Archer Assessment 12/27

The nurse is caring for a client receiving a continuous infusion of heparin. The label reads 25,000 units of heparin in 500 mL of Dextrose 5% in water (D5W). The client is receiving 1,250 units per hour. How many milliliters (mL) did the client receive in an eight-hour shift? Fill in the blank.

200 mL 1250 units / 25000 units x 500 mL = 25 mL/hr Next, take the mL/hr and multiply it by eight to determine the total volume delivered. 25 mL/hr x 8 hours = 200 mL

The nurse is educating a diabetic client regarding foot care. Which of the following statements by the client indicates that he understood the nurse's instructions? Select all that apply. A. "I need to check my feet daily for sores, blisters, dry skin, and cuts." B. "I need to wash my feet daily and keep them dry." C. "If I get sores or blisters on my feet, I should not pop them." D. "I need to apply cream to my heels and between my toes daily."

A, B, C Thin creams or lotions can be applied on the tops and bottoms of feet to keep the feet soft and prevent cracking. However, creams should not be applied between the toes because it promotes moisture, which can lead to chafing, blisters, and open wounds. Moisture between toes may also predispose to fungal infections. Instead, the skin between the toes should be kept dry by sprinkling talcum powder or cornstarch between the toes.

The nurse is caring for an 8 year old boy in the pediatric unit. The nurse, when caring for this age group should be aware that: A. The child will do something for another if that person does something for the child. B. The child now follows social standards for the good of all. C. The child wants to follow rules because of a need to be seen as "good." D. The child finds satisfaction in following rules.

C. The child wants to follow rules because of a need to be seen as "good." The school-age children ages 7-10 find a need to follow the rules as they want to be a "good" person in their eyes, and for others. A: This applies to children ages 4-7 years old. B: It applies to adolescents. The child now follows social standards for the good of all people. D: This applies to the 10-12 years old age group. This is where the child finds satisfaction in following rules.

Which of these would be most relevant to include in discharge teaching for a patient with a platelet count of 40,000 per mcL (40 x 10^9/L)? A. Be sure to take your aspirin with meals daily B. You may continue to shave with a straight edge razor C. Use a soft toothbrush and floss gently D. You should take a multivitamin daily

C. Use a soft toothbrush and floss gently This patient has thrombocytopenia and should be on bleeding precautions. Using a soft toothbrush and flossing gently can prevent the gum tissue from bleeding.

The primary healthcare provider (PHCP) prescribes 250 mL of 0.9% saline to infuse over 75 minutes. How many mL per hour will be administered to the client? Fill in the blank.

200 75min / 60 min = 1.25 250 / 1.25 hours = 200 mL/hr

The nurse is caring for a client in labor who just received epidural analgesia. The nurse should monitor the client for which adverse effects? A. Hypertension B. Bladder distention C. Hypothermia D. Precipitous labor

B. Bladder distention Epidural analgesia may cause bladder distention. Bladder distention may cause pain that remains after initiation of the block and may interfere with fetal descent in labor. cause hypotension and commonly slows the progression of the second stage of labor because it relaxes pelvic muscles.

The primary healthcare provider (PHCP) prescribes medication via the buccal route. To correctly administer this medication the nurse plans to place the medication A. in the client's ear while holding the pinna down and back. B. under the client's tongue. C. in the client's mouth toward the cheek. D. into the client's nasal passage.

C. in the client's mouth toward the cheek. When administering a medication via the buccal route, the nurse should put the medication inside the client's mouth toward their cheek.

The emergency department (ED) nurse cares for a client who presents with irritability, nuchal rigidity, and a fever. Which of the following actions should the nurse take first? A. Administer prescribed ibuprofen. B. Place the client on droplet precautions. C. Notify the public health department. D. Obtain prescribed blood cultures.

B. Place the client on droplet precautions. Initiating droplet precautions is a high priority for this client. The classic bacterial meningitis triad is fever, neck stiffness, and altered mental status. Protecting the other clients and staff from disease transmission is essential for the nurse. Thus, the nurse should initiate droplet precautions by placing the client in a room with all visitors and staff wearing a surgical mask in the client's presence.

