Adult NCLEX

Which statement made by a client diagnosed with Addison's disease indicates to the nurse that the client needs further teaching about fludrocortisone therapy? 1. "Taking my medicine at night will help me sleep." 2. "It is important to wear a medical alert bracelet all of the time." 3. "My medication dose may change based on my daily weight." 4. "I may need more medication if I feel weak or dizzy."

1. "Taking my medicine at night will help me sleep." (1. Correct: Steroids can cause insomnia so the client does not need to take the medication prior to going to bed. 2. Incorrect: This is a correct statement of understanding by the client. Wearing a medical alert bracelet is an excellent way of informing healthcare providers of a life threatening condition if the client is unable to verbalize that information. 3. Incorrect: Another correct statement. Steroid therapy is adjusted according to the client's weight and signs of fluid volume status. 4. Incorrect: This statement indicates that the client understands therapy. Signs of being undermedicated include weakness, fatigue, and dizziness. The client will need to report these symptoms so more medication can be given to the client.)

A home health nurse is planning home safety education for a client and spouse. Which actions should be included to promote fire safety in the home setting? Select all that apply 1. A fire extinguisher should be kept on each level of the home. 2. Keep matches and lighters away from children by storing them in a locked cabinet. 3. Install carbon monoxide smoke alarms, and test them monthly. 4. You may leave Christmas lights lit all night as long as the tree is artificial. 5. Have a planned route of exit and a place where all family members will meet.

1. A fire extinguisher should be kept on each level of the home. 2. Keep matches and lighters away from children by storing them in a locked cabinet. 3. Install carbon monoxide smoke alarms, and test them monthly. 5. Have a planned route of exit and a place where all family members will meet. (1., 2., 3. & 5. Correct: A fire extinguisher should be placed on each level of the home, near an exit, but out of reach of children. Keeping matches and lighters away from children by storing them in a locked cabinet can prevent fire-related deaths. Carbon monoxide smoke alarms will alarm for smoke as well as carbon monoxide, which is an odorless gas than can kill quickly. Alarms should be tested every month and repaired or replaced immediately if malfunction occurs. A plan facilitates exit from the building, and a place to meet helps identify that all family is out of the building. 4. Incorrect: Lit Christmas lights should be turned off when no one is home and when people go to bed for the night. It does not matter whether the tree is real or artificial.)

A client has been admitted to the telemetry unit with a diagnosis of a cerebral vascular accident. What should the nurse assess to determine the client's risk for aspiration? Select all that apply 1. Ability to swallow 2. Gag reflex 3. Level of consciousness 4. Cough reflex 5. Ability to follow commands

1. Ability to swallow 2. Gag reflex 3. Level of consciousness 4. Cough reflex (1., 2., 3., & 4. Correct: Assessing the ability of a client to swallow is something the nurse can and should do. A small amount of water should be given to the client as the nurse observes for coughing or gurgling. If the nurse suspects a client is having difficulty safely swallowing, further assessment by a speech and language therapist is recommended. To test for a gag reflex use a tongue depressor. Ask the client to open the mouth and look at their throat with a penlight. If the uvula and pharynx rise as the client says "aaahh" then the gag reflex is intact. If it does not rise, touch the back of the throat at the soft palate and watch for the rise in the pharynx in a gag response, If intact,the client should not be at risk for aspiration with eating. A client with a decrease level of consciousness is always at risk for dysphagia and aspiration. A cough reflex is assessed by administering a small sip of water and observing for a cough. if the client coughs, feeding should be withheld until further testing can be performed. 5. Incorrect: Assessing ability to follow commands does not identify a problem with swallowing. It does not provide a great deal of information about cognitive function. The other tests provide more information specific to aspiration.)

A client diagnosed with cancer has been losing weight. What should the nurse teach the client regarding methods for improving nutritional needs to maintain weight? Select all that apply 1. Add butter to foods. 2. Cup of cubed beef broth. 3. Add powdered creamer to milkshake. 4. Use biscuits to make sandwiches. 5. Fish sauted in olive oil. 6. Put honey on top of hot cereal.

1. Add butter to foods. 3. Add powdered creamer to milkshake. 4. Use biscuits to make sandwiches. 6. Put honey on top of hot cereal. (1., 3., 4., & 6. Correct: Butter added to foods adds calories. This client needs more calories and more protein. Spread peanut butter or other nut butters, which contain protein and healthy fats, on toast, bread, apple or banana slices, crackers or celery. Use croissants or biscuits to make sandwiches which provides more calories. Add powered creamer or dry milk powder to hot cocoa, milkshakes, hot cereal, gravy, sauces, meatloaf, cream soups, or puddings to add more calories. Top hot cereal with brown sugar, honey, dried fruit, cream or nut butter. 2. Incorrect: One cube of beef broth is 11 calories. Supplementing the diet with beef broth would not add significant calories. 5. Incorrect: Although cooked in olive oil, fish is low in calories.)

Twelve hours post coronary artery bypass surgery (CABG), the nurse notes the client's level of consciousness has decreased from alert to somnolent. BP 88/50, HR 130 and thready, resp 32, urinary output (UOP) has dropped from 100 mL one hour earlier to 20 mL this hour. What would be the nurse's first action? 1. Administer 100% oxygen per mask. 2. Lower the head of the bed. 3. Give furosemide STAT. 4. Re-check the BP in the other arm.

1. Administer 100% oxygen per mask. (1. Correct: This client has developed signs of cardiogenic shock, one of the complications post CABG. Cardiac output is decreased, so the client needs more oxygen for the circulating blood volume. 2. Incorrect: Lowering the HOB will not help in cardiogenic shock but will actually make it harder for the heart to pump. 3. Incorrect: Poor kidney perfusion is the reason for the decreased UOP. The kidneys are trying to conserve what little volume the body has to maintain vital organ perfusion as long as possible. 4. Incorrect: Rechecking the BP will not help the problem. With the other symptoms, this BP is most likely accurate. This would only delay treatment and would not fix the problem.)

An alert elderly client has been admitted to the hospital and placed on bedrest following a fall at home. During evening medication rounds, the nurse notes the client has become disoriented to time and place. The nurse is aware a new onset of confusion could be the result of what factors? Select all that apply 1. Admission to the hospital. 2. Amount of physical pain. 3. Current bed confinement. 4. Advanced age. 5. Response to analgesic.

1. Admission to the hospital. 2. Amount of physical pain. 3. Current bed confinement. 5. Response to analgesic. (1, 2, 3, & 5. Correct: The nurse is aware that multiple factors can contribute to acute confusion in clients. The sudden relocation to a new environment, along with pain from injury, could definitely contribute to an acute onset of confusion. The client's ordered bedrest and response to new pain medications are additional factors that could produce an acute change in mental status. 4. Incorrect: Age alone is not a factor for confusion. New onset of confusion may be successfully resolved once any contributing factors are addressed.)

The nurse is discussing frostbite prevention with a group of teenagers who participate in cold weather activities. What risk factors for developing frostbite will the nurse include? Select all that apply 1. Alcohol use 2. Dehydration 3. Diabetes 4. Exhaustion 5. Low level altitude

1. Alcohol use 2. Dehydration 3. Diabetes 4. Exhaustion (1., 2., 3., & 4. Correct: Risk factors for developing frostbite include alcohol and drug abuse, dehydration, medical conditions such as diabetes or any condition that results in poor blood flow to the extremities, fatigue and exhaustion. 5. Incorrect: Being at a high altitude reduces the oxygen supply to extremities and places the person at increased risk for developing frostbite.)

A 65 year old client is admitted for management of dehydration with an IV infusion of LR @ 125 mL/hr. What assessment findings would be of concern to the nurse? Select all that apply 1. Anxiety 2. BP 136/80 3. CVP 5 mmHg 4. Crackles noted right posterior lung field 5. S3 heart sound

1. Anxiety 4. Crackles noted right posterior lung field 5. S3 heart sound (1., 4. & 5. Correct: Volume overload is an adverse effect of IV therapy in the elderly. Anxiety is an early sign of hypoxia due to FVE. Crackles to the bases are an early sign of fluid volume excess (FVE). S3 heart sounds are also an indication of FVE. 2. Incorrect: This blood pressure is not considered hypertension in this age group. Blood pressure of >140/90 is cause for concern in this age group. Also, one BP is not cause for concern. In assessing for FVE, it is important to compare to the client's baseline. 3. Incorrect: Normal CVP is 2-6 mmHg. A CVP reading of 5mmHg does not indicate FVE.)

When shopping at the mall, a nurse witnesses an individual collapse in cardiac arrest. A bystander begins CPR while the nurse opens an automatic external defibrillator (AED) brought by security. What critical actions should the nurse perform before delivering a shock? Select all that apply 1. Apply defibrillator pads to bare skin. 2. Verify that synchronizer button is on. 3. Continue CPR until advised to deliver shock. 4. Stop CPR while machine analyzes the rhythm. 5. Shout "clear" prior to activating shock button. 6. Apply cream under de-fib pads to prevent burns.

1. Apply defibrillator pads to bare skin. 3. Continue CPR until advised to deliver shock. 4. Stop CPR while machine analyzes the rhythm. 5. Shout "clear" prior to activating shock button. (1, 3, 4 and 5. Correct: Even in a public setting, the defibrillator pads must be applied directly to bare skin for a solid connection, with one pad in the left axillary area and the other pad just below the right clavicle. CPR should be initiated immediately while the machine is set up and the pads are positioned. CPR should stop momentarily while the AED analyzes the rhythm. Then, if a shock is advised, the nurse shouts "clear" to any individual near the client prior to administering a shock. If no shock is advised, CPR should continue. 2. Incorrect: The synchronized cardioversion mode is used only when converting erratic rhythms back into sinus rhythm, such as atrial fibrillation or atrial flutter. Cardioversion administers a low-voltage shock at a specific point during a heartbeat and can only be used on beating heart. When utilizing the AED for a client in cardiac arrest, the machine must be set to the defibrillate mode only. 6. Incorrect: Defibrillator pads are applied directly to dry, bare skin in order to maintain an optimal connection to deliver a shock. In the hospital setting, clients with excessive chest hair may need to be shaved, but not in the public setting. Substances such as cream or oils would actually increase the severity of a burn while diminishing the effectiveness of the shock.)

A client arrives at the emergency department (ED) after sustaining a high-voltage electrical injury. Which interventions should the nurse initiate in the ED? Select all that apply 1. Assess entry and exit wound. 2. Monitor vital signs. 3. Monitor for myoglobinuria. 4. Connect to cardiac monitor. 5. Perform the rule of nines.

1. Assess entry and exit wound. 2. Monitor vital signs. 3. Monitor for myoglobinuria. 4. Connect to cardiac monitor. (1., 2., 3., & 4. Correct: These are correct interventions for the nurse to initiate when caring for a client who has sustained a high-voltage electrical injury. Remember, electricity kills vessels, nerves, and organs. 5. Incorrect: The rule of nines would not be used for an electrical injury. Visual examination is not predictive of burn size and severity with an electrical burn injury.)

A client was admitted 48 hours ago in septic shock. Treatment included oxygen at 40% per ventimask, IV therapy of Lactated Ringer's (LR) at 150 mL/hr, vancomycin 1 gram IV every 8 hours, and methylprednisolone 40 mg IVP twice a day. Which clinical data indicates that treatment has been successful? Select all that apply 1. Blood pressure 96/68; HR 98; RR 20 2. WBC 12,000/mm (12 x 10⁹)/L 3. CVP- 6 mmHg 4. pH- 7.30; pCO₂- 44; pO₂ -92; HCO₃⁻ 20 5. Urinary output of 20 mL/hr

1. Blood pressure 96/68; HR 98; RR 20 3. CVP- 6 mmHg (1., & 3. Correct: The systolic BP should be greater than 90. Normal CVP is 2-6 mmHg. 2. Incorrect: Incorrect: WBC is elevated. 4. Incorrect: The client is still in metabolic acidosis, so no improvement. 5. Incorrect: Urinary output should be adequate if treatment is successful. The urinary output should be 30 mL/hr for an adult.)

A client presents to the after-hours clinic with reports of pain that occurs with walking but generally subsides with rest. The nurse's assessment reveals coolness and decreased pulses in lower extremities bilaterally. What condition would the nurse recognize these symptoms being most indicative of? 1. Chronic Arterial Insufficiency 2. Chronic Venous Insufficiency 3. Chronic Unstable Angina 4. Chronic Coronary Artery Disease

1. Chronic Arterial Insufficiency (1. Correct: These symptoms are indicative of arterial insufficiency as there is pain with walking that is relieved by rest. This pain is known as intermittent claudication. In addition, the pulses are decreased or may be absent with arterial insufficiency and the extremities are cool to touch. Other s/s include: paleness of extremity when elevated or possible redness when lowered, loss of hair on affected extremity, and thick nails. 2. Incorrect: Venous insufficiency is not characterized by pain with walking. Pulses are generally normal and color is generally normal with the exception of the brown pigmentation that may be noted (especially around the ankles). 3. Incorrect: The description in the stem is evident of peripheral arterial insufficiency and is not descriptive of decreased coronary artery perfusion. No reports of chest pain were noted. 4. Incorrect: The description is evident of peripheral arterial insufficiency and is not descriptive of decreased coronary artery perfusion. The symptoms listed in the stem are indicative of a peripheral artery problem.)

Which information should the nurse plan to teach family members of a client diagnosed with hepatitis B? 1. Do not share personal items with the client, such as razors or toothbrushes. 2. Wash dishes separately from the rest of the family's. 3. Wear a surgical mask when in close proximity to the client. 4. Use a separate bathroom from the client.

