpm. A heart rate of 110-120 tells the nurse to be "worried and watching", but the range is acceptable.

The nurse is preparing to provide oral care to an unconscious client. What is the most important step for the nurse to provide? 1. Performing hand hygiene. 2. Explaining the procedure to the family. 3. Positioning the client in side-lying position. 4. Raising the head of bed 30 degrees.

3. Correct: Positioning the client in a side-lying position allows secretions to drain from the mouth and prevents aspiration. The most important aspect of care is the protection of the airway of this unconscious client. This is accomplished through proper positioning of the client in a side-lying position. 1. Incorrect: Hand hygiene is a key component of standard precautions. Hand hygiene is not a priority over preventing aspiration. 2. Incorrect: Informing the family about the procedure should be done, but is not the most important step in oral care. The nurse should explain the oral care procedure to the family. Maintaining the clients airway is the priority action. The client should be placed in the side lying position. 4. Incorrect: No, side lying is the appropriate position to allow drainage of secretions from mouth and prevent aspiration. Positioning the client with the HOB elevated to 30 degrees will not promote drainage of secretions from the client's mouth. The priority action is to maintain the client's airway.

What should a nurse teach a client who has been diagnosed with hepatitis A? 1. Hepatitis A is spread through blood and body fluid. 2. Chronic liver disease is a common complication of hepatitis A. 3. Symptoms of hepatitis A include malaise, dark colored urine, and jaundice. 4. Treatment includes alpha-interferon and ribavirin.

3. Correct: Symptoms of hepatitis A include fever, malaise, loss of appetite, diarrhea, nausea, abdominal discomfort, dark-colored urine, and jaundice. 1. Incorrect: Hepatitis A is spread when an uninfected person ingests food or water that is contaminated with the feces of an infected person. This disease is closely associated with unsafe water, inadequate sanitation, and poor personal hygiene. 2. Incorrect: Hepatitis A infection does not cause chronic liver disease and is rarely fatal, but it can cause debilitating symptoms and fulminant hepatitis, which is associated with high mortality. 4. Incorrect: Used for hepatitis C.

The nurse is performing the admission assessment on a client who is having a breast augmentation. Which client information would be most important for the nurse to report to the surgeon before surgery? 1. Client is concerned about who will care for her two children while she recovers. 2. There is a history of postoperative dehiscence after a previous C-section. 3. Client's last menstrual period was 8 weeks ago. 4. Client is concerned over pain control postoperatively.

3. Correct: The client may be pregnant, so a pregnancy test will need to be completed prior to administering anesthetic agents. As you look at these options they are all possible but only one is a priority and in this case life threatening. 1. Incorrect: Adequate caregivers can be discussed with the client without contacting the primary healthcare provider. This is important but not the priority to report to the surgeon. 2. Incorrect: Every person who has a surgical wound is at risk for dehiscence especially in the first two weeks after surgery. Educate the client concerning signs and symptoms and causes of dehiscence but this is not your priority here. 4. Incorrect: The client's postoperative pain control will be discussed both before and post surgery. Always discuss clients concerns prior to surgery and consult the primary healthcare provider if you are unable to satisfy the client.

The nurse is teaching a class to primiparas on breastfeeding. How many extra kilocalories per day would the nurse instruct the class participants to consume post-delivery to compensate for the increased energy requirements of lactation? 1. 1000 2. 300 3. 500 4. 800

3. Correct: The client needs an extra 500 kcal/day above the usual allowance because the average woman will secrete between 425-700 kcals per day in her breast milk. By increasing the daily caloric intake by 500 kcal the client will offset these losses. 1. Incorrect: 1000 kcal/day is more calories than are needed to offset the caloric loss of breastfeeding. 2. Incorrect: 300 kcal/day is not enough calories to offset the caloric loss of breastfeeding. 4. Incorrect: 800 kcal/day is more calories than are needed to offset the caloric loss of breastfeeding.

The charge nurse has received report from the emergency department about a client diagnosed with Cushing's disease being admitted to the unit. Which client in a semi-private room would be appropriate for the charge nurse to have this client share? 1. Client who has leukemia. 2. Client diagnosed with gastroenteritis. 3. Client who has a fractured hip. 4. Client diagnosed with bronchitis.

3. Correct: The client with Cushing's disease could go in the room with the client who has a fractured hip, as this client does not have an infection. 1. Incorrect: Both of these clients are immunocompromised and should not share a room with each other. 2. Incorrect: The client with gastroenteritis poses a risk of infection to the client with Cushing's disease because this client is immunosuppressed. 4. Incorrect: The client with bronchitis poses a risk of infection to the client with Cushing's disease.