The nurse is assisting a client using a fracture bedpan. Which action should the nurse take? A. Position the client prone while applying the bed pan B. Raise the head-of-bed to 30 degrees C. Place the open rim of the bedpan facing toward the head of the bed D. Lower all of the side rails

B. Raise the head-of-bed to 30 degrees Placing the head-of-bed at 30 to 60 degrees will facilitate comfort by preventing strain on the lumbar spinal column. When applying the bedpan, the client should be supine, not prone. The open rim of the bedpan should be facing toward the foot of the bed. This will prevent spillage and promote comfort. All of the side rails should not be lowered. The nurse should raise the side rail on the opposite side of the bed. This will allow the client to turn so the nurse may place the bedpan.

Your client presents with conjunctivitis, numbness in the extremities, and atrioventricular heart block following a tick bite that occurred two months ago. You suspect Lyme disease. Which stage of Lyme disease does this presentation represent? A. First stage B. Second stage C. Third stage D. Fourth stage

B. Second stage This reflects the second stage of Lyme disease. Neurological and cardiac involvement are hallmarks. Manifestations may include atrioventricular heart block and neuropathy. Ocular manifestations such as conjunctivitis can be seen in 10% of cases. The second stage occurs typically around seven weeks after the initial tick bite. It is also referred to as "early, disseminated Lyme" disease.

The nurse is assessing a child with glomerulonephritis. Which assessment finding requires follow-up by the nurse? A. Periorbital edema B. Decreased urine output C. Headache D. Hematuria

C. Headache A complication of glomerulonephritis is encephalopathy caused by severe hypertension associated with the disease process. A client's report of a headache should clue the nurse into checking the client's blood pressure. The client should be monitored for this potential complication, which can be avoided by closely monitoring the client's blood pressure.

The nurse is caring for a post-operative client at risk for a pressure ulcer. Which intervention should the nurse include in the plan of care? A. Apply sequential compression devices B. Apply an extra sheet to the bed C. Position the client on a donut pillow D. Encourage the consumption of high-protein foods

D. Encourage the consumption of high-protein foods High-protein foods are encouraged because they promote wound healing and prevent fluid shifting, which may lead to a pressure ulcer. The prevention of fluid shifting (edema) contributes to a pressure ulcer. Optimal protein intake is key to preventing (and healing) a pressure ulcer.

Which of the following is a neurological complication that may occur when a vest restraint is too tight around a patient's body? A. Skin breakdown B. Strangulation C. Changes in skin pallor D. Numbness

D. Numbness The neurological complication can occur when a vest restraint is too tight around the client's body causing numbness and tingling that, unless corrected, can lead to neurological damage.

The nurse is demonstrating the appropriate use of a car seat to a client. The nurse is demonstrating which level of prevention? A. Primary B. Secondary C. Tertiary D. Quaternary

A. Primary Primary prevention is often referred to as the true level of prevention because it occurs before disease or illness. Demonstrating the appropriate use of a car seat is primary prevention because it happens before an automobile crash, a leading cause of death for those younger than 19. Secondary: early identification of the disease (screening, health fairs) Tertiary: treats de disease and prevents further complications (nutritional educational to someone w/ CHF)

The primary healthcare provider (PHCP) prescribes 100 mL of 0.9% saline to infuse over 45 minutes. How many mL per hour will be administered to the client? Fill in the blank. Round your answer to the nearest whole number.

133 mL/hr 45 min / 60 min = 0.75 hour 100ml / 0.75hour =133.33 --> 133

The nurse is caring for a client with a phosphorus level of 5.3 mg/dL. The nurse identifies which of the following as possible causes of this condition? SATA A. Tumor lysis syndrome B. Hypoparathyroidism C. Hypercalcemia D. Renal failure E. Anorexia

A, B, D When there is too little PTH, there are decreased calcium levels (hypocalcemia). Since calcium and phosphorus have an inverse relationship, when there are low levels of calcium there are high levels of phosphorus. Renal failure is a cause of hyperphosphatemia. Due to reduced kidney function, phosphorus is not able to be excreted as readily as it normally would, so increased levels of phosphorus build up in the blood causing hyperphosphatemia.