1. Do not share personal items with the client, such as razors or toothbrushes. (1. Correct: Hepatitis B is a bloodborne pathogen that can spread via sharing personal items, such as razors or toothbrushes where infected blood can get into a person's cut, mucous membranes, etc. 2. Incorrect: Unlike some forms of hepatitis, Hepatitis B is not spread through sharing eating utensils, contaminated food or water. Hepatitis B is spread by infected blood or body fluids. 3. Incorrect: Hepatitis B is not airborne, therefore, there is no need to wear a mask. 4. Incorrect: Hepatitis B is not spread by sharing a bathroom. It is blood borne, not spread by the fecal route.)

Which signs/symptoms does the nurse expect to see in a client diagnosed with Bell's Palsy? Select all that apply 1. Drooping of one side of the face. 2. Inability to wrinkle forehead. 3. Excessive tearing. 4. Decreased sensitivity to sound. 5. Inability to taste. 6. Numbness of affected side of face.

1. Drooping of one side of the face. 2. Inability to wrinkle forehead. 3. Excessive tearing. 5. Inability to taste. 6. Numbness of affected side of face. (1., 2., 3., 5., & 6. Correct: Symptoms of Bell's Palsy include sudden weakness or paralysis on one side of the face that causes it to droop (main symptom), drooling, eye problems (such as excessive tearing or a dry eye), loss of ability to taste, pain in or behind ear, numbness in the affected side of face, increased sensitivity to sound. 4. Incorrect: There would be increased sensitivity to sound with Bell's Palsy.)

A nurse suspects that a client admitted to the emergency department is in diabetic ketoacidosis. What data would lead the nurse to this conclusion? Select all that apply 1. Dry mucous membranes 2. Fruity-smelling breath 3. Biot's respirations 4. Glycosuria 5. Client report of abdominal pain

1. Dry mucous membranes 2. Fruity-smelling breath 4. Glycosuria 5. Client report of abdominal pain (1., 2., 4., & 5. Correct: The client with diabetic ketoacidosis will have signs of dehydration due to polyuria and includes dry mucous membranes. Fruity breath odor is from the acetone that occurs with breakdown of fats and formation of ketones, which are acids.. With DKA, the client would be spilling glucose into the urine. Vomiting and abdominal pain are frequently the presenting symptoms of DKA. 3. Incorrect: The client will have Kussmaul respirations. Biot's respiration is a respiratory pattern characterized by periods of rapid respirations, then apnea periods. These are not the type of respirations that occur with diabetic ketoacidosis (metabolic acidosis).)

A nurse is caring for a client with a suspected myocardial infarction (MI). What lab work or diagnostics should the nurse anticipate the primary healthcare provider prescribing to specifically confirm the diagnosis? Select all that apply 1. ECG 2. Troponin Level 3. PTT 4. Metabolic Panel 5. CPK-MB 6. CPK-BB

1. ECG 2. Troponin Level 5. CPK-MB (1., 2., & 5. Correct: Yes, when a client is suspected of having an MI, the client needs an ECG, Troponin, and CPK-MB levels. Remember Troponin is our favorite, because Troponin will confirm an MI even when the client delays seeking care. CPK-MB is right because CPK-MB is cardiac specific. 3.Incorrect: No, PTT looks at clotting factors and does not tell you if the client is having an MI. 4 Incorrect: A metabolic panel will tell you about metabolism and that is not the concern. 6.Incorrect: No, CPK-BB is used to assess for brain damage, not cardiac damage.)

Which signs and symptoms experienced by the client correlate with chronic renal failure diagnosis? Select all that apply 1. Fatigue 2. Anorexia 3. Dark skin pigmentation 4. Swollen extremities 5. Hyperkalemia

1. Fatigue 2. Anorexia 4. Swollen extremities 5. Hyperkalemia (1., 2., 4. & 5. Correct: The client will have fatigue from anemia and anorexia from toxins. Fluid volume excess leads to swollen extremities. Hyperkalemia can be caused by reduced renal excretion or excessive intake. 3. Incorrect: The client may have an uremic frost not dark skin pigmentation.)

What signs/symptoms would the nurse expect to assess in a client diagnosed with multiple sclerosis (MS)? Select all that apply 1. Fatigue 2. Ptosis 3. Blurry vision 4. Leg weakness 5. Limited facial expression 6. Electric shock sensation when bending neck forward

1. Fatigue 3. Blurry vision 4. Leg weakness 6. Electric shock sensation when bending neck forward (1., 3., 4., & 6. Correct: Multiple sclerosis causes fatigue which often comes on in the afternoon and causes weak muscles, slowed thinking, or sleepiness. Vision problems are common with this diagnosis and include blurry vision, double vision, and pain on eye movement. Partial or complete vision loss can occur in one eye. Because this disease affects nerves, symptoms often affect movement such as extremity weakness, numbness, tingling, and coordination. Electric-shock sensations that occur with certain neck movements, especially bending the neck forward (Lhermitte sign) develop because of the nerve damage that is occurring. 2. Incorrect: Drooping of one or both eyelids (ptosis) would be seen in myasthenia gravis rather than multiple sclerosis. 5. Incorrect: Limited facial expressions occur in myasthenia gravis rather than multiple sclerosis. The muscles (not nerves) that control facial expressions have been affected.)

The nurse plans to teach a client how to manage the use of a behind the ear hearing aid. What teaching strategies should the nurse include? Select all that apply 1. Hairspray should not be used while wearing the hearing aid. 2. A whistling sound when the hearing aid is inserted indicates proper placement. 3. Submerse hearing aid in cool water daily to clean. 4. Illustrate where damage commonly occurs on a hearing aid. 5. Batteries last 6 months with daily wearing of 10-12 hours.

1. Hairspray should not be used while wearing the hearing aid. 4. Illustrate where damage commonly occurs on a hearing aid. (1. & 4. Correct: The residual from the hair spray causes the hearing aid to become oily and greasy. The client should routinely inspect the hearing aid for damage, especially where damage is more likely: ear mold, earphone, dials, cord, and connection plugs. 2. Incorrect: A whistling sound indicates incorrect ear mold insertion, improper fit of aid, and buildup of earwax or fluid. 3. Incorrect: Do not submerse hearing aid in water, as it will damage the device. 5. Incorrect: Batteries last 1 week with daily wearing of 10-12 hours.)

What strategies for smoking prevention could the school nurse recommend to the community task force? Select all that apply 1. Have a "Pledge Campaign" asking students not to use tobacco. 2. Include effects of smoking in health classes. 3. Enlist help from celebrities who are against smoking. 4. Conduct a "Don't Smoke" poster contest aimed at seventh graders. 5. Start a smoking cessation class for students who currently smoke.

1. Have a "Pledge Campaign" asking students not to use tobacco. 2. Include effects of smoking in health classes. 3. Enlist help from celebrities who are against smoking. 4. Conduct a "Don't Smoke" poster contest aimed at seventh graders. (1., 2., 3., & 4. Correct: These are all activities that the nurse could recommend. All are primary prevention strategies that may educate and influence students to abstain from smoking. 5. Incorrect: This is a worthy activity; however, it is for students who are already smoking and wish to stop. This is not primary but tertiary prevention.)

What lab values should the nurse monitor when caring for a client diagnosed with acute leukemia? Select all that apply 1. Hemoglobin 2. Hematocrit 3. Lactate dehydrogenase (LDH) 4. Platelets 5. White blood cells 6. Metanephrine

1. Hemoglobin 2. Hematocrit 4. Platelets 5. White blood cells (1., 2., 4., & 5 Correct: The client with acute leukemia usually has a decreased hemoglobin and hematocrit level, a low platelet count, and an abnormal white blood cell count. 3. Incorrect: If lymphoma has been diagnosed, the lactate dehydrogenase (LDH) level may be checked. LDH levels are often increased in patients with lymphomas. LDH is not a lab test monitored in the client with acute leukemia. 6. Incorrect: Plasma free metanephrine is up to 99% sensitive for diagnosing pheochromocytoma. It measures circulating epinephrine and norepinephrine levels. Grossly elevated plasma norepinephrine renders the diagnosis of pheochromocytoma highly probable.)

When assessing for the development of an infection following the application of a plaster cast to the leg, the nurse should teach the client to observe for the presence of which sign of infection? 1. Hot spots 2. Cold toes 3. Warm toes 4. Paresthesia

1. Hot spots (1. Correct: Hot spots is the best answer. Redness and increased warmth are indicators of localized infection. If the cast covers the extremity, redness cannot be visualized, but the client can feel more warmth (a "hot spot") in an area becoming infected. 2. Incorrect: "Cold toes" is a neurovascular check, not an indication of infection. 3. Incorrect: "Warm toes" is a neurovascular check, not an indication of infection. 4. Incorrect: Paresthesia is a neurovascular check, not an indication of infection.)

What is the first nursing action that should be taken in caring for a client with suspected tuberculosis? 1. Identify the client's symptoms promptly. 2. Instruct the client to cover the mouth and nose with tissues when sneezing. 3. Isolate the client in a negative pressure room. 4. Place a surgical mask on the client.

1. Identify the client's symptoms promptly. (1. Correct: First, identify the client's symptoms. 2. Incorrect: Not before proper identification of client's symptoms. 3. Incorrect: Not before proper identification of client's symptoms. 4. Incorrect: Not before proper identification of client's symptoms.)

A client with acute pancreatitis is prescribed total parenteral nutrition (TPN), methylprednisolone, and sliding scale insulin. What is the rationale for the insulin prescribed? Select all that apply 1. Impaired endocrine function of the pancreas 2. Inability of the liver to convert glucose 3. Steroid therapy side effects 4. Dextrose concentration of TPN 5. Re-establish serum potassium level

1. Impaired endocrine function of the pancreas 3. Steroid therapy side effects 4. Dextrose concentration of TPN (1., 3., & 4. Correct: Really what we are saying here is why would the client be on insulin? Well, the pancreas is damaged and so the endocrine function of the pancreas is impaired. We know that hyperglycemia or pseudo diabetes is a side effect of steroid therapy and TPN is high in glucose and may require additional insulin. These are the three rationales for why they might need insulin. 2. Incorrect: If the liver can't convert glucose that will decrease the insulin need so that one is false. 5. Incorrect: Is not related at all. The NCLEX people want you to say,"I remember something about potassium and glucose, but I am not sure what. Don't fall for that, this is false. The rationale for the Insulin order is not to re-establish potassium in this question.)

What is the most important action for the nurse to take in order to decrease an adverse drug reaction/interaction in an elderly client who takes multiple medications? 1. Implementing a thorough client assessment. 2. Instructing the client about adverse drugs reactions. 3. Explaining to the client that hospital admissions of older adults are often due to a drug reaction. 4. Teaching the client that adverse reactions are directly proportional to the number of medications taken.

1. Implementing a thorough client assessment. (1. Correct: To prevent complications of medication administration, such as adverse drug reactions and interactions, careful planning is priority. A thorough assessment of the client is vital when planning care. 2. Incorrect: Instructing the client about adverse drug reactions is a true statement that supports client education, but not more important than thorough client assessment. 3. Incorrect: Explaining the prevalence of drug reactions in the elderly is a true statement that supports client education, but not more important than thorough client assessment. 4. Incorrect: Teaching the client that risk increases with the number of medications taken is a true statement that supports client education, but not more important than thorough client assessment.)

A client with a history of peptic ulcer disease arrives at the emergency department reporting weakness, and vomiting "a lot of dark coffee-looking stomach contents." The client's skin is cool and moist to the touch. BP 90/50, HR 110, RR 26, T 98, O₂ sat 88%. Which primary healthcare provider prescription should the nurse perform first? 1. Initiate oxygen at 2 liters/nasal cannula. 2. Start an IV of NS at 150 ml/hr. 3. Insert nasogastric (NG) tube to low suction. 4. Attach client to the electrocardiography (ECG) monitor.

1. Initiate oxygen at 2 liters/nasal cannula. (1. Correct: The client is showing signs of shock and needs all of the above interventions. However, go back to the ABC's. Oxygen needs to be initiated first because the O₂ sat and the increased respiratory rate. 2. Incorrect: Fluids are needed to increase blood pressure and tissue perfusion. If O₂ sats were above 90 then this would be the first priority. 3. Incorrect: The "coffee looking" contents indicate GI bleeding. The NG tube will empty the stomach and monitor the bleeding but is not the top priority to prevent harm to the client. 4. Incorrect: The client has an increased heart rate and if the oxygen and circulation are not improved, problems could occur. Attaching the client to an ECG monitor will allow you to monitor thew heart for arrthymias or impending damage due to decrease oxygen. Necessary but not the first priority.)

A client with type II diabetes reports normal blood glucose levels at bedtime and high blood glucose levels in the morning for the past week. What instruction would the nurse give the client? 1. Monitor blood sugar around 2am. 2. Decrease bedtime snacking. 3. Decrease intermediate acting insulin. 4. Increase intermediate acting insulin.

1. Monitor blood sugar around 2am. (1. Correct: Morning hyperglycemia may be the result of dawn's phenomenon or the Somogyi effect. The client must take their blood sugar between two and three o'clock in the morning for several days to determine the cause of morning hyperglycemia. If the client has decreased blood sugar between two and three o'clock in the morning, suspect Somogyi effect. 2. Incorrect: This is an intervention; assessment should come first. The nurse must determine the cause of morning hyperglycemia in order to treat the condition appropriately. 3. Incorrect: This is an intervention; assessment should come first. The nurse must determine the cause of hyperglycemia in order to treat the condition appropriately. An appropriate intervention for a client with Somogyi effect would be to decrease the evening dose of intermediate acting insulin, however, the nurse must first determine that the client is in fact experiencing the Somogyi effect. 4. Incorrect: This is an intervention; assessment should come first. Increasing the intermediate acting insulin would not be appropriate action for a client experiencing Somogyi effect.)