The nurse is caring for a client with renal failure. The client has a 24 hour intake of 2500 mL and a 24 hour urinary output of 200 mL. What is the priority nursing assessment? 1. Assess for dependent edema. 2. Monitor for cardiac arrhythmias. 3. Auscultate breath sounds. 4. Monitor sodium and potassium levels

3. Correct: The nurse is "worried" about fluid volume excess. In fluid volume excess (FVE), the number one concern is heart failure with resultant pulmonary edema. In FVE, you can stress the heart so much that the heart begins to fail. With heart failure, the cardiac output decreases. With decreased cardiac output, there is decreased forward flow out of the heart. With decreased forward flow there is back flow. Back flow from the left ventricle results in fluid accumulation in the lungs. The best assessment for heart failure is to auscultate lung sounds. 1. Incorrect: Inspecting for dependent edema does not address the biggest problem/concern in FVE. The nurse is "worried" about pulmonary edema. This client will probably have edema, but it is not more important than breath sounds. 2. Incorrect: After evaluating the output versus the input amounts, the lungs should be assessed to evaluate the pressure of FVE. Cardiac arrhythmias are a possibility, due to the stress on the heart due to FVE. 4. Incorrect: Electrolytes may be abnormal due to FVE. The number one concern is FVE and pulmonary edema.

A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM). The newborn weighs 6 lbs (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What should the nurse do? 1. Administer the drug intravenously (IV) since a large volume is required. 2. Choose three injection sites and give the medication as prescribed. 3. Consult with the pharmacy for a different medication concentration. 4. Read the available drug information to determine how to administer the medication.

3. Correct: The nurse must consult with the pharmacy to receive further instructions. The dose is greater than the allowed volume to be given IM, which warrants clarification by the pharmacy. 1. Incorrect: Since the drug is prescribed IM, the route should not be changed to IV administration because this violates the prescription as written. 2. Incorrect: The dose is greater than the allowed volume to be given IM, which warrants clarification by the pharmacy. You want to avoid having to give three injections. 4. Incorrect: The concern is not drug information or administration; it is the concentration, which can only be provided by the pharmacy.

A home care nurse is preparing to perform venipuncture to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What should be the nurse's first action? 1. Hug the client to provide support. 2. Take the client to the emergency department for sedation. 3. Decrease stimuli in the room. 4. Teach the client deep breathing exercises.

3. Correct: The nurse should remain calm and quiet by the client. A stimulating environment may increase the client's level of anxiety. 1. Incorrect: Hugging a client is moving into the client;s personal space. Hugging may confine the person and intensify feelings. The nurse should use touch cautiously. 2. Incorrect: Panic attacks usually last minutes, rarely longer. The client is not exhibiting symptoms at this time that would warrant administration of a sedative. 4. Incorrect: This is good; however, you need to wait until the panic attack is over. The client must be ready to learn prior to initiating teaching. The nurse should wait until the symptoms resolve for learning to occur.

Blood and urine samples are sent to the laboratory for a client who has had a spinal cord injury. After reviewing these results, the nurse would expect which finding? EXHIBIT: - CBC: RBCs 5 million/mm3 (5 X 106 /mm3)​ (5 X 1012 /L​) WBCs 5,000 (5 X 103/mm3) ​(5 X 109 /L​) - Urinalysis: RBCs 2 to 3/hpf WBCs greater than 5/hpf. 1. Gross hematuria 2. Septicemia 3. Urinary tract infection 4. Anemia

3. Correct: The urinalysis results of red blood cells (RBC) of 2/hpf or greater and urine white blood cells (WBC) of greater than 4/hpf indicate a urinary tract infection (UTI). 1. Incorrect: The urinalysis results of 2 to 3/hpf RBCs is not indicative of gross hematuria 2. Incorrect: The blood WBCs are normal. In septicemia, the blood WBCs are elevated. 4. Incorrect: Blood RBCs of 5 million/mm3 (5 x 106 ​/ mm3) (5 x 1012/ mm3) is a normal finding.

A client develops pernicious anemia after a Billroth II procedure and is to receive vitamin B12 intramuscularly. What should the nurse include in discharge instructions? 1. B12 can be stored in a lighted area. 2. The B12 injections will be stopped when symptoms disappear. 3. The B12 injections will be continued for the client's life. 4. Vitamin B12 will be taken by mouth once the maintenance dose is determined.