The LPN is assigned to take care of a patient with hemophilia. When she reviews the lab values, she would expect to find which of the following? SATA A. Normal PT level B. Abnormal PTT level C. Normal thrombin time D. Abnormal INR

A, B, C

The nurse is providing sensitivity training to new members of the health care team about the best ways to manage and care for families after a miscarriage. The nurse explains that when it comes to telling children about a woman's pregnancy or pregnancy loss, it is the health care team's job to: A. Provide available resources and ultimately support the mother's decision. B. Inform the children of the parents so that they don't have to worry over the task. C. Encourage the parent's not to inform the children of the status of their mother's pregnancy. D. Use a hands-off approach and let the family come up with a solution alone.

A. Provide available resources and ultimately support the mother's decision. It is the health care team's job to provide resources and support to the mother and her family when it comes time to discuss pregnancy and pregnancy loss.

A 28-year-old woman is status-post thyroidectomy and has stayed at the post-anesthesia care unit for several hours. She is now ready to return to her room. Which action demonstrates that the nurse understands the possible complications of a thyroidectomy? A. Dressings are done every 2 hours to best detect postoperative bleeding, so the nurse should place the dressings at the bedside. B. Pain is managed the moment the client returns to her room by administering narcotics promptly. C. The bedside is ready with a tracheostomy set, oxygen, and suction. D. The nurse teaches the client alternative means of communication.

C. The bedside is ready with a tracheostomy set, oxygen, and suction. The most serious complication after a thyroidectomy is ineffective airway and breathing pattern because of tracheal compression and edema. It is essential to have a tracheostomy set, oxygen, and suction available at the bedside for at least 24 hours postoperatively. The client may have difficulty communicating due to laryngeal edema or nerve damage, but it most commonly occurs due to endotracheal intubation. The client will still be able to talk but may experience hoarseness of the voice.

What are the expected fundal assessment findings for a woman who delivered a set of twins one hour ago via Cesarean section? A. The fundus is hard, midline, and 1-2 fingerbreadths above the umbilicus. B. The fundus need not be assessed because of the C-section. C. The fundus is to the right of the umbilicus and soft. D. The fundus is hard, midline, and at the level of the umbilicus.

D. The fundus is hard, midline, and at the level of the umbilicus. Regardless of the mode of delivery, this is the normal postpartum fundus at one to two hours. the height of the fundus decreases by at least 1 cm or one fingerbreadth daily as the uterus goes through the process of involution. By the 10th day, the fundus is usually not palpable.

Analyze the following ABG: pH 7.62, CO2 19, HCO3 24 A. Compensated metabolic acidosis B. Uncompensated metabolic acidosis C. Compensated respiratory acidosis D. Uncompensated respiratory alkalosis

D. Uncompensated respiratory alkalosis First, determine if the ABG is compensated or uncompensated. Since the pH is not between 7.35 and 7.45, it is uncompensated.

The nurse is teaching a group of nursing students about the five rights of delegation. The nurse is correct to include that this involves the right A. intention. B. alternative. C. assessment. D. task.

D. task. The right task is within the five rights. When a nurse is delegating, the task must be within the individual's scope of practice and competency. For example, a right task would be delegating a practical/vocational nurse to administer an intramuscular (IM) injection of vitamin B12. The "Five Rights of Delegation" are: The "right" task The "right" circumstances The "right" person The "right" directions and communication The "right" supervision and evaluation

The nurse is reviewing their written documentation and notices an error. The nurse should correct the error by Select all that apply. A. drawing a line through the documentation, and writing the date, time, initials, and the word 'error.' B. using correction tape and write over the error. C. writing over the error in darker ink. D. completely black out the error with a black marker. E. discarding the documentation in the trash and starting over.

A. drawing a line through the documentation, and writing the date, time, initials, and the word 'error.' If the nurse makes an error in written documentation, the nurse should strikeout out the erroneous documentation, date, time, and initial the error. Finally, the nurse should put the word 'error' near the documentation, not over the erroneous text.

A nurse is caring for a child who has autism. Which of the following actions should the nurse take? SATA A. Withhold prescribed vaccines B. Have a family member bring in the child's favorite toys C. Dim the lights in the room D. Seclude the child for any misconduct E. Maintain consistent caregivers

B, C, E Clients with autism do well with an established routine; thus, having familiar objects from home is effective nursing care. Further, a low-stimulation environment with dim lights and low noise is more conducive for a client with autism. Finally, consistent caregivers may decrease the anxiety associated with change.