The nurse is preparing to administer a dose of ondansetron 0.15 mg/kg. The nurse has not administered this medication before and is using a drug reference to review information about the medication. Which client and drug reference information supports the nurse's decision to withhold the ondansetron? Client Information: Medical diagnosis: Right mastectomy Current vital signs: BP 112/82, HR 104, R 24. Weight - 54 kg Medical history: Right breast cancer Physical examination: Alert/oriented. Reports a dry mouth and nausea. Vomited x 1. PERRLA. Nystagmus noted. Skin warm/dry. PMI 6 intercostal space 1 cm left of midclavicular line. Clear lung sounds. Right breast incision approximated, clean, dry, without drainage. Pill rolling movement of right thumb and forefinger. Bowel sounds present x 4 quadrants. Lab test results: Hgb - 12.3 g/dL (123 g/L) Hct - 37% (0.370) WBC - 10,000/microliter (10.0 × 10⁹/L). ALT - 16 U/L

1. Nystagmus 3. Pill rolling movement (1., & 3. Correct: Nystagmus and the pill rolling movement are signs of extrapyramidal effects of ondansetron, which would require the nurse to hold the medication and notify the primary healthcare provider. 2. Incorrect: This client has been prescribed hydromorphone for pain, which is not the same as apomorphine. Apomorphine is used to treat "wearing-off" episodes in people with advanced Parkinson's disease. 4. Incorrect: The client has mild tachycardia, which does not warrant withholding ondansetron. Bradyarrhythmias due to prolonged QT intervals are of more concern. 5. Incorrect: The prescribed dose is not greater than 16 mg. The dose would be 8.1 mg for this client weighing 54 kg (0.15 mg/kg). 6. Incorrect: The liver enzymes are not elevated. In fact, all lab values are within normal range. The normal number of WBCs in the blood is 4,500 to 11,000 WBC per microliter (4.5 to 11.0 × 10⁹/L). ALT - 3 to 36 U/L AST - 0 to 35 U/L)

The palliative care nurse is instructing the family of a client who is experiencing nausea and vomiting on methods of controlling these symptoms. What methods should the nurse include? Select all that apply 1. Offer electrolyte replacement drinks or broths. 2. Avoid cooking close to the client 3. Provide light, bland food. 4. Drink liquids less often 5. Chew 5-30 paw paw seeds

1. Offer electrolyte replacement drinks or broths. 2. Avoid cooking close to the client 3. Provide light, bland food. (1., 2., & 3. Correct: These are all methods that can help control n/v symptoms. Sports drinks and broths can help with hydration. Juices and soft drinks should be avoided. Smells from foods cooking can lead to nausea and vomiting. Bland foods in small portions may be tolerated vs. fried or heavy foods. 4. Incorrect: The client should drink small amounts of liquid more often. If tolerated, fluids will help prevent dehydration. Avoid milk products and sugary drinks as they will increase nausea and loss of fluids. 5. Incorrect: Paw paw seed is an herb that can be used for constipation. The question is not related to relieving constipation. It is related to nausea and vomiting prevention/control.)

Which interventions should the nurse include in the plan of care for a client who has been admitted with a head injury? Select all that apply 1. Pad side rails. 2. Place hips in flexed position for 15 minutes every 4 hours. 3. Elevate head of bed 35 degrees. 4. Maintain neck in neutral position. 5. Cluster nursing activities. 6. Maintain a quiet environment.

1. Pad side rails. 3. Elevate head of bed 35 degrees. 4. Maintain neck in neutral position. 6. Maintain a quiet environment. (1., 3., 4., and 6. Correct: The client with a head injury is at risk for seizures. Padding the side rails is a safety precaution. Elevate the HOB 30-45 degrees to facilitate venous drainage and reduce ICP. Maintain the client's head midline to facilitate blood flow. A quiet environment is necessary to keep the client calm. An increase in environmental stimuli can increase ICP. 2. Incorrect: Do not allow pronounced neck or hip flexion as ICP will increase. Maintain HOB at 30-45 degrees and body in neutral position to avoid an increase in ICP. 5. Incorrect: Clustering nursing activities will increase ICP. Activities should be spaced out. Remember, the client needs a quiet environment.)

A client requires external radiation therapy. The nurse knows external radiation may cause which problems? Select all that apply 1. Pancytopenia 2. Leukocytosis 3. Erythema 4. Fever 5. Fatigue

1. Pancytopenia 3. Erythema 5. Fatigue (1., 3. & 5. Correct: Effects of radiation therapy include, but are not limited to pancytopenia (marked decrease in the number of RBCs, WBCs and platelets), erythema (redness of the skin), and fatigue. 2. Incorrect: Leukocytosis is an increase in WBCs. External radiation causes pancytopenia which is a decrease in the number of blood cells including WBCs. 4. Incorrect: Fever is not typically seen with external radiation.)

The nurse is caring for a burn client in the emergent phase. The client becomes extremely restless while on a ventilator. What is the priority nursing assessment? 1. Patency of endotracheal tube. 2. Adventitious breath sounds. 3. Fluid in the ventilator tubing. 4. Ventilator settings.

1. Patency of endotracheal tube. (1. Correct: With restlessness, think hypoxia so the nurse should start assessment with airway first. Check for patency of the ET tube. If this is patent, then the other options would be next. 2. Incorrect: This is the next best answer, but hypoxia and airway comes first. 3. Incorrect: This is the third step. Rule out the other two before checking tubing for kinks or obstructions. 4. Incorrect: Start with the client first. Then move toward the ventilator. Always assess the client first.)

The community health nurse is planning to teach nutritional education to a group of adults attending a health fair. What tips about health eating should the nurse include? Select all that apply 1. Pay attention to fullness cues during meals. 2. Make one fourth of the plate fruits and vegetables. 3. Drink sweet tea rather than soft drinks with meals. 4. Eat foods low in dietary fiber. 5. Consume less than 30% of calories from saturated fatty acids. 6. Use a smaller plate for meals.

1. Pay attention to fullness cues during meals. 6. Use a smaller plate for meals. (1., & 6. Correct: Pay attention to hunger and fullness cues before, during, and after meals. Use them to recognize when to eat and when you have had enough. Portion out foods before eating. A smaller plate will make the amount of food look larger. 2. Incorrect: Make half the plate fruits and vegetables. 3. Incorrect: Cut calories by drinking water or unsweetened beverages rather than drinks with sugar, such as soft drinks and sweet tea. 4. Incorrect: Diets should be high in fiber coming from fruits, vegetables, and whole grains. 5. Incorrect: Individuals should consume less than 10% of calories from saturated fatty acids (approximately 20 grams of saturated fat per day in a 2000 calorie diet).)

The nurse is caring for a postoperative client. The client asks the nurse the purpose of anti-embolic stockings. What is the nurse's best response? 1. Promotes the return of venous blood to the heart and assists in preventing blood clots. 2. Stabilizes any clots to prevent embolization. 3. To increase the blood pressure in the venous system in the legs to promote perfusion. 4. Promotes lymphatic drainage to prevent swelling and arterial congestion.

1. Promotes the return of venous blood to the heart and assists in preventing blood clots. (1. Correct: The anti-embolic stockings promote return of venous blood to the heart and assist in preventing the stasis of blood that can lead to blood clots. 2. Incorrect: The purpose of the anti-embolism stockings is to promote venous return and prevent blood stasis which can result in blood clot formation. Anti-embolitic stockings will not stabilize existing blood clots. 3. Incorrect: Anti-embolism stockings are used to increase venous return. They are not used to increase blood pressure or perfusion to the legs. 4. Incorrect: Compression garments, not anti-embolitic stockings, are used by persons with lymphedema to reduce edema by promoting the flow of lymph fluid out of the affected limb. Anti-embolitic stockings are to help with venous return and preventing stasis of blood and blood clots.)

A nurse is attempting to help a client who has self-care difficulty due to left-sided hemiparesis. Which interventions should the nurse plan to include? Select all that apply 1. Provide the client with a button hook for dressing. 2. Discourage use of electric razors and toothbrushes. 3. Have client comb own hair. 4. Offer to take the client to the toilet every four hours. 5. Avoid relying on furniture for support when walking.

1. Provide the client with a button hook for dressing. 3. Have client comb own hair. 5. Avoid relying on furniture for support when walking. (1., 3. & 5. Correct: The use of a button hook or loop and pile closure on clothes may make it possible for a client to continue independence in this self-care activity. This is a one handed task that will enable the client to maintain autonomy for as long as possible. Having client comb own hair helps maintain autonomy. The client should use prescribed assistive devices for ambulation. Furniture may move or not be in the correct place for support while walking. 2. Incorrect: The client can be helped by using an electric razor and toothbrush. These will improve client safety during self care. 4. Incorrect: Offer bedpan or place client on toilet every 1 to 2 hours during the day and three times during the night.)

The nurse is monitoring the client's heart rhythm. The monitor shows sinus tachycardia. What is expected with this assessment finding? Select all that apply 1. Regular rhythm 2. Rate of 101-200 3. P wave normal 4. P-R interval not measurable 5. QRS complex normal

1. Regular rhythm 2. Rate of 101-200 3. P wave normal 5. QRS complex normal (1., 2., 3. & 5. Correct: Sinus tachycardia indicates a regular rhythm, although the rate is elevated. The term tachycardia is defined as a heart rate above 100. The P-wave is normal in a sinus rhythm. Sinus rhythms have a normal QRS complex. 4. Incorrect: P-R interval is not measurable in atrial flutter, atrial fib, PVCs, V tach or V fib.)

A nurse is caring for a client who is on bed rest following admission to the hospital two days ago with a diagnosis of new onset heart failure. While evaluating the client's progress, what assessment findings would indicate to the nurse that further treatment is required? Select all that apply 1. Sacral edema 2. Orthopnea 3. Shiny skin 4. S3 heart sound 5. Heart rate 88/min 6. CVP 8mmHg

1. Sacral edema 2. Orthopnea 3. Shiny skin 4. S3 heart sound 6. CVP 8mmHg (1., 2., 3., 4., & 6. Correct: These are all signs of fluid volume excess seen with heart failure. 5. Incorrect: This is a normal heart rate which would indicate the client is improving.)

Which male client condition in the after-hours clinic should the nurse assess first? 1. Scrotal pain and edema. 2. Erection lasting for 2 hours. 3. Inability to void with a history of benign prostatic hyperplasia (BPH). 4. Purulent drainage from the penis.

1. Scrotal pain and edema. (1. Correct: This client is likely to have testicular torsion, which requires immediate intervention. Infarction of the testes can occur if not treated promptly. 2. Incorrect: This is not the most life threatening problem. Priapism, a persistent, often painful erection that lasts for more than 4 hours should be treated. 3. Incorrect: With BPH the prostate gland increases in size, leading to disruption of the outflow of urine. This can cause inability to void and needs to be assessed but is not the first priority. 4. Incorrect: This client does not have the most serious condition and would not take priority.)

What is priority for the client experiencing hyperparathyroid crisis? 1. Support for airway and breathing. 2. Continuous cardiac monitoring for arrhythmias. 3. Provide safety precautions. 4. Prepare for emergency tracheostomy.

1. Support for airway and breathing. (1. Correct: Always remember ABC, if it is relevant, and it is with hyperparathyroid crisis. 2. Incorrect: Circulation is important. This priority comes after attention has been directed toward airway and breathing. What good would come of circulating deoxygenated blood, and how long can the heart muscle last without oxygen? Always remember ABC when prioritizing in emergency situations. 3. Incorrect: Muscle weakness, thus risk for falls is a concern, but airway takes priority! 4. Incorrect: Trach would be more likely with hypoparathyroidism. Remember, in hypoparathyroidism, the client would have rigid and tight muscles which would cause laryngospasms.)

The nurse is providing teaching for a client who is being scheduled for outpatient 24 hour electrocardiogram monitoring using a Holter monitor. What should the nurse tell the client to avoid while monitoring is in progress? Select all that apply 1. Taking a shower or bath 2. Performing daily exercises 3. Working around high voltage equipment 4. Being screened at airport security 5. Eating foods that are sources of potassium

1. Taking a shower or bath 3. Working around high voltage equipment 4. Being screened at airport security (1., 3., and 4. Correct: The nurse should teach this client to continue the usual activities while wearing the monitor with a few exceptions. The monitor should be kept dry to ensure that it functions properly. The client should avoid taking a shower or bath or swimming while wearing the monitor. The electrodes could also become detached from the skin if they get wet, which would also interfere with the accuracy of the reading. The client should be advised to not work around high voltage equipment because areas of high voltage can interfere with the function of the electrocardiogram monitoring. In addition, magnetic fields, such as those used for airport screenings, can interfere with the function of the Holter monitor and should be avoided. 2. Incorrect: This client should be encouraged to continue regular routine unless otherwise directed by the primary healthcare provider. The client can perform the usual daily exercise, but should be advised to avoid activities that may cause excessive perspiration that could lead to the electrodes becoming loosened from the skin. 3. Incorrect: There are generally no dietary restrictions while wearing the Holter monitor unless otherwise prescribed by the primary healthcare provider.)

Which interventions should be included in the nutritional teaching plan to accomplish the goal of a diet lower in fat? Select all that apply 1. Use 2% milk instead of whole milk. 2. Eat air-popped popcorn instead of potato chips. 3. Eat more red meat instead of fish. 4. Incorporate plant sources of protein. 5. Use olive oil instead of vegetable oil when frying.

1. Use 2% milk instead of whole milk. 2. Eat air-popped popcorn instead of potato chips. 4. Incorporate plant sources of protein. (1., 2. & 4. Correct: Two percent milk can reduce the amount of fat consumed daily, not only in milk that the client drinks, but also in foods that contain milk as an ingredient. Air-popped corn contains no fat unless butter is added after popping. The client still is able to have a crunchy snack without the fat. Plant proteins such as kidney, black, or lima beans are good sources of protein without the fat from a meat source. 3. Incorrect: Red meats are high in fat. Chicken, fish, and seafood are better meat choices. 5. Incorrect: Olive oil is low in saturated fat but still a source of fat. While olive oil may be a healthier choice, all fats have essentially the same number of calories per serving. The goal is to reduce the amount of fat in the diet.)