3. Correct: With pernicious anemia, the client lacks the intrinsic factor. Without the intrinsic factor, B12 cannot be absorbed. The client will require B12 shots throughout the lifespan. 1. Incorrect: B12 should be protected from the light. 2. Incorrect: Cannot be stopped once symptoms disappear due to lack of intrinsic factor. Must be continued throughout the lifespan. 4. Incorrect: B12 cannot be administered orally. The client lacks the intrinsic factor, therefore B12 cannot be absorbed in the GI tract. B12 must be given by injection.

A charge nurse is planning care for several clients on the unit. Which activities can the nurse safely delegate to an unlicensed assistive personnel (UAP)? Select all that apply. 1. Administer a nebulizer treatment to a client diagnosed with pneumonia. 2. Obtain vital signs on a postoperative client who required naloxone 5 minutes ago. 3. Report a urinary output (UOP) less than 50 ml/hr on a post-op client. 4. Assist a client with obtaining a clean catch urine sample. 5. Remove an indwelling urinary catheter from a client.

3., & 4. Correct: A UAP can report the amount of UOP but cannot interpret it. A clean catch urine sample is a noninvasive procedure. The UAP can assist the client to obtain the clean catch urinary sample. Both activities are the right person and right task of delegation. 1. Incorrect: A UAP cannot administer medications. This is the wrong task for an UAP. 2. Incorrect: The client received naloxone to reverse the action of an opioid medication. A UAP should not be assigned to obtain vital signs on an unstable client. This is the wrong person to perform removal of an indwelling urinary catheter. 5. Incorrect: A UAP cannot remove an indwelling urinary catheter.

Which actions by the nurse, working in the recovery room, should be performed to prevent injury from a needle stick? Select all that apply. 1. Recap the needle after use to prevent injury. 2. Reinsert the sylet if it becomes loose in the vascular assess device. 3. After drawing up saline to flush an intravenous (IV) line, place the syringe in a pocket to prevent possible injury. 4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible.

4. & 5. Correct: Puncture resistant biohazard containers should be replaced when three-quarters full to prevent hand injury when disposing of sharps. Use of "needleless" devices reduces the risk of needle stick injuries. 1. Incorrect: For safety precautions and transmissions of infection, needles should never be recapped due to the possibility of injury while recapping. 2. Incorrect: Reinserting the stylet may cause injury to the nurse and client. 3. Incorrect: For safety precautions of the nurse or another person, a needle should never be placed in a pocket. The cap could come off and stick someone.

Which client must the nurse assign to a private room? 1. Primiparous client who delivered twins at 28 weeks gestation two days ago 2. Postpartum client on IV Ampicillin and Gentamicin for chorioamnionitis 3. Postpartum client whose 2 hour old infant is being worked up for sepsis 4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C)

4. Correct: A temperature of 100.5° F (38.05° C) or greater in a client more than 24 hours postpartum is likely an indication of infection. This client should be kept separate from other mothers and babies. 1. Incorrect: The preterm twins are in the NICU and not in their mother's room (a client with term twins would need a private room because of space considerations). 2. Incorrect: Chorioamnionitis is not contagious. 3. Incorrect: The infant may have an infection and will remain in the NICU. The mother is not infected.

A client has an order for two units of packed red blood cells (PRBCs) to be administered. The current IV prescribed is D5LR with 20 mEq KCL at 125 mL/hr infusing through a 22 gauge needle to the left hand. What action should the nurse take? 1. Piggyback the PRBCs to the current IV fluid at the lowest port on the tubing. 2. Change the current IV fluid to NS so the blood can infuse through the IV tubing. 3. Disconnect the current IV fluid and connect NS with a y-tubing blood administration set. 4. Start another IV with an 18 gauge needle to the right arm.

4. Correct: Blood should be administered through a large bore IV needle such as an 18 gauge, but no smaller than a 20 gauge. Smaller needles can cause the PRBCs to lyse. 1. Incorrect: The PRBCs must be administered through a y-tubing blood administration set that has a filter. Do not infuse through a normal IV tubing. The current IV that is infusing has 20 mEq KCL added. PRBCs should not be infused with KCL. Also the current IV was initiated with a 22 gauge needle, and the PRBCs should be infused with a needle no smaller than 20 gauge. 2. Incorrect: The IV needle is too small, and the client has an order for the IV fluids and potassium. It is out of the scope of the RN to change the prescription for the D5LR with 20 mEq KCL. Also the client requires additional KCL. 3. Incorrect: The problem here is that the IV needle is too small.