A nurse is instructing a client about prescribed risperidone. Which statements, if made by the client, require follow-up? A. "I should report any abnormal movements that I develop." B. "I will need to have weekly tests to monitor my white blood cells." C. "If I get muscle stiffness, I should notify my physician." D. "I will need to chew sugarless gum if I develop a dry mouth."

B. "I will need to have weekly tests to monitor my white blood cells." Risperidone is a second-generation antipsychotic used in delirium, schizophrenia, and some childhood disorders. Weekly white blood cell tests are not required with risperidone as this is appropriate for an individual receiving clozapine.

The nurse is performing community health screenings. A client tells the nurse that they smoke two packs a day of cigarettes and have smoked for six years. The nurse should document this finding as how many pack years? A. 3.5 pack years B. 3 pack years C. 12 pack years D. 6 pack years

C. 12 pack years Pack-years are calculated by multiplying the number of packs smoked per day by the years the client has smoked. Pack-years (PY) = number of packs of cigarettes per day (P) x number of years of smoking (Y) In this client, twelve is the correct amount of pack-years. The client has smoked two packs of cigarettes for six years (PY = two packs x six years = twelve pack-years).

The nurse is performing a health assessment on a newborn. Which assessment finding would lead the nurse to suspect cystic fibrosis? A. Steatorrhea B. Hyperhidrosis C. Meconium ileus D. Barrel chest

C. Meconium ileus Meconium Ileus is frequently the first sign of cystic fibrosis in a newborn. Meconium ileus is a small bowel obstruction that occurs when the infant's first stool is thicker and stickier than usual, causing a blockage in the ileum. Often, it presents within a few hours of birth with bilious vomiting as soon as feedings are initiated. Abdominal distension may be present. Some infants may manifest with just delayed passage of meconium rather than acute symptoms of obstruction. Meconium peritonitis may occur if there is perforation and may manifest with abdominal tenderness, fever, and shock.

The nurse is caring for a client at the first prenatal visit. The primary healthcare provider (PHCP) has prescribed testing for syphilis. The nurse anticipates which laboratory testing? A. Brain Natriuretic Peptide (BNP) B. Comprehensive Metabolic Panel (CMP) C. Complete Blood Count (CBC) D. Rapid Plasma Reagin (RPR)

D. Rapid Plasma Reagin (RPR) An RPR is a common screening test for syphilis infections. This test is often confirmed with a fluorescent treponemal antibody absorption (FTA-ABS) test. A BNP test is utilized to assist in the diagnosis of heart failure. A CMP is testing that may detect problems with the liver or any other electrolyte abnormalities. A CBC is testing that may reveal disorders associated with blood dyscrasias.

The nurse is giving discharge instructions to a client recently diagnosed with vaginitis. Which of the following instructions should the nurse include? A. Use oral contraceptives during sexual intercourse. B. Practice regular douching. C. Abstain from eating yogurt. D. Wear loose-fitting clothing and cotton underwear.

D. Wear loose-fitting clothing and cotton underwear. Clients are encouraged to wear loose-fitting clothing and cotton underwear, avoid tight pants and thongs, and avoid using tampons to facilitate ventilation and improve circulation.

The nurse is reviewing the laboratory results of assigned clients. Which of the following results would require immediate follow-up? Select all that apply. A. Creatinine 2.7 mg/dl for a client receiving vancomycin. B. Hemoglobin A1C of 6.9% for a client with diabetes mellitus. C. Platelet count of 152,000 mm3 for a client receiving methotrexate. D. Potassium 3.1 mEq/dl for a client receiving bumetanide. E. Calcium 11.2 mg/dL for a client receiving hydrochlorothiazide.

A, D, E

You are assessing a 9-month-old infant in the clinic. Which of the following findings requires follow up? Select all that apply. A. Infant sits up with the help of mom B. Infant is rolling over from front to back C. Infant holds a cube in the palm of his hand and closes his fingers around it D. Infant cannot bring toys to their mouth

A. Infant sits up with the help of mom D. Infant cannot bring toys to their mouth At 7 months old, the infant should be able to sit up without any support. At 4 months of age, the infants should have developed the fine motor skill of bringing objects to their mouths.