What discharge education should a nurse provide to a client post hip replacement with a metal joint? Select all that apply 1. Weight bearing limits. 2. Use of a high seated chair. 3. Sexual intercourse in dependent position for up to six months. 4. Avoid taking showers. 5. Use of long handled tongs to assist with dressing.

1. Weight bearing limits. 2. Use of a high seated chair. 3. Sexual intercourse in dependent position for up to six months. 5. Use of long handled tongs to assist with dressing. (1., 2., 3., & 5. Correct: Weight bearing limits on the involved extremity varies according to the healthcare providers preference but are commonly prescribed. The client needs to avoid flexion. This includes sitting in low chairs and getting into a bath tub; elevated toilet seats and raised seats are necessary. Sexual intercourse should be carried out with the client in a dependent position (flat on the back) for 3-6 months to avoid excessive adduction and flexion of the new hip. To avoid flexion when dressing, adaptive devices and utensils may be used to help with bathing, dressing and personal hygiene. 4. Incorrect: Showers are preferable as getting into a tub would cause flexion of the new hip. This could cause the hip to dislocate.)

A client who has diabetes calls the nurse hot-line reporting shakiness, nervousness, and palpitations. Which questions would yield information that would help the nurse decide that this is a hypoglycemic episode? Select all that apply 1. What have you eaten today and at what times? 2. Are you using insulin as a treatment of diabetes, and if so, what kind? 3. Do you feel hungry? 4. Do you have access to a glucose monitor to check your current glucose level? 5. Does your skin feel hot and dry?

1. What have you eaten today and at what times? 2. Are you using insulin as a treatment of diabetes, and if so, what kind? 3. Do you feel hungry? 4. Do you have access to a glucose monitor to check your current glucose level? (1., 2., 3. & 4. Correct. This question will give the nurse information about how much time has elapsed since the last meal and will indicate the amount of protein and carbohydrates consumed at the last meal. Even a minor delay in meal times may result in hypoglycemia. Insulin type will give the nurse information about duration of action and peak time. Hunger is a symptom of hypoglycemia.If the client has a glucose monitor, an accurate reading would give the nurse valuable information about how much food the client should consume now. 5. Incorrect. Hot and dry skin is not an indicator of hypoglycemia and would not help the nurse determine if the client is experiencing a hypoglycemic episode. Cool, clammy skin is a symptom of hypoglycemia.)

The nurse is monitoring a client in diabetic ketoacidosis (DKA). Which arterial blood gas value would be expected? 1. pH 7.32 2. PaCO₂ 47 3. HCO₃⁻ 25 4. PaO₂ 78

1. pH 7.32 (1. Correct: In DKA, the client is acidotic. Normal pH is 7.35-7.45. A pH of 7.32 indicates acidosis and will be expected for a client in DKA. 2. Incorrect: Normal PaCO₂ is 35-45. Remember CO₂ is considered an acid. The client in DKA will have an increased respiratory rate, so the PaCO₂ will either be normal or low. This value of 47 is high and not an expected finding. 3. Incorrect: Normal HCO₃⁻ is 22-26. For a client in DKA, the expected HCO₃⁻ would be less than 22. HCO₃⁻ is a base. In acidosis, the expected finding is low HCO₃⁻​. 4. Incorrect: Normal PaO₂ is 80-100. An expected finding in DKA will be normal or increased PaO₂, not decreased.)

What dietary information should the nurse provide to a client diagnosed with Celiac disease? Select all that apply 1. "The most cost effective way to follow the lactose free diet is to eat more fruits and vegetables." 2. "Creamed based canned soups are a source of hidden wheat." 3. "You can eat foods containing fax, corn, or rice." 4. "Avoid foods and beverages that contain malt." 5. "Do not eat traditional wheat products such as pasta."

2. "Creamed based canned soups are a source of hidden wheat." 3. "You can eat foods containing fax, corn, or rice." 4. "Avoid foods and beverages that contain malt." 5. "Do not eat traditional wheat products such as pasta." (2., 3., 4., & 5. Correct: Soups and sauces are one of the biggest sources of hidden gluten, as many companies use wheat as a thickener. It is always a good idea to read the label of any pre-prepared or canned soups and sauces, paying special attention to those that are cream based. Grains that are naturally gluten free include rice, corn, potato, quinoa, kasha, flax, and nut flours. Malt flavoring or extract, which contains gluten may be found in cornflakes and puffed rice cereal. It is also found in beers, ales, and malt vinegars. As a rule, traditional wheat products such as pastas, breads, crackers, and other baked goods are not gluten-free. However, there are many gluten-free options available that use alternative flours and grains. 1. Incorrect: The client who has Celiac disease is prescribed a gluten free diet rather than a lactose free diet.)

A client with tuberculosis (TB) has been coming to the health department for directly observed therapy (DOT) for the past month. Today, the client states, "I don't think I need to come back anymore. I am feeling much better now." What should the nurse tell the client? 1. "You have taken your medication long enough so, the primary healthcare provider should discontinue it today." 2. "If you stop taking your medication now, your disease could become resistant to this medication, making it harder for you to be cured." 3. "I will be required to have you arrested if you do not come back for further treatment." 4. "Just let us decide when you should stop taking the medication."

2. "If you stop taking your medication now, your disease could become resistant to this medication, making it harder for you to be cured." (2. Correct: This is true regarding TB treatment. The Medication has to be taken for the entire course. The minimal length of time for therapy is 3 months.1. Incorrect: Treatment usually lasts 4-7 months. If the medication regimen is not strictly and continuously followed, the disease may become drug-resistant. It is not the nurse's place to determine when enough medication has been taken. 3. Incorrect: The nurse needs to discuss the reason for continuing to take the medication. This step is premature and intimidating. Also, threatening to have the client arrested will not likely maintain a good patient-nurse relationship. 4. Incorrect: This statement is non-therapeutic and dismissive of the client. This does not address the client's statement of thinking they have had enough medicine and should stop.)

The following clients arrive to the emergency department (ED) at the same time. The triage nurse gives priority to which client? 1. A client with a possible fracture of the tibia 45 minutes ago. 2. A client with left hemiparesis and aphasia beginning 1 hour ago. 3. A client smelling of alcohol and reporting of severe abdominal pain. 4. A client involved in a motor vehicle accident (MVA) with a possible fractured pelvis.

2. A client with left hemiparesis and aphasia beginning 1 hour ago. (2. Correct: The client who is started experiencing hemiparesis and aphasia 1 hour ago is likely having a stroke. The window for treatment with fibrolytics is 3 hours, thus taking priority over the other clients. Time is brain! 1. Incorrect: This client has a possible fracture of the tibia. This is not a large bone, which would be at risk for hemorrhage. Splinting and ice packs could be used until after seeing the client having a stroke. 3. Incorrect: With this client, you would worry about pancreatitis. This client needs to be seen soon but not prior to the client having a stroke. 4. Incorrect: The MVA client could have bleeding from a fractured pelvis. This client is high on the admit list, but after the client having a stroke.)

An elderly client with a history of CAD has just been admitted to the telemetry unit following a syncopal episode at home. The admitting nurse places EKG leads on the client and notes the following rhythm on the monitor. When the client indicates the need to void, the nurse knows that what would be the safest action? 1. Request prescription for a foley catheter. 2. Assist client with the use of a bedpan. 3. Provided incontinent pads to the client. 4. Have UAP ambulate client to the bathroom.

2. Assist client with the use of a bedpan. (2. Correct: The exhibit shows sinus rhythm with premature ventricular contractions (PVC's), and more specifically, bigeminy. The safest approach for a syncopal client with this rhythm is the use of a bedpan for bathroom needs. Even with assistance, this client would be at risk for falls when ambulating. 1. Incorrect: Because the client has experienced syncope and is having frequent PVCs, keeping the client in bed is safer than ambulating to the bathroom. However, a foley catheter is an invasive procedure that could place the client at risk of infection. There is a better option. 3. Incorrect: Using incontinent pads, either on the bed or personal pads for the client, is only appropriate if the client is unable to control urinary flow, or requests the use of same. It is embarrassing to ask clients who are continent to void onto a bed pad. 4. Incorrect: This client is newly admitted with a diagnosis of syncope. The exhibit shows frequent PVC's, which are non-perfusing beats. Even with assistance from the UAP, ambulating to the bathroom is not the safest action for this client.)

A client with a diagnosis of endocarditis and a new peripherally inserted cential catheter (PICC) line has been discharged home to receive daily intravenous antibiotics for six more weeks. The home health nurse is making an assessment visit today. What instruction by the nurse is most important initially? 1. Take antibiotics before dental procedures. 2. Brush and floss teeth at least twice daily. 3. Report any flu like symptoms immediately. 4. Include rest periods throughout the day.

2. Brush and floss teeth at least twice daily. (2. Correct: Poor dental hygiene is one of the chief causes of endocarditis in adults, leading to growth of vegetation on heart valves, emboli, strokes, or even death. Instructions on proper oral care is considered primary or preventative teaching and encourages the client to take an active role in personal health care. Decreasing mouth bacteria or disease will decrease the potential for a reoccurrence of endocarditis. 1. Incorrect: Although primary healthcare providers may order antibiotics prior to a dental visit, it depends on what procedure the dentist is going to perform. Invasive mouth procedures where bleeding is likely generally require pre-visit antibiotics. However, this is not the most important information by the nurse initially. 3. Incorrect: Flu like symptoms are an indication of a possible exacerbation or reoccurrence of endocarditis. The client would be instructed to report such signs as fever, chills, malaise, or night sweats immediately to the primary healthcare provider. While it is important for the client to understand what to report, preventative measures are more important at this time. 4. Incorrect: Infection within the heart is very serious and, despite aggressive treatment, may have lasting effects on the client's cardiovascular system. Decreasing the workload of the heart during treatment and recovery time would certainly assist with the healing process. However, the need for frequent rest periods throughout the day is determined by a variety of factors, such as the client's age and morbidity factors, general health, amount of damage to the heart, and response to antibiotics. Rest is not the most important instruction the nurse must present initially.)

What signs/symptoms would the nurse expect to find in a client admitted to the unit with a diagnosis of Cushing's disease? Select all that apply 1. Hyperpigmentation 2. Buffalo hump 3. Hirsutism 4. Acne 5. Moon face 6. Hypertension

2. Buffalo hump 3. Hirsutism 4. Acne 5. Moon face 6. Hypertension (2., 3., 4., 5., & 6. Correct: Cushing's disease results in an increase in glucocorticoids, mineralocorticoids, and sex hormones resulting in a buffalo hump, hirsutism, acne, moon face, and hypertension. 1. Incorrect: Hyperpigmentation occurs when the body has too little cortisol, such as with Addison's disease.)

A client rescued from a house fire is being treated for burns to both arms and suspected inhalation injury. What data collected by the nurse has the highest priority? 1. Estimation of total surface burn area 2. Characteristics of cough and sputum 3. Calculation of client weight and age 4. Extent of edema to arms

2. Characteristics of cough and sputum (2. Correct: A client rescued from a burning house is presumed to have inhaled super-heated air during that process. Though calculating fluid replacement is vital to the client's survival, the ABCs dictate the highest priority is airway. Noting any cough or sputum can help determine whether prophylactic intubation may be necessary. 1. Incorrect: The total amount of body surface burned is crucial information needed to determine fluid replacement using the Parkland Formula. However, though IV fluids are necessary, calculating the burn percentage is not the highest priority. 3. Incorrect: The client's age is not an immediate priority, although a complete health history will be essential to the final outcome. The client's weight will be used to calculate fluid replacement; however, there is a higher initial priority. 4. Incorrect:. A burn causes cellular damage that leads to edema. Depending on the location and extent of that edema, circulation could be greatly impaired. However, when monitoring a burned client, the ABCs place circulation third on the priority list.)

A client is being scheduled for a cat scan (CT) of the abdomen with contrast. When considering client safety, what should be the priority action for the nurse to implement? 1. Verify that informed consent has been provided. 2. Confirm with client the accuracy of allergies listed. 3. Force fluids following procedure. 4. Monitor output following procedure.

2. Confirm with client the accuracy of allergies listed. (2. Correct: When considering client safety, the nurse should confirm allergies with the client. Clients should be asked about allergies to iodine or shellfish. The radiocontrast agents in the dye contain iodine and have resulted in severe reactions and even death in a few cases. If the client is allergic to iodine, the healthcare provider should be notified before the CT is performed. The use of contrast dye for the procedure will typically be omitted to avoid the risk of a severe reaction. 1. Incorrect: It is very important that a client receive information regarding risks and benefits of a procedure before providing consent (informed consent), but assuring that the consent was provided is not the priority for client safety over the risk of a severe reaction to the dye. 3. Incorrect: Again, it is very important to implement increased fluid intake following procedures, such as this CT of the abdomen, to help flush the dye through the kidneys. However, the safety priority remains the potential for a severe reaction that should be avoided by asking about allergies to iodine. 4. Incorrect: Monitoring urine output is an important nursing action following the CT because sometimes dye can lead to kidney problems or can increase problems in clients with existing renal disease. But this is not a priority over assessing for allergies that could lead to severe reactions.)