A nurse is teaching a client about the prescription aripiprazole discmelt. The nurse documents that teaching has been effective when the client makes which statement? 1. "If I start to have shakiness and sweating I need to call my primary healthcare provider at once." 2. "I must be certain to take this medication with food to eliminate vomiting." 3. "If I miss a dose of medication, I need to take an extra dose to make up for the missed dose." 4. "I will allow the tablet to dissolve in my mouth."

4. Correct: Discmelt is an orally disintegrating tablet. Since this tablet is formulated to dissolve on the tongue, the tablet should not be swallowed. 1. Incorrect: Hyperglycemia can occur. Signs/symptoms include polydipsia, polyphasia, polyuria. Hyperglycemia is a potential adverse reaction of aripiprazole discmelt. The symptoms listed are indicative of hypoglycemia. 2. Incorrect: Can be taken with or without food. Aripiprazole can be taken with or without food. Taking the medication with food does not increase or decrease side effects. 3. Incorrect: Skip the missed dose if it is almost time for the next scheduled dose. Do not take extra medication to make up for missed dose.

What is most important for the nurse to have at the client's bedside when inserting a large orogastric tube for rapid gastric lavage? 1. Emesis basin 2. Portable x-ray machine 3. Oxygen 4. Suction equipment

4. Correct: Insertion of a large orogastric tube designed for rapid lavage often causes gagging and vomiting, so suction equipment should be readily available to reduce the risk of aspiration. Maintaining the client's airway is the priority. 1. Incorrect: You would need an emesis basin because of the chance of vomiting, but suction equipment is the priority due to aspiration. 2. Incorrect: An x-ray is the preferred method to check initial placement, once the tubing is inserted. Suction equipment is the priority when inserting the tube due to risk of aspiration. 3. Incorrect: There are no key words in the question to suggest the client needs oxygen at this time.

The charge nurse observes a staff nurse caring for a new mother with oral herpes simplex type I. Which action by the nurse indicates that further instruction on transmission of this disease is needed? 1. Instructs the new mother that she should not kiss the newborn. 2. Wears gloves during the perineal and lochia assessment. 3. Washes hands before and after each client contact. 4. States that the newborn may contract herpes from the birth canal.

4. Correct: Oral herpes simplex type I is more often manifested by lesions on the lips or nose (cold sores/fever blisters) and is contagious, but not through the birth canal. Genital herpes type 2 can be transmitted to the newborn during child birth. 1. Incorrect: The newborn can contract herpes simplex 1 through direct skin contact with the lesions or oral secretions such as kissing. This is an appropriate instruction. 2. Incorrect: Wearing gloves during the assessment is not related to the mother's diagnosis of oral herpes simplex type These are standard precautions and are appropriate. 3. Incorrect: Washing hands prior to and after each client contact are standard precautions and are appropriate.

What is most important for the nurse to do prior to initiating peritoneal dialysis? 1. Aspirate for placement. 2. Have the client void. 3. Irrigate the catheter for patency. 4. Warm the dialysate fluid.

4. Correct: The peritoneal fluid is inserted into the abdominal cavity. To promote the exchange of wastes and fluid through the peritoneal membrane, the peritoneal fluid should be warmed. This will promote vasodilation of the capillaries in the peritoneal cavity. 1. Incorrect: The peritoneal catheter should not be aspirated. This would not tell you anything and could irritate the peritoneal membrane. After the cover of the dialysate fluid is removed, the tubing should be connected to the peritoneal catheter. 2. Incorrect: This is not a bad choice, just not the most important. Voiding would make the client more comfortable during the procedure but will not affect the success. 3. Incorrect: It is not necessary to irrigate a peritoneal catheter because you are irrigating with the dialysate.

The nurse is caring for a client with myasthenia gravis. What is essential for the nurse to teach this client regarding treatment? 1. Frequent low-calorie snacks. 2. Strict monitoring of intake and output. 3. Use of sweeping gaze when walking. 4. Setting the alarm clock for medication times.

4. Correct: Yes! Medication must be taken on time. Too early can cause weakness and too late can cause extreme weakness to point of paralysis. 1. Incorrect: No, the client needs frequent high calorie snacks. 2. Incorrect: No, this is not a cardiac or renal client. 3. Incorrect: No, this is done when the client has homonymous hemianopsia.