The nurse is caring for a newborn immediately following birth. Which of the following actions by the nurse will prevent radiant heat loss in the newborn? A. Drying the newborns skin with a towel B. Placing the newborn on a padded, covered surface C. Using warmed, humidified oxygen D. Positioning the bassinet away from windows

D. Positioning the bassinet away from windows Radiant heat loss may occur if the infant is placed near air conditioner vents or drafts. The infant's warmth is lost to the cooler object in this type of heat loss. This will occur despite the surrounding (ambient) air will not fix this problem. The nurse must remove the source of the radiant heat loss, not adjust the air temperature.

The nurse is teaching a group of students about using reminiscence therapy. Which statements should the nurse include in the teaching? Select all that apply. A. This approach helps support self-esteem B. This is an effective intervention in a group setting C. This intervention focuses on looking forward D. Establishing future goals is important part of this intervention E. Reminiscing is a way to express personal identity

A, B, E Reminiscence helps support self-esteem by having an individual look back on past accomplishments and positive life experiences. This strategy may be used one-on-one or in a group setting, facilitating rapport building with other individuals. Finally, reminiscence is a way for an individual to express their personal identity by reflecting on past accomplishments (college work, occupations, marriage, etc.).

The nurse is caring for a client who has developed retinal detachment. Which of the following actions should the nurse take first? A. Instruct the client to restrict activity B. Establish a vascular access device C. Review the client's current medications D. Educate the client about topical eye ointments

A. Instruct the client to restrict activity A retinal detachment is an ocular emergency. The client moving may hasten the detachment. It is important to inform the client to restrict their activity, and the nurse should apply an eye patch to the affected eye.

An 11-week pregnant client is complaining to the nurse about her hemorrhoids. The nurse understands that hemorrhoids occur because of pressure on the rectal veins from the bulk of the growing fetus. All of the following are measures to alleviate hemorrhoid pain, except: A. Instruct the client to use mineral oil to soften her stools. B. Rest in a side-lying position daily. C. Increase the client's fiber and water intake. D. Apply a cold compress to the area.

A. Instruct the client to use mineral oil to soften her stools. Mineral oil is contraindicated in pregnancy as it decreases nutrient absorption in the mother. Sleeping in a side-lying position removes the weight of the fetus on the superior and inferior vena cava, promoting venous return and decreasing venous pressure. Increasing fiber and water intake promote the formation of bulkier stools. Preventing constipation and relieving rectal pain. Cold compresses relieve pain by vasoconstriction of the hemorrhoids.

The nurse is caring for a client with an acute exacerbation of Bell's palsy. Which of the following prescriptions would the nurse anticipate? SATA A. Prednisone B. Donepezil C. Pyridostigmine D. Valacyclovir E. Topiramate

A. Prednisone D. Valacyclovir Bell's palsy classically causes facial nerve paralysis. It is usually idiopathic. However, etiologies such as herpes simplex virus may be present. Exacerbations of Bell's palsy are treated with corticosteroids (prednisone, choice A) and antivirals (valacyclovir, choice D). Corticosteroids decrease facial nerve inflammation, and antivirals address the possible underlying viral etiology.

The nurse is reviewing the laboratory results of a patient scheduled for surgery. Which of the following should be reported to the primary health care provider (PHCP)? A. Glycosylated hemoglobin (HbA1c) of 7.2% B. International Normalized Ratio (INR) of 3.5 C. Hematocrit (Hct) of 42% D. Blood urea nitrogen (BUN) level of 5

B. International Normalized Ratio (INR) of 3.5 An INR of 3.5 seconds is elevated and needs to be reported because the client may bleed. NORMAL RANGE 2 - 3

When assessing a 2-year-old patient for potential neglect. Which of the following signs should the nurse assess for? SATA A. Height and weight B. Bruising C. Developmental milestones D. Temperature

A, C The nurse should assess the child's height and weight to evaluate for potential neglect. A child who has been neglected will likely fall behind the growth and development of other children their age. Their height and weight should be plotted on the growth chart specific to their age and sex to determine where they fall. If they are steadily falling behind, it could be a physical sign of their neglect (Choice A). A child who has been neglected will likely fall behind in both the growth and development of other children their age. For example, developmental milestones that the average two-year-old should achieve include: knowing the names of body parts, saying 2-4 word sentences, building towers of 4 or more blocks, kicking a ball, running, and walking up/downstairs.