The nurse is updating the client's plan of care 24 hours after admission. What data would indicate to the nurse that the client is improving? While in the emergency department, 68 year old client being treated for flu symptoms, became symptomatic with an episode of atrial tachycardia which was successfully treated with cardioversion. After stabilization, the client was admitted to the telemetry unit with a diagnosis of the flu, and a history of angina. Treatment included: Bedrest with bathroom privileges. Continuous cardiac monitoring remaining in NSR ½ Normal Saline at 75 mL/hour. 2 gm Low sodium diet. Peramivir 600 mg IVPB times one dose. ECG every 8 hours times three - NSR Select all that apply 1. Troponin T - 0.10 ng/mL 2. Coughing up moderate amount of clear to white sputum 3. Urinary output past 8 hours - 225 mL 4. BP - 100/64, Respirations - 18/min, Temperature - 99.2° F (37.3° C) 5. Current Telemetr

2. Coughing up moderate amount of clear to white sputum 4. BP - 100/64, Respirations - 18/min, Temperature - 99.2° F (37.3° C) 5. Current Telemetry ECG (2., 4., & 5. Correct: Clients who have had the flu are going to cough and expectorate sputum for a while. The important thing is that the sputum is not green which would indicate a bacterial infection. These vital signs have improved since admit. A low-grade temperature may continue for several days. This ECG strip shows that the client is in a normal sinus rhythm, which is a good thing. 1. Incorrect: Troponin T values greater than or equal to 0.1 ng/mL are a prognostic sign in patients with ischemic heart disease and most other situations. 3. Incorrect: The average UOP here is 28 mL/hour and means the client is still dehydrated or the kidneys are not working properly. Remember, this client had Peramivir IVPB.)

What preoperative information should the nurse provide to the client who is scheduled for an exercise stress test tomorrow morning? 1. Eat a light breakfast two hours before the test. 2. Dress in loose, comfortable clothing. 3. Take nitroglycerin dose 15 minutes prior to test. 4. Limit drinks with caffeine to 8 ounces (240 mL) within 12 hours.

2. Dress in loose, comfortable clothing. (2. Correct: The client should dress in loose, comfortable clothing the day of the test because the stress test consists of intense exercise. 1. Incorrect: Don't eat or drink anything except water for 4 hours before the test. The fullness from a meal makes it difficult to perform the stress test. 3. Incorrect: Clients are asked to hold beta-blockers, calcium channel blockers, and nitroglycerin medicines prior to a stress test. These medications either increase or slow down the heart rate, which can affect the test. 4. Incorrect: The client should avoid products containing caffeine for 24 hours prior to the stress test. Caffeine increases the heart rate and can affect the results of the test.)

An elderly client is admitted to the floor with vomiting and diarrhea for three days. The client is receiving IV fluids at 200 mL/hr via pump. What would be the priority nursing action? 1. Obtaining Intake and Output 2. Frequent lung assessments 3. Vital signs every shift 4. Monitoring the IV site for infiltration

2. Frequent lung assessments (2. Correct: IV fluids at 200 mL/hr is a rapid infusion rate. The elderly adult is at risk for circulatory overload and should be closely monitored during rapid infusion rates. Lung assessments are important in detecting fluid overload. The client may experience shortness of breath and moist crackles on auscultation. 1. Incorrect: I and O are important, but 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. 4. Incorrect: The IV site should be monitored for infiltration, but will not be priority over lung assessment in the elderly client.)

The nurse is caring for a client following a total thyroidectomy. What findings would alert the nurse to potential complications? Select all that apply 1. Neck dressing intact, clean and dry 2. Increased blood pressure and pulse 3. High-pitched, harsh respirations 4. Vocal quality weak and clear 5. Left-sided cheek twitching

2. Increased blood pressure and pulse 3. High-pitched, harsh respirations 5. Left-sided cheek twitching (2, 3 and 5. Correct: There are several potential complications following a thyroidectomy. One life-threatening problem is the potential for a thyroid storm in which a large bolus of thyroid hormone is dumped into the system, causing increased blood pressure and pulse which could lead to intracranial hemorrhage. High pitched, harsh respirations indicate increasing edema and the potential for obstructed airway. A third potential problem may occur if one or more parathyroid glands are removed, placing the client at risk for hypocalcemia, as evidenced by a positive Chvostek's sign. 1. Incorrect: The surgical dressing around the neck should definitely be intact and dry post-op. Any drainage that may develop would take a while to seep through the dressing. No concerns here. 4. Incorrect: The client has just had surgery on the thyroid, causing swelling that could affect vocal cords. A weak initial voice is not unusual as long as the vocal quality is clear.)

Two hours after admission, a client reports palpitations, chest discomfort, and light-headedness. The nurse connects the client to a cardiac monitor and notes a weak, thread pulse, and a BP of 90/50. Which action should the nurse take? Select all that apply 1. Administer Lidocaine 50 mg intravenous push (IVP). 2. Initiate oxygen at 2 liters per nasal cannula. 3. Apply oxygen saturation monitor to client. 4. Prepare for immediate synchronized cardioversion. 5. Perform carotid massage. 6. Begin cardiopulmonary resuscitation.

2. Initiate oxygen at 2 liters per nasal cannula. 3. Apply oxygen saturation monitor to client. 4. Prepare for immediate synchronized cardioversion. (2., 3., & 4. Correct. This client has a rapid heart rate of 188/min. The actual rhythm is atrial tachycardia, but can also be identified as supraventricular tachycardia because the heartrate is greater than 150/min. This client is considered unstable so requires oxygen therapy, with O₂ saturation monitoring, and synchronized cardioversion. 1. Incorrect. Lidocaine is not indicated for an atrial or supraventricular dysrhythmia. 5. Incorrect. Carotid massage is not within the scope of practice of the nurse. Asystole could result. 6. Incorrect. This client has a pulse, so CPR is not needed now.)

What interventions should the nurse include when planning care for a client post heart transplant? Select all that apply 1. Place on airborne precautions. 2. Instruct visitors to wash hands prior to entering the room. 3. Maintain strict aseptic technique. 4. Initiate pulmonary hygiene measures. 5. Provide for early ambulation.

2. Instruct visitors to wash hands prior to entering the room. 3. Maintain strict aseptic technique. 4. Initiate pulmonary hygiene measures. 5. Provide for early ambulation. (2., 3., 4., & 5. Correct: The transplant recipient is at high risk for infection due to the suppression of the body's normal defense mechanisms. All of these interventions decrease the incidence of the client developing an infection. The heart transplant client is prescribed medications to reduce the risk of organ rejection by inhibiting or suppressing the immune system. Handwashing is the main defense against infection. Pulmonary hygiene measures are are implemented to maintain open airways and prevent respiratory infections. The pulmonary measures can include oral hygiene, deep breathing exercises, mucus-controlling agents, and intermittent positive-pressure breathing. Pulmonary hygiene helps to decrease the development of pneumonia. Early ambulation helps increase general strength and lung expansion. Also ambulation increases circulation,peristalisis,and joint mobility, Emotionally ambulation improves self-esteem and feelings of independence. 1. Incorrect: The client needs to be protected from everyone else so a private room and protective isolation are needed. All persons entering the room must wash hands well and wear a mask and gloves. The client must wear a mask when leaving the room.)

The nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) guidelines for immunization recommendations with a group of parents whose children are preparing to attend college in the fall. Which immunization recommendations should the nurse include? Select all that apply 1. Rotavirus 2. Meningococcal 3. Herpes zoster 4. Seasonal influenza 5. Human papilloma virus

2. Meningococcal 4. Seasonal influenza 5. Human papilloma virus (2., 4., & 5. Correct: Meningococcal vaccine protects against bacterial meningitis and is recommended for students entering college. Influenza vaccine is recommended annually for protection against the viruses predicted to be most common for the season. Human papilloma virus vaccine is recommended for protection against the virus which causes cervical and anal cancers. 1. Incorrect: Rotavirus vaccine is recommended during infancy. Rotavirus is the most common cause of diarrheal disease among infants and children. 3. Incorrect: Herpes zoster vaccine is recommended for adults, over the age of 60 to reduce the risk of getting shingles.)

What signs/symptoms would the nurse expect to assess in a client diagnosed with acute pericarditis? Select all that apply 1. Petechiae on trunk 2. Muffled heart sounds 3. Pericardial friction rub 4. Pulsus paradoxus 5. Chest pain on deep inspiration

2. Muffled heart sounds 3. Pericardial friction rub 5. Chest pain on deep inspiration (2., 3., & 5. Correct: Muffled heart sounds are indicative of pericarditis. Fluid is between the heart and the chest wall; heart sounds are lowered and distant. A pericardial friction rub is a classic symptom of acute pericarditis. Chest pain is the most common symptoms of pericarditis, and is aggravated by deep inspiration, coughing, position change, and swallowing. 1. Incorrect: Petechiae on the trunk, conjunctiva, and mucous membranes are indicative of endocarditis. 4. Incorrect: Pulsus paradoxus is an exaggerated decrease of systolic blood pressure during inspiration exceeding 12 mmHg. It is the hallmark of cardiac tamponade.)

The telemetry unit nurse is assessing a newly admitted client following a fall at home. The client has been diagnosed with a left sided cerebrovascular accident (CVA), including aphasia, and a sprained wrist. What is the most effective method the nurse could use to assess the client's pain? 1. Monitor vital signs for elevations. 2. Observe client's non verbal behaviors. 3. Assess sleeping position client chooses. 4. Ask client to point to the pain rating scale.

2. Observe client's non verbal behaviors. (2. Correct: The client has had a left sided stroke which damages the left hemisphere of the brain. Although the question does not specify whether this is receptive or expressive aphasia, the client may have great difficulty identifying the location or amount of pain. Because of the client's difficulty in communicating at this time, the nurse must rely on non-verbal cues such as facial expressions, vocalizations (moaning, crying) or client attention to the injured portion of the body (massaging or holding the painful area). 1. Incorrect: Despite the fact that vital signs often become elevated in the presence of pain, this is not a reliable indicator, particularly since the vital signs could be impacted by the recent CVA. Additionally, tolerance to pain varies, and changing vitals would not provide the most accurate data about the severity or even the location of the client's pain. 3. Incorrect: This method is the least reliable approach in evaluating client discomfort. Waiting for the client to fall sleep delays effective treatment, assuming the client is able to rest at all while experiencing pain. Also, the nurse is assuming that the client would be able to position self in a manner indicating what area is most painful. The impact of a stroke in the left brain might prevent the client from accurately locating or identifying the exact painful area. 4. Incorrect: The client has had left hemisphere damage to the brain with resulting aphasia. There is no data provided in the question regarding the category of aphasia; therefore, the nurse would be aware the client may not be able to indicate the correct location or severity of pain, even if utilizing the smiling face picture scale. This client also may not be able to understand instructions on the use of the scale, or to self

What assessments would be appropriate for the school nurse to perform related to school safety practices and emergency preparedness? Select all that apply 1. Teach about gun control laws. 2. Observe for gaps or changes in levels of sidewalks. 3. Identify which students have special healthcare needs. 4. Locate all entrances and exits to buildings. 5. Identify threats and hazards in the school and surrounding community. 6. Perform a check of all fire extinguishers.

2. Observe for gaps or changes in levels of sidewalks. 3. Identify which students have special healthcare needs. 4. Locate all entrances and exits to buildings. 5. Identify threats and hazards in the school and surrounding community. 6. Perform a check of all fire extinguishers. (2., 3., 4., 5., & 6. Correct: One of the first things that a school nurse should do is to assess where an accident might happen. Observing for gaps or changes in the level of sidewalks is an example of this assessment. The school nurse should assess for special healthcare needs in the event that the school enters a time of extended lockdown. Some students would require attention during the time of lockdown, such as diabetics who could not wait to receive insulin or have food available. All entrances to the schools must be identified to know where a potential entry for intruder might could occur. Some access points may need to be changed to reduce risk to students. Becoming familiar with all exits is crucial to planning timely and safe evacuation of students if needed. The school nurse can draw upon a wealth of information that exists regarding threats or events that have occurred in the past at the school or in the local community in order to plan for possible future events. Fire extinguishers should be checked on a regular schedule for assessment of access, date of expiration, and functionality. 1. Incorrect: Teaching about laws on gun control is not an assessment, but rather an intervention that can be done. Teaching is not the initial step of the nursing process. Assessment comes first.)

After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention? 1. Have the client take slow deep breaths in through the mouth and out through the nose. 2. Post signs on the client's door and in the client's room indicating that oxygen is in use . 3. Apply Vaseline petroleum to both nares and 2 x 2 gauze around the oxygen tubing at the client's ears. 4. Encourage the client to hyperextend the neck, take a few deep breaths and cough.

2. Post signs on the client's door and in the client's room indicating that oxygen is in use . (2. Correct: This is an oxygen therapy safety precaution that the nurse should implement after applying oxygen. It is also the only correct and safe option in the question. 1. Incorrect: The bi-nasal prongs would mean that the oxygen is going in through the nose. Breathing deeply through the mouth and out through the nose would not increase oxygenation for a client having chest pain and would disrupt the flow of oxygen through the nose. 3. Incorrect: The nurse should avoid using petroleum products where oxygen is in use because they are flammable. 4. Incorrect: These client actions have nothing to do with oxygen administration and would cause more distress to the client with chest pain.)

What is the primary electrolyte that the nurse should be aware to monitor for in a client who is receiving an insulin infusion? 1. Sodium 2. Potassium 3. Calcium 4. Phosphorus

2. Potassium (2. Correct: Insulin causes movement of potassium into the cells, which can lead to a severe reduction in serum potassium if not regulated appropriately. A severe decrease in serum potassium could be fatal. 1. Incorrect: Although insulin has been shown to increase sodium reabsorption in the kidneys, the change is not as rapid and not as life threatening as the change in potassium can be. 3. Incorrect: A significant change in the calcium level is not anticipated with the insulin infusion. 4. Incorrect: A significant change in the phosphorous level is not anticipated with the insulin infusion.)