The nurse is teaching a 57-year-old client about screening for colorectal cancer. Which of the following information should the nurse include? A. "It is recommended that colon cancer screening with a colonoscopy should begin at age 45." B. "It is recommended that colon cancer screening with a colonoscopy should begin at age 70." C. "It is recommended that colon cancer screening with a colonoscopy should begin at age 40." D. "It is recommended that colon cancer screening with a colonoscopy should begin at age 65."

A. "It is recommended that colon cancer screening with a colonoscopy should begin at age 45." The nurse should inform the client that a colonoscopy should begin at age 45. Current screening guidelines state that colon cancer screening with a colonoscopy should begin at age 45 unless known risk factors exist. Screening for colon cancer is a form of secondary prevention.

After talking to her family, an elderly client says that she wants to change the living will she wrote two weeks ago. The nurse's most appropriate reply would be: A. "You can only change your living will a year after it is formulated." B. "Let me see if I can find someone to help you." C. "You can only make changes to your will after 3 weeks." D. "Let's call your lawyer first and see what he thinks."

B. "Let me see if I can find someone to help you." It is the nurse's responsibility to be the client's advocate. She should be responsible for finding someone that can help the client with her request.

The nurse is caring for a client with the following clinical data. Which prescription would the nurse request from the primary healthcare provider (PHCP) based on the clinical data? Select all that apply. See the exhibits. HPI: the client was found disoriented upon arrival and in acute respiratory distress. The client's caregiver noted that the prescribed medications had not been taken for several days. Medical history include hypertension, diabetes mellitus, congestive heart failure, and arthritis. Client Assessment: Bounding peripheral pulses, normotensive, crackles in the lung fields, tachypnea, jugular venous distention, and abdominal distention Diagnosis: Pulmonary edema and Acute decompensated HF A. Albuterol B. Hydrocortisone C. Diltiazem D. Nitroglycerin E. Furosemide

D. Nitroglycerin E. Furosemide Pulmonary edema secondary to acute decompensated heart failure (ADHF) is a medical emergency and requires rapid treatment. Vasodilators such as nitroglycerin help decrease preload and afterload, reducing the heart's workload. This medication is often combined with a loop diuretic such as furosemide or bumetanide to decrease volume. If vasodilators or loop diuretics are prescribed, close blood pressure monitoring is essential. Albuterol would be unnecessary and harmful for a client with pulmonary edema and ADHF. This would be useful for a client experiencing bronchoconstriction, such as an asthma exacerbation. The assessment for this client revealed crackles in the lung fields - not wheezes. Hydrocortisone is a steroid and would be unhelpful in the management of ADHF. This medication may be detrimental as this medication leads to fluid retention. Diltiazem is a calcium channel blocker and is grossly contraindicated in ADHF because of its negative inotropic effects.

While on day seven of antibiotic therapy, a 7-month-old infant develops oral thrush. Nystatin drops, 2 mL (200,000 units) four times daily, is prescribed by the infant's health care provider (HCP) for the thrush. Which nursing consideration should be implemented when administering this medication? A. Administer the medication with water B. Administer this medication through a nipple C. Give the medication with food D. Place 1 mL of the medication in each side of the infant's mouth

D. Place 1 mL of the medication in each side of the infant's mouth For nystatin to be effective, the medication should come into contact with the infected area. Nystatin drops are dispensed with a calibrated dropper to allow easier administration in young children. Administering half of the dose into each side of the mouth increases the likelihood the infected area has come into contact with the medication. Specifically, when administering this medication, use the calibrated dropper to place one-half of the dose (i.e., 1 mL (100,000 units)) in each side of the infant's mouth. Additionally, avoid providing oral intake to the infant for a minimum of 5 to 10 minutes following the administration of nystatin.

A client is currently experiencing bradycardia, low blood pressure, and dizziness. Which of the following does the nurse expect to be ordered? A. Defibrillation B. Digoxin C. Monitor the client closely D. Prepare patient for transcutaneous pacing

D. Prepare patient for transcutaneous pacing The normal heart rate in an average adult is between 60 to 100 beats per minute. A heart rate less than 60 beats per minute is referred to as bradycardia. It is accomplished by delivering pulses of electric current through the patient's chest, stimulating the heart to contract.

Which of the following indicators would most likely signify to the nurse that a patient with dementia is in pain? A. Rubbing a body part B. Facial droop C. Falling asleep D. A relaxed body position

A. Rubbing a body part Vocalizations, facial grimaces, bracing, rubbing, restlessness, and vocal complaints are behaviors in patients with dementia who cannot accurately express their pain. A critical component in evaluating pain is the knowledge of the person's normal behavior and interactions with others. This information is often best provided by family, who can answer questions about typical mood and behavior, body posture, life-long history of pain, and response to pain medications.

The emergency department nurse is caring for a client with an abdominal aortic aneurysm at risk of rupturing. The nurse will anticipate the primary healthcare provider (PHCP) to prescribe A. esmolol. B. dexamethasone. C. heparin. D. pantoprazole.

A. esmolol. For a client with a suspected ruptured (or rupturing) abdominal aortic aneurysm, tight blood pressure control is essential. Having tight blood pressure control decreases the pressure on the aneurysm. Esmolol is a beta-blocker and will exert antihypertensive effects. For a client with an unstable abdominal aortic aneurysm, the nurse should provide close monitoring of their vital signs and adequate pain control.

The nurse has received a prescription for tenofovir and emtricitabine. The nurse understands that this medication is used to treat A. multiple sclerosis. B. human immunodeficiency virus (HIV). C. Parkinson's disease. D. Guillain-Barré syndrome.

B. human immunodeficiency virus (HIV). Tenofovir and emtricitabine are antiretrovirals indicated in the prevention and treatment of HIV infection. This combination of medication aims to decrease the viral load (VL) and increase the CD4/CD8 count.

The nurse is speaking with her patient who is undergoing chemotherapy treatment. The patient states, "My friend beat cancer using complementary therapies; I think I should try that too." Which of the following responses from the nurse is most appropriate? A. "Complementary therapies are not safe with your chemotherapy." B. "I would be desperate if I had cancer too." C. "Let us go get your healthcare provider so that we may discuss it with him." D. "Tell me more about what you mean when you say complementary therapies."

D. "Tell me more about what you mean when you say complementary therapies." This is the most therapeutic statement. Effective communication always begins with an "open" statement. It addresses the question asked by the client and will lead to further discussion. The nurse should explore what therapies the client is interested in talking about first, so that she may better help the client when discussing the therapies with the healthcare provider. C: The healthcare provider always needs to be aware of complementary therapies that the client is considering, but this should not be the nurse's first response.

The nurse is caring for a patient who has recently had a femoral vein catheter placed. The nurse would be most correct in advising the patient to do which of the following? A. Refrain from drinking more than 500 mL per day B. Perform toe touch stretches in bed every morning C. Refrain from sitting up more than 45 degrees D. Remove the dressing if it becomes itchy

C. Refrain from sitting up more than 45 degrees Patients who have undergone a femoral vein catheter should refrain from sitting up more than 45 degrees because this could kink the catheter, thus interfering with treatment.

The nurse is caring for a client scheduled for an amniocentesis. Which of the following statements would require follow-up? Select all that apply. A. "This test may tell me the gender of my baby." B. "I will receive intravenous (IV) sedation for this test." C. "I may have cramping after this procedure." D. "I may be given a medicine to stimulate contractions." E. "The results will tell me how my baby will handle labor."

B, D, E hese statements are false and require follow-up. Amniocentesis is an ultrasound-guided test used in the detection of fetal abnormalities. Under ultrasound guidance, a thin needle is inserted into the amniotic sac to remove a sample of amniotic fluid. The fluid is then sent for analysis. Amniocentesis does not require intravenous sedation (choice B). The client will not be given medication to stimulate contractions for the amniocentesis procedure (choice D). Ureterotonic drugs (oxytocin challenge) are administered in a contraction stress test (CST), not amniocentesis. Once again, a CST will determine how the fetus will handle labor, not an amniocentesis (choice E). These statements require follow-up counseling and education to correct the client's understanding.