The nurse is preparing to administer a dose of potassium iodide 300 mg by mouth to a client diagnosed with hyperthyroidism. The nurse has not administered this medication before and is using a drug reference to review information about the medication. Which client and drug reference information supports the nurse's decision to hold the potassium iodide dose and notify the primary healthcare provider? Client Information: Medical diagnosis: Hyperthyroidism Current vital signs: BP 142/88, HR 102, R 20 Medical history: Hypertension Physical examination: Alert/oriented. PERRLA. Skin warm/dry. Lungs sounds clear bilaterally. Normal S1/S2 without murmurs, clicks, rubs. Lab test results: Glucose- 98 mg/dl (5.4 mmol/L), Sodium- 139 mEq/L (139 mmol/L), Potassium- 5.5 mEq/L (5.5 mmol/L), Creatinine - 0.9 mg/dL (79.5 µmol/L), Creatinine Clearance 110 mL/min Current medications: Losartan 50 mg one by mouth daily, Methimazole 10

2. Potassium- 5.5 mEq/L (5.5 mmol/L) 4. Taking losartan 50 mg one by mouth daily. 5. Currently taking methimazole 10 mg by mouth daily. (2., 4., & 5. Correct: The medication is potassium iodide, which can lead to hyperkalemia when administered, so it is contraindicated if the client already has hyperkalemia. This client's potassium level is 5.5 mEq/L (5.5 mmol/L), which would support the nurse holding the medication and contacting the primary healthcare provider. Additionally, the drug guides states that potassium iodide increases the antithyroid effect of methimazole and propylthiouracil. Increased hyperkalemia may result from combined use with potassium-sparing diuretics, Ace inhibitors, angiotensin II receptor antagonists or potassium supplements. This client is currently on both losartan, an ARB, and methimazole. 1. Incorrect: This is a normal creatinine level. Normal range is 0.8 - 1.4 mg/dL (70-124 µmol/L) in males and 0.56-1.0 mg/dL (50-88 µmol/L) in females. 3. Incorrect: Potassium iodide does not affect glucose and this is a normal glucose level. 6. Incorrect: The normal creatinine clearance is 75-125 mL/min. Therefore, 110 mL/min is within normal limits and would not require withholding the potassium iodide.)

A client diagnosed with advanced cirrhosis is admitted with dehydration and elevated ammonia levels. While discussing dietary issues, the client requests larger portions of meat with meals. Which response by the nurse provides the most accurate information to the client? 1. I will ask the dietician to add more meat with dinner. 2. Protein must be limited because of elevated ammonia levels. 3. You need to drink more fluids because of your dehydration. 4. We can ask for between meal snacks with more carbohydrates.

2. Protein must be limited because of elevated ammonia levels. (2. Correct: Normally, protein is broken down into ammonia, which the liver converts into urea, and the kidneys then easily excrete. However, in a diseased liver, this conversion is not possible, and ammonia continues to build up in the body, ultimately affecting the brain. The nurse would be aware that additional protein would be harmful for this client. 1. Incorrect: Increasing meat at mealtimes would be detrimental to the client's health. When protein is taken into the body, a healthy liver will convert this into urea that is then excreted by the kidneys. However, this client's impaired liver is not able to make that conversion; therefore, the ammonia levels would continue to increase. The nurse can discuss with the client other foods that might safely be added to meals. 3. Incorrect: While it is true this client is dehydrated, the issue is that the client wants to increase the amount of meat at mealtimes. This response does not address the client's request nor does it provide any teaching that would help the client once discharged. 4. Incorrect: Although this response indicates that the nurse is focusing on the client's issue with food, this reply does not address the request for more meat with meals. This would be the appropriate opportunity to educate the client on the need to limit daily protein in the diet.)

What interventions should the nurse include when teaching a client how to prevent and treat fungal infections of the feet? Select all that apply 1. Apply cornstarch to the feet after bathing. 2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 3. Wear socks at all times until infection has cleared up. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe.

2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe. (2., 4. 5, & 6. Correct: Athlete's foot is treated with topical antifungal in most cases. Severe cases may require oral drugs. The feet must be washed daily with soap and water and dried thoroughly since the fungus thrives in moist environments.Steps to prevent athlete's foot include wearing shower sandals in public showering areas and wearing shoes that allow the feet to breathe. 1. Incorrect: Clients with fungal skin infections should avoid the use of cornstarch. The carbohydrates in cornstarch may provide nutrition to fungal infections and should be avoided. 3. Incorrect: Allow feet to have exposure to the air. The feet must be kept clean and dry since fungus thrives in moist environments. Keeping the feet covered all the time causes a dark, moist environment for the fungus to thrive.)

The medical surgical nurse is admitting a client diagnosed with deep vein thrombosis (DVT) of the right leg. The client suddenly begins to report shortness of breath. Which additional early signs/symptoms indicative of a complication would the nurse need to report to the primary healthcare provider immediately? 1. Tachycardia with tachypnea. 2. Restlessness and dizziness. 3. Pain in the lower right leg. 4. A positive Homan's sign.

2. Restlessness and dizziness. (2. Correct: The worst complication of a DVT is the potential for a pulmonary embolism, resulting when part of the blood clot breaks free and travels to the lungs. This life-threatening complication presents with symptoms of hypoxia, including restlessness, agitation, or dizziness. The client may also develop chest pain, depending on the size of the clot. 1. Incorrect: While these symptoms may require further assessment, the question does not provide any parameters for vital signs. Individually, tachycardia and tachypnea could be attributed to pain, anxiety, or even hospitalization. There is not enough information provided to necessitate an immediate call to the Primary healthcare provider. 3. Incorrect: Pain in the affected extremity is not an unexpected finding with this diagnosis, although the nurse would need to further assess and evaluate the level and location of the pain in relation to the blood clot. This symptom is not surprising and would not require immediately alerting the primary healthcare provider. 4. Incorrect: The Homan's sign was a method formerly used to assess for the presence of a DVT and was performed by dorsiflexing the foot of the affected leg in an effort to elicit pain. However, this technique has proven to be unreliable and is no longer part of the assessment process.)

A community health nurse is presenting a seminar to a group of senior citizens on ways to reduce the risks of peripheral artery disease (PAD). What topics should the nurse include? Select all that apply 1. Anti-embolic stockings 2. Smoking cessation 3. Moderate exercise 4. Application of heat 5. Low cholesterol diet 6. Decrease blood pressure

2. Smoking cessation 3. Moderate exercise 5. Low cholesterol diet 6. Decrease blood pressure (2., 3., 5. & 6. Correct: Senior clients are at increased risk for peripheral artery disease for a variety of reasons, though many erroneously believe that this process is an unavoidable part of the aging process. Educating clients on preventative activities will help reduce incidence of atherosclerosis and improved mobility along with quality of life. Smoking is a major risk factor in developing PAD by contributing to arterial constriction. Clients can increase collateral circulation with a moderate exercise program of at least 30 minutes three times a week. A low cholesterol, heart healthy diet with more fruits and vegetables helps reduce cholesterol while decreasing blood pressure, both important goals towards controlling PAD. 1. Incorrect: Increasing arterial blood flow is important in the prevention or management of peripheral artery disease; however, anti-embolic stockings are designed to improve venous return in clients with decreased mobility. The use of these stockings would actually hinder arterial flow in lower extremities. 4. Incorrect: Clients with PAD often complain of cold extremities secondary to decreased arterial blood flow. But the application of heat such as use of a heating pad is unsafe and is always contraindicated in the elderly with PAD. Inability to sense temperature extremes may result in serious burns to lower extremities. Additionally, clients with PAD do not heal as well from injuries or wounds.)

What signs/symptoms would the nurse expect to find in a client diagnosed with pernicious anemia? Select all that apply 1. Pain 2. Smooth, red tongue 3. Burning feeling in feet 4. Lightheadedness 5. Dyspnea on exertion

2. Smooth, red tongue 3. Burning feeling in feet 4. Lightheadedness 5. Dyspnea on exertion (2., 3., 4., & 5. Pernicious anemia symptoms could include a smooth tongue that is red in color rather than a healthy pink. And neurological problems such as a burning feeling in the feet, slow reflexes, and disorientation. Light headedness, dyspnea on exertion, fatigue, and breathlessness are anemia symptoms that clients often report. 1. Incorrect. Pain is a symptom seen in sickle cell anemia.)

After a thoracotomy, which interventions will the nurse initiate to reduce the risk of acute respiratory distress? Select all that apply 1. Allow 4 hours of rest between deep breathing and coughing exercises. 2. Splint the incision during deep breathing and coughing exercises. 3. Have the client drink a glass of water before coughing. 4. Perform percussion and vibration every 2 hours. 5. Promote incentive spirometer use several times per hour while awake.

2. Splint the incision during deep breathing and coughing exercises. 5. Promote incentive spirometer use several times per hour while awake. (2., & 5. Correct: Splinting helps with the ability to control pain and produce an effective cough. Incentive spirometry encourages deep inspiratory efforts, which are more effective in re-expanding alveoli than forceful expiratory efforts. 1. Incorrect: They need to cough more often than every 4 hours. It is the best when this is done every 2 hours. 3. Incorrect: It takes longer than a few minutes to liquefy secretions and, if the stomach is full, vomiting may occur which would put the client at risk for aspiration. 4. Incorrect: After the surgery, we do not want to percuss and vibrate the incision. Besides being extremely painful, this could potentially disrupt the suture line.)

After discontinuing a peripherally inserted central line (PICC), it is most important for the nurse to record which information? 1. How the client tolerated the procedure. 2. The length and intactness of the central line catheter. 3. The amount of fluid left in the IV solution container. 4. That a dressing was applied to the insertion site.

2. The length and intactness of the central line catheter. (2. Correct: This is the most important information that needs to be documented. This information would be important in determining if a potential safety issue/complication could occur as a result of the PICC line being removed or a portion of the line breaking off before removal. 1. Incorrect: This is not the most important information that needs to be documented. There are no client safety issues with charting the client's tolerance of the procedure. 3. Incorrect: This would be charted so the intake and output could be calculated. This is not the most important data that needs to be documented related to the removal of the PICC line. 4. Incorrect: This would need to be documented because a dressing is applied to the insertion site after removal. However, this is not the most important data that would need to be documented after this procedure.

The nurse is cleaning and dressing a foot ulcer of a diabetic client. Which actions are appropriate? Select all that apply 1. Uses a clean basin and washcloth to clean the ulcer. 2. Wears sterile gloves to clean the ulcer. 3. Cleans ulcer with normal saline. 4. Warms saline bottle in microwave for 1 minute. 5. Cleans ulcer in a full circle, beginning in the center and working toward the outside.

2. Wears sterile gloves to clean the ulcer. 3. Cleans ulcer with normal saline. 5. Cleans ulcer in a full circle, beginning in the center and working toward the outside. (2., 3., & 5. Correct: The nurse needs to wear sterile gloves when cleaning the wound. Normal saline solution is the preferred cleansing agent because, as an isotonic solution, it doesn't interfere with the normal healing process. Gently clean the wound in a full or half circle, beginning in the center and working toward the outside. 1. Incorrect: Sterile supplies should be used with this procedure because the client is at risk for infection and gangrene. Gauze and salve should be used instead of a wash cloth. 4. Incorrect: Before you start, make sure the cleansing solution is at room temperature. Do not heat in the microwave. It could scald the client!)

A small community has experienced a mudslide that hit a restaurant causing mass casualties. What would the nurse do first? 1. Assess the immediate area for electrical wires on the ground. 2. Attend to victim injuries as they are encountered. 3. Activate the community emergency response team. 4. Triage and tag victims according to injury.

3. Activate the community emergency response team. (3. Correct: With mass casualties, community response teams are needed. 1. Incorrect: This would be the second step so that further injuries are not encountered. 2. Incorrect: Triage must occur before treatment of anyone so that an accurate assessment of level of injuries can be made. With mass casualties, a color tag system is usually implemented. 4. Incorrect: This would be the third step.)

The nurse is preparing to administer scheduled medications for a client. Which medication would require clarification prior to administration? Diagnosis: Heart failure Current vital signs: BP 110/64, HR 70, R 18 Allergies: Sulfonamides Medical history: Hypertension Lab results: Glucose- 98 mg/dl (5.4 mmol/L), Sodium- 142 mEq/L (142 mmol/L), Potassium- 3.8 mEq/L (3.8 mmol/L), Digoxin level - 0.8 ng/mL (1.02 nmol/L) Diet: 2 gm Sodium Scheduled procedures: Echocardiogram Chest x-ray Scheduled medications to administer: Digoxin 0.125 IV push every morning Sacubitril/valsartan 24/26 mg by mouth twice a day Bumetanide 0.5 mg by mouth twice a day Potassium chloride 20 mEq by mouth three times a day 1. Digoxin 2. Sacubitril/valsartan 3. Bumetanide 4. Potassium chloride

3. Bumetanide (3. Correct: Bumetanide is a loop diuretic. What is worrisome about giving this medication is the fact that the client is allergic to sulfonamides. It is contraindicated because there is a cross-sensitivity with thiazides and sulfonamides. 1. Incorrect: Digoxin is a cardiac glycoside. There is nothing in the chart or other medications that prevent this medication from being administered. 2. Incorrect: Sacubitril/valsartan is a combination medication used to reduce the risk of cardiovascular death and hospitalization for heart failure. The client should not take this medication within 36 hours before or after taking any ACE inhibitor or other ARB medication. Watch for hypotension, hyperkalemia, and impaired renal function. There are no indications of adverse effects in this question. 4. Incorrect: Administering potassium chloride is acceptable since this client is on a loop diuretic which depletes potassium and digoxin. You do need to monitor for hyperkalemia as well since the client is on sacubitril/valsartan. The serum potassium level is normal in this client.)

Following surgery, a client has an indwelling urinary catheter attached to a collection bag. The nurse empties the collection bag at 0900. At the change of shift at 1500, the collection bag contains 100 mL of urine. The system has no obstructions to urinary flow. What would be the nurse's most appropriate initial response? 1. Elevate the head of the client's bed. 2. Start giving the client 8 ounces of oral fluid per hour. 3. Check circulation and take the vital signs of the client. 4. Continue monitoring, because this is an expected finding.

3. Check circulation and take the vital signs of the client. (3. Correct: A urine output (U/O) of 100 mL over a 6 hour period is dangerously low. This client could be experiencing hypovolemic shock. In clients who are "shocky", the kidneys stop making urine to try to hold on to what little volume the body has left. The nurse is checking the vital signs for low BP and increased HR, indicators of hypovolemic shock. Also, when the urine output is this low, the client is at risk for renal failure. 1. Incorrect: Elevating the head of the client's bed is a good choice when the client is having difficulty breathing, but not here. Raising the HOB will cause the BP to drop lower. Clients in shock should be supine. 2. Incorrect: Normally, pushing fluids is a good choice if the urine output were low. 100 mL over six hours requires more aggressive treatment to combat shock. 4. Incorrect: This is not an expected finding. Urine output less than 240 mL in an eight hour time frame should alert the nurse to a serious problem such as shock.)

The ICU nurse is caring for a client with massive head injuries. The nurse notices that the client's respirations have a rhythmic increase and decrease of rate and depth and include brief periods of apnea. How would the nurse document this respiratory pattern? 1. Apneusis 2. Ataxic 3. Cheyne-Stokes 4. Cluster

3. Cheyne-Stokes (3. Correct: The respiratory pattern described is Cheyne-Stokes. A client with massive head injuries is at risk for this breathing pattern due to an injury with the cerebal hemispheres. 1. Incorrect: Apneusis is characterized by a sustained inspiratory effort. It does not typically have a period of apnea. 2. Incorrect: Ataxic respirations have an irregular, random pattern of deep and shallow respirations with irregular apneic periods. The irregularity of it differentiates ataxic respirations from Cheyne-Stokes respirations. 4. Incorrect: Cluster breathing is characterized by a closely grouped series of gasps followed by a period of apnea. There is no rhythmic increase and decrease as in Cheyne-Stokes respirations.)

The nurse is monitoring the healing of a full-thickness wound to a client's right thigh. The wound has a small amount of blood during the wet to dry dressing change. What action should the nurse initiate next? 1. Notify the primary healthcare provider. 2. Obtain wound culture. 3. Document the findings. 4. Remove dressing and leave open to air.

3. Document the findings. (3. Correct: Look at the clues: full thickness wound, small amount of blood, wet to dry dressing. With a full thickness wound there is destruction of the epidermis, dermis, and subcutaneous tissues going down to the bone. ​So you would expect to see a small amount of blood or drainage wouldn't you? Yes. This is expected. Simply document this normal finding. 1. Incorrect: Is there really anything to worry about in this situation? No, so you do not need to notify healthcare provider. Now, with most questions on NCLEX there is something to worry about but just not with this one. 2. Incorrect: No, bleeding is not a sign of infection which is what you would be worried about if you got a wound culture. 4. Incorrect: Probably not, just a sign of blood flow in healing wound. Wet to dry dressing helps to debride the wound. So if you remove the dressing will debridement occur? No.)

Which signs and symptoms will the nurse include when teaching a client about indicators of recurrent nephrotic syndrome? Select all that apply 1. Dysuria 2. Hematuria 3. Foamy urine 4. Periorbital edema 5. Weight loss

3. Foamy urine 4. Periorbital edema (3. & 4. Correct: Foamy urine, which may be caused by excess protein in the urine, is seen with nephrotic syndrome. Swelling (edema), particularly around the eyes (periorbital) and in the ankles and feet, is a symptom. 1. Incorrect: Dysuria would be a symptom of disorders such as kidney stone or UTI, rather than nephrotic syndrome. 2. Incorrect: Proteinuria rather than hematuria is seen. 5. Incorrect: Weight gain is seen with renal disorders due to poor renal function and increased fluid volume.)

A client arrives at the emergency department (ED) in obvious emotional distress, reporting perioral numbness and tingling of the fingers and toes. The nurse notes a respiratory rate is 56/min. What should be the initial intervention performed by the nurse? 1. Send the client for a CT of the head. 2. Place on 100% O₂ per non-rebreathing face mask. 3. Have the client breathe into a paper bag. 4. Administer diazepam 2 mg IV push.

3. Have the client breathe into a paper bag. (3. Correct: Recognize the respiratory rate is too fast. This client is hyperventilating and blowing off too much CO₂ which has resulted in symptoms of respiratory alkalosis, perioral numbness, and tingling of the fingers and toes. The nurse should try to help calm the client and encourage the client to slow the rate of breathing. This will help hold onto CO₂. By breathing into a paper bag, the client will re-breathe CO₂ therefore increasing the CO₂ level. 1. Incorrect: The client is not demonstrating signs of a stroke. A CT is not warranted based on the information provided. 2. Incorrect: Administration of O₂ is not warranted at this time. The client is blowing off too much CO₂ and needs to re-breathe CO₂ using a paper bag. Increasing O₂ will not fix the problem of emotional distress. 4. Incorrect: Diazepam has sedative effects. Although hysterical clients may have to be sedated to decrease the respiratory rate, the less invasive means of using the paper bag should be attempted first.)

A nurse is providing discharge teaching to a client who has had a cystectomy and formation of an ileal conduit. What client statement indicates that teaching was successful? 1. I should restrict my fluid intake to decrease the need to empty the drainage bag. 2. I will change my appliance daily to prevent skin excoriation from the leakage of urine. 3. I will change my drainage bag whenever it is leaking, giving special attention to my skin around the bag. 4. I will restrict going to events outside the home because leakage is common and embarrassing.

3. I will change my drainage bag whenever it is leaking, giving special attention to my skin around the bag. (3. Correct: The goal is to prevent skin irritation by changing the bag regularly and using proper equipment to prevent leakage. The client with an ileal conduit (urinary diversion) must be educated appropriately to ensure that self-care abilities are complete and safe. As long as the bag is not leaking and no skin breakdown is evident, changing the appliance bag only has to be done as needed, not daily. 1. Incorrect: Clients with ileal conduits are encouraged to increase fluid intake, as opposed to restricting it, to maintain adequate urine flow for prevention of urinary tract infections (UTI). 2. Incorrect: Changing the apparatus daily is too often and will cause trauma and skin breakdown. 4. Incorrect: Clients with ileal conduits are encouraged to maintain an active and normal lifestyle. People with ileal conduits have a generally low incidence of complications and high client satisfaction level due to the ease of care and minimal lifestyle changes.)

A client has been admitted to the emergency department after repeated food binging and purging by vomiting and laxative abuse. The client reports leg pains and weakness. ECG reveals a depressed ST segment and flattened T wave. Based on this data, what does the nurse anticipate that this client will need to receive first? 1. Oral fluids 2. Kayexalate enemas 3. Intravenous potassium (KCl) 4. An antidiarrheal medication

3. Intravenous potassium (KCl) (3. Correct: Look at the clues in the stem: vomiting, laxative abuse, symptoms of hypokalemia including weakness, muscle cramps, and arrhythmias. Due to repeated laxative abuse and vomiting, the client has lost potassium. Normal potassium is 3.5-5.0 mEq/L. IV potassium is required for a severely low potassium. 1. Incorrect: Oral fluids are needed, but with symptoms this severe, IV resuscitation is needed with potassium. The client is exhibiting symptoms of severe hypokalemia. The potassium is prescribed to correct this imbalance. 2. Incorrect: Kayexalate is given for high potassium. This client's potassium is low. The therapeutic effect of kayexalate is to reduce the serum potassium level. 4. Incorrect: We are worried about low potassium here. This won't solve the problem. An antidiarrheal medication may be prescribed, but the client is exhibiting symptoms of hypokalemia. The client should be administered the IV potassium first to correct the low potassium level.)

A client reports dizziness and weakness while walking down the hall. The nurse notes the client's cardiac rhythm displayed on the telemetry monitor. What actions should the nurse take? Select all that apply 1. Have client ambulate back to bed. 2. Initiate 100% oxygen per nonrebreather mask. 3. Obtain client's blood pressure. 4. Prepare for cardioversion. 5. Auscultate lung sounds. 6. Administer nitroglycerin 1 tab SL.

3. Obtain client's blood pressure. 4. Prepare for cardioversion. 5. Auscultate lung sounds. (3. & 5. Correct: The client is dizzy and weak. This client is at risk for falling, so think safety and get the client back in bed. Use a wheelchair to accomplish this. Then obtain the client's BP. It may be low indicating poor tissue perfusion to the vital organs. One cause of premature ventricular contractions (PVCs) includes heart failure, so assess the lungs for adventitious sounds. 1. Incorrect: This client is dizzy and weak. Having the client ambulate back to the bed is a safety risk. The client could fall. 2. Incorrect: Oxygen may abate the PVCs; however, it should be initiated at 2 liters/NC rather than at 100%. Start with the least amount of oxygen that could relieve symptoms. 4. Incorrect: Cardioversion is not indicated with an underlying rhythm that is normal (NSR) with PVCs. Oxygen may decrease the PVCs. If not, medication can be administered to decrease the rate of the PVCs. 6. Incorrect: Nitroglycerin would be given if the client is experiencing chest pain or is suspected of having an MI. Get the client back in bed and provide the client with oxygen at 2 L/NC first.)

A hospitalized client diagnosed with rheumatoid arthritis is receiving IV methylprednisolone every six hours. What is the best method for the nurse to provide client safety? 1. Place "fall precautions" sign above client's bed. 2. Change the intravenous site for steroids daily. 3. Restrict any visitors with visible illnesses. 4. Put client on full contact precautions.

3. Restrict any visitors with visible illnesses. (3. Correct: Rheumatoid arthritis is an autoimmune disease that affects not only body joints but also organs of the body. Receiving methylprednisolone as treatment further suppresses the immune system, making the client even more at risk of infection. Restricting visitors with colds, respiratory problems and other infectious processes is the best method to protect the client. 1. Incorrect: The question states the diagnosis is rheumatoid arthritis, but there is no indication the client is unsteady or needs to be on "Fall Precautions". Although the client is fatigued and has brittle bones, there is no evidence the client needs assistance ambulating. A sign is not necessary. 2. Incorrect: Most facilities have policies to change an IV site at specific intervals, usually every three days. Changing the site daily exposes the client to an increased chance of infection from the invasive procedure. Steroids do not irritate veins and do not require frequent site changes. 4. Incorrect: There is no rationale for contact precautions since the client's disease process is not contagious. The main concern is to protect the client from other individuals.)

A client is to be discharged following cataract removal with lens implantation. What statement by the client indicates to the nurse that teaching has been successful? 1. "I must keep both eyes covered till my check-up." 2. "I should only have pain for about two days." 3. "I will no longer have to wear reading glasses." 4. "My vision will be blurry for a couple weeks."

4. "My vision will be blurry for a couple weeks." (4. Correct: Following cataract removal, a new lens is sutured in place, which slightly alters the corneal curve. Newer surgical approaches involve the use of a "suture-less glue" but that method is less common. Although the client's vision will eventually improve and stabilize, minor blurring may exist during the 6 to 12 week healing period. After that time, any remaining visual issues can be corrected with glasses. 1. Incorrect: Only the operative eye is protected by an eye patch during the healing process. The primary healthcare provider will remove that covering at the first post-operative checkup. Covering both eyes would pose a greater safety risk and decrease the client's self care abilities. 2. Incorrect: Pain following cataract surgery is the sign of a serious complication and should be reported to the surgeon immediately. Clients may experience a small amount of serous drainage or scratchy sensation, but should not have pain. 3. Incorrect: Implantation of a new lens causes a mild astigmatism that will be permanent. The client may still need to use corrective lenses, even if just for reading.)

The emergency room nurse is assessing a client reporting severe abdominal pain for several hours prior to arrival at the hospital. Assessment findings include slight mottling of the lower extremities and a pulsating mass near the umbilicus. Which actions should the nurse implement immediately? Select all that apply 1. Position client on the left side. 2. Apply warm blankets to legs. 3. Administer I.M. pain medication. 4. Alert the operating room staff. 5. Notify the primary healthcare provider. 6. Palpate mass to determine size.

4. Alert the operating room staff. 5. Notify the primary healthcare provider. (4. & 5. Correct: The client's symptoms indicate the presence of an aortic abdominal aneurysm that may be dissecting (rupturing) at this time. This is a life-threatening emergency and the client will need urgent surgery to survive. The nurse should immediately notify the healthcare provider and alert the operating room staff of impending surgery. 1. Incorrect: These are the classic symptoms of a dissecting abdominal aneurysm, a life-threatening situation requiring immediate surgery. Positioning the client on either side is contraindicated as that action may cause further internal bleeding, complete rupture of the aneurysm, or death. 2. Incorrect: Mottling of lower extremities accompanied by severe abdominal pain suggests a dissecting abdominal aneurysm. The discoloration of lower extremities indicates compromised circulation secondary to interrupted blood flow because of the aneurysm. This client would not benefit from warm blankets but rather needs immediate surgery to survive. 3. Incorrect: Pain medications in general are not administered until an exact diagnosis is confirmed, since relieving pain would mask those signs or symptoms needed to verify the problem. While the client may be given medications at some point, this is not the life-saving action the nurse must take immediately. 6. Incorrect: The client's symptoms are suggestive of a dissecting abdominal aneurysm, a life-threatening emergency requiring immediate surgical intervention. It is never acceptable for the nurse to palpate an abdominal mass, particularly a pulsating mass, since this would likely cause complete rupture of the blood vessel and immediate death.)

The charge nurse is making assignments for the evening shift. Which client would be an appropriate assignment for a new LPN/VN graduate? 1. A middle aged adult admitted with syncope. 2. An adolescent with skin grafts to right hand. 3. A young adult receiving IV chemotherapy. 4. An elderly adult diagnosed with diverticulitis.