You are a registered nurse who is performing the role of a case manager in your hospital. You have been asked to present a class to newly employed nurses about your role, your responsibilities, and how they can collaborate with you as the case manager. Which of the following is a primary case management responsibility associated with reimbursement that you should include in this class? A. The case manager's role includes the organization of wide performance improvement activities. B. The case manager's role includes complete, timely, and accurate documentation. C. The case manager's role in terms of the clients' being at the appropriate level of care. D. The case manager's role in terms of contesting denied reimbursements

C. The case manager's role in terms of the clients' being at the appropriate level of care. A failure to ensure the appropriate level of care jeopardizes reimbursement. For example, care in an acute care facility will not be reimbursed when the client's current needs can be met in a subacute or long-term care setting. RN case managers have a primary case management responsibility associated with reimbursement because they are responsible for ensuring the patient is cared for at the appropriate level, consistent with medical necessity and current patient needs.

You are caring for a client in the step-down unit who tells you that they are an active member of the Seventh-Day Adventist church. When their breakfast tray comes up, you see the following items. Knowing the religious dietary preferences of these clients, which items should the nurse remove from the breakfast tray? SATA A. Coffee B. Bacon C. Scrambled eggs D. Pancakes

A. Coffee B. Bacon Members of the Seventh-Day Adventist church are not permitted to consume alcohol or caffeinated beverages. Due to this dietary preference, the nurse should remove the coffee from the client's breakfast tray. Furthermore, Seventh-Day Adventists are usually lacto-ovo vegetarians, and pork is avoided for those who consume meat. Therefore, the nurse should remove the bacon from the breakfast tray.

Ergonomically designed chairs are best designed to provide support to which region of the spine? A. The cervical spine B. The thoracic spine C. The lumbar spine D. The sacral spine

C. The lumbar spine Ergonomically designed chairs are commonly designed with a primary focus on providing lumbar spine support. Although the chairs often provide some level of support to various levels of the spinal column, the lumbar spine is the most common region for back pain to occur and therefore is the spinal region ergonomically designed chairs routinely support. Each curve of the spine (including lumbar) is shown in the image below.

The nurse is observing unlicensed assistive personnel (UAP) care for assigned clients. Which of the following actions by the UAP would require the nurse to intervene? Select all that apply. A. While helping the client with an active range of motion, the UAP flexes and extends the client's elbow. B. Obtains orthostatic blood pressure by having the client stand first. C. Places the cane on the unaffected side of a client who had a stroke. D. Provides a hot foot soak for a client with diabetes mellitus. E. Obtains a urine culture from an indwelling urinary catheter.

A, B, D, E A: When supervising a UAP, the nurse should intervene if the UAP is flexing and extending the client's elbow as that is not an active range of motion. The UAP doing the exercise for the client would be considered a passive range of motion B: The correct sequence is supine, sitting, and standing when obtaining orthostatic blood pressures D: Neuropathy is a common manifestation in diabetic clients. Loss of sensation in the feet resulting from diabetic neuropathy may impair the client's ability to remove the feet despite the heat damage. E: UAPs may not perform any tasks involving sterility. This includes aspirating urine from an indwelling catheter's tubing using a sterile syringe. UAP can collect urine specimens from the urine bag for other tests.

The nurse is planning care for a client with a borderline personality disorder. The nurse recognizes that the client will likely demonstrate which defense mechanism? SATA A. Splitting B. Sublimination C. Altruism D. Projection E. Conversion

A, D Severe impairments in functioning characterize borderline personality disorder. Its major features are patterns of marked instability, impulsivity, identity or self-image distortions, unstable mood, and unstable interpersonal relationships. Splitting is a hallmark manifestation of this disorder in which an inability to view both positive and negative aspects of others as part of a whole, results in viewing someone as either a wonderful person or a horrible person. Projection is also a cardinal defense mechanism for this disorder in which an individual unconsciously rejects emotionally unacceptable features and attributes them to others.

The nurse is teaching a client about newly prescribed doxycycline. Which of the following statements, if made by the client, would require further teaching? SATA A. "I should take this medication with milk or cheese." B. "If I develop foul-smelling diarrhea I