4. An elderly adult diagnosed with diverticulitis. (4. Correct: Diverticulitis is a bowel disorder of undetermined origin, characterized by pain to the lower abdomen, along with bloating, fever and diarrhea. Treatment may include hospitalization, antibiotics, liquid diet and bedrest. Because there is usually no bleeding involved, this would be an appropriate assignment for a new LPN/VN graduate. 1. Incorrect: A new admission requires assessments that must be completed by a registered nurse. Additionally, syncope could be an indication of a serious cardiac issue; therefore, this would not be a client suitable for the LPN/VN. 2. Incorrect: Although sterile wound care is within the scope of practice for an LPN/VN, skin grafts require special assessment techniques during dressing changes, in order to determine quality of tissue perfusion and potential for rejection. This client should be assigned to a more experienced nurse. 3. Incorrect: This client will need extensive assessments of multiple body systems while receiving I.V. chemotherapy, requiring an experienced registered nurse with knowledge of both chemo drugs and different types of cancer. This client would not be appropriate for a new LPN/VN.)

The nurse is caring for a post op client who is drowsy but arousable. The client will take a few deep breaths when instructed but drifts to sleep when left alone. The O₂ saturation while sleeping drops to 82% on 3 liters of nasal oxygen. The client received a dose of oxycodone/acetaminophen 2 tabs one hour ago. What is the nurse's best action at this time? 1. Keep the O₂ sat machine at the bedside and set the alarm to beep loudly when O₂ sat drops below 93%. 2. Give bath to arouse client and then report that oxycodone/acetaminophen 2 tabs is too much for next dose. 3. Let the client sleep until he has rested, then discuss abuse potential of narcotics. 4. Call the primary healthcare provider and report client assessment findings.

4. Call the primary healthcare provider and report client assessment findings. (4. Correct: Yes, this client has unstable respirations and is in respiratory distress. The client needs naloxone, the antidote for narcotic overdose. Since that is not an option, you need to call the primary healthcare provider to get a prescription for the antidote. 1. Incorrect: That will work the first time, but the client is too sedated to remain awake and take deep breaths. The client will continue to have respiratory distress until naloxone can be given. 2. Incorrect: No, that won't fix the problem of too much medication. We need to fix the problem now. 3. Incorrect: No, client is too sedated. Naloxone is needed, so the nurse needs to notify the primary healthcare provider.)

A client presenting at the clinic has a history of systemic lupus erythematosus (SLE). Which finding would indicate to the nurse that the client is having a flare-up of the disease? 1. Alopecia 2. Arthritis of hands 3. Weight gain 4. Fever

4. Fever (4. Correct: Fever is the classic sign of a flare, or exacerbation of SLE. 1. Incorrect: Lupus can cause the hair on your scalp to gradually thin out, although a few people lose clumps of hair. 2. Incorrect: Most SLE clients will develop arthritis with their illness. Arthritis from SLE commonly involves swelling, pain, stiffness, and even deformity of the small joints of the hands, wrists, and feet. Sometimes, the arthritis of SLE can mimic that of rheumatoid arthritis, another autoimmune disease. 3. Incorrect: Weight gain is not a sign of exacerbation but is a side effect of long-term corticosteroid use.)

A community health nurse is assessing a migrant farmer who raises chickens. The nurse notes the client has developed a cough, fever, dyspnea, and hemoptysis. What infection should the nurse suspect? 1. Lyme disease 2. Toxoplasmosis 3. Tuberculosis 4. Histoplasmosis

4. Histoplasmosis (4. Correct: Histoplasmosis is a fungal infection transmitted through ingestion of soil contaminated by bird manure. 1. Incorrect: The classic symptom of Lyme disease is usually an expanding target-shaped or "bull's-eye" rash which starts at the site of the tick bite. Fever, headache, muscle aches, and joint pain may also occur. 2. Incorrect: Toxoplasmosis occurs from contact with cat feces. Symptoms may be influenza-like: swollen lymph nodes, headaches, fever, and fatigue, or muscle aches and pains. 3. Incorrect: TB is often suspected; however, the primary difference is exposure to bird feces.)

The nurse is teaching a group of clients who have osteoarthritis how to protect joints. What should the nurse include? Select all that apply 1. Use small joints and muscles. 2. Turn doorknobs clockwise. 3. Sit in a chair that has a low, straight back. 4. Push off with the palms of hands when getting out of bed. 5. Use hairbrush with extended handle.

4. Push off with the palms of hands when getting out of bed. 5. Use hairbrush with extended handle. (4. & 5. Correct: Pushing off with the palms of the hands is using a larger joint and muscles. Using the fingers will cause more joint injury. Use long handled devices such as a hairbrush with an extended handle to decrease stress on joints (in this case the wrist). 1. Incorrect: Larger joints and muscles can take more stress and weight than smaller ones. Using small joints again and again puts more stress on them and may lead to deformity. Try to spread the strain and weight over several joints. This helps you use each part of your body to its best advantage. 2. Incorrect: Do not turn a doorknob clockwise. Turn it counterclockwise to avoid twisting the arm and promoting ulnar deviation. 3. Incorrect: Sit in a chair that has a high, straight back. This will provide more support for the back.)

A post-operative client becomes anxious and reports acute onset of chest pain when taking a deep breath and shortness of breath. Initial vital signs obtained by the nurse reveals tachycardia, hemoptysis, and a pulse oximeter reading of 90%. What intervention should the nurse initiate first? 1. Administer oxygen. 2. Obtain a blood pressure reading. 3. Connect to cardiac monitor. 4. Raise head of bed to 90 degrees.

4. Raise head of bed to 90 degrees. (4. Correct: This is your priority. This position will facilitate maximum lung expansion. It will also decrease venous return to the right side of the heart so that pressure decreases in the pulmonary vascular system. 1. Incorrect: Oxygen is needed, but the first thing the nurse should do is raise the head of the bed, so the client can breathe easier. Then get the oxygen set up. 2. Incorrect: Obtaining a blood pressure reading at this point is delaying treatment. The problem is a breathing problem. Do something to fix the breathing problem first. Then, you can continue your assessment by checking circulation status. 3. Incorrect: Connecting the client to a cardiac monitor is an appropriate intervention, but facilitating breathing takes priority and should be done first.)

A client with Bell's palsy is having difficulty eating. Which action by the nurse will be most helpful? 1. Teach the client to perform active facial exercises several times a day. 2. Provide a liquid diet high in protein and calories that will be easily swallowed. 3. Provide oral hygiene after eating. 4. Teach the client to chew food on the unaffected side of the mouth.

4. Teach the client to chew food on the unaffected side of the mouth. (4. Correct: Maintenance of good nutrition is most important. Teaching the client to chew on the unaffected side will help the client avoid food trapping. This will decrease the risk of aspiration which prioritizes higher than the other options. 1. Incorrect: Performances of facial exercises is important in recovery from Bell's palsy and will help over a long period of time. This intervention is not the highest priority. 2. Incorrect: Liquids are too difficult for the client to manage, as lip closure and chewing are impaired. A purely liquid diet increases the risk for aspiration. 3. Incorrect: Providing oral hygiene is important to prevent dental caries; however, this is not more important than preventing aspiration.)

The nurse initiates sterile wound care on a client's newly debrided foot ulcer. After removing the dressing and beginning a betadine cleanse, the client mentions an allergy to iodine not previously reported. Place the nursing actions in order of priority. Observe client for signs or symptoms of reaction. Ask client about the type of "allergic response". Cover wound with temporary sterile dressing. Notify primary healthcare provider of the allergy. Remove betadine solution from wound with normal saline.

Ask client about the type of "allergic response". Remove betadine solution from wound with normal saline. Cover wound with temporary sterile dressing. Observe client for signs or symptoms of reaction. Notify primary healthcare provider of the allergy. (First: Because many individuals confuse the term "allergy" with expected side effects, the nurse first needs to quickly determine the type of response this client may have previously experienced. Second: Whether or not the client is able to give a clear description of an allergic response, such as hives, swelling or reddened skin, the nurse must assume the worst and then immediately remove the betadine solution from the open wound/skin before any reaction occurs. Third: The previously unreported allergy may require a change in the plan of care; however, at this moment the nurse has a fresh wound exposed to air. The nurse should cover the wound with a dry sterile dressing. Fourth: Then observe the client for at least 10 minutes to determine the need for any emergency intervention in case of anaphylaxis. Fifth: Once it is determined the client is stable, the healthcare provider should be contacted regarding the new information, client's status and whether new wound care orders are needed.)

The nurse is caring for a client receiving peritoneal dialysis. Place the steps for peritoneal dialysis in the correct order. Access Tenckhoff catheter Begin dwell time Assess effluent Warm dialysate Complete exchange

Warm dialysate Access Tenckhoff catheter Begin dwell time Complete exchange Assess effluent (First, warm the dialysate. Would you put cold or even cool dialysate in your peritoneal cavity? NO, it would feel uncomfortable but more importantly, it would vasoconstrict the vessels of the peritoneal membrane. Would that affect the success of the dialysis? Yes, you want dilated blood vessels to promote osmosis and diffusion. Second, access the Tenckhoff catheter, assess it for patency and look at the site for infection. Just like you would do with any IV access. Third, begin the dwell time. Fourth, complete exchange by removing effluent by gravity drainage. Fifth, assess effluent. What would I assess the effluent for? Color, clarity, amount...just like urine? What am I worried about? Infection. How would my effluent look if I had an infection? Cloudy. If I have an infection in my peritoneal cavity, I need immediate antibiotic therapy to prevent peritonitis and damage to the membrane. The primary healthcare provider is going to want to culture the effluent and start a broad spectrum antibiotic.)

A male client diagnosed with primary hyperaldosteronism is receiving spironolactone. Which potential side effect should the nurse educate the client regarding? Select all that apply 1. Erectile dysfunction 2. Gastrointestinal upset 3. Gynecomastia 4. Hypernatremia 5. Hypokalemia

1. Erectile dysfunction 2. Gastrointestinal upset 3. Gynecomastia (1., 2., & 3. Correct: Spironolactone blocks androgen and progesterone receptors and may inhibit the action of these hormones. Side effects can include gynecomastia, decreased sexual desire, impotence, menstrual irregularities, and gastrointestinal distress. 4. Incorrect: Hyponatremia, rather than hypernatremia, may be seen. 5. Incorrect: Hyperkalemia, rather than hypokalemia, may be seen.)

The nurse would make which recommendations when conducting community health teaching about obesity to a group of adolescents? Select all that apply 1. Limit TV viewing and video game playing to 4 hours a day 2. At least 60 minutes of moderate-intensity activity daily 3. Exercise should be structured 4. A strict diet should be followed avoiding all junk food and drinking water only 5. Set a goal of at least 11,000 to 13,000 steps each day

2. At least 60 minutes of moderate-intensity activity daily 5. Set a goal of at least 11,000 to 13,000 steps each day (2. & 5. Correct: 60 minutes of moderate-intensity physical activity 7 days a week. Girls should take a least 13,000 steps daily and boys should take 11,000 steps daily. 1. Incorrect: TV viewing and video game playing should be 2 or fewer hours each day. 3. Incorrect: Exercise does not need to be structured. 4. Incorrect: If the diet is too restrictive, it is likely to fail.)

A 35 year old client, concerned about weight, asks a clinic nurse, "What is my BMI?" The client weighs 135 pounds and is 5 feet 2 inches tall. Determine the client's BMI to the nearest tenth? Ans:______

24.7 (Standard formula: BMI = (703 × lb) ÷ in² BMI = (703 × 135) ÷ (62)² BMI = (94,905) ÷ (3,844) BMI ≈ 24.7 Metric formula: BMI = kg ÷ m² BMI = (135 ÷ 2.2) ÷ (((5 × 12) + 2) × 2.54 ÷ 100)² BMI = (135 ÷ 2.2) ÷ ((62 × 2.54) ÷ 100)² BMI = (135 ÷ 2.2) ÷ (157.48 ÷ 100)² BMI = (135 ÷ 2.2) ÷ 1.5748² BMI ≈ 24.7 Ans: 24.7)

The nurse is caring for an oncology client with a WBC-5.5 x 10³/mm³, Hgb-12g/dL, PLT-90 x 10³/mm³. Which measure should be instituted? 1. Protective isolation 2. Oxygen therapy 3. Bleeding precautions 4. Strict intake and output

3. Bleeding precautions (3. Correct: Yes. That is the only value that is not a normal level, and it is way too low, so this client is at risk for bleeding. Bleeding precautions are the appropriate intervention. A normal platelet count ranges from 150,000 to 450,000 platelets per microliter of blood. Having more than 450,000 platelets is a condition called thrombocytosis; having less than 150,000 is known as thrombocytopenia. 1. Incorrect: The WBC is okay. An average normal range is between 4,500 and 10,000 white blood cells per microliter (mcL). Leukopenia is the medical term used to describe a low WBC count. 2. Incorrect: There is no indication of hypoxia in stem, and the Hgb is normal, so the client is not anemic. A low hemoglobin count is generally defined as less than 13.5 grams of hemoglobin per deciliter (135 grams per liter) of blood for men and less than 12 grams per deciliter (120 grams per liter) for women. 4. Incorrect: There is no indication for I & O measurement. I&O should be done with clients who have a fluid volume, cardiac, or renal problem.)

What should the nurse teach a client about testicular self examination? 1. This exam should be performed bi-annually. 2. The exam should be performed during a cold shower. 3. Gently roll each testicle with slight pressure between the fingers. 4. The epididymis should feel like a hard, knotty rope.

3. Gently roll each testicle with slight pressure between the fingers. (3. Correct: Examine one testicle at a time. Use both hands to gently roll each testicle, with slight pressure, between the fingers to feel for lumps, swelling, soreness or a harder consistency. 1. Incorrect: All men 15 years and older need to perform this examination monthly. 2. Incorrect: The exam should be performed during or right after a warm shower or bath when the the scrotum is less thick. 4. Incorrect: The epididymis should feel soft, rope like, and slightly tender to pressure. It is located at the top of the back part of each testicle. It is not a lump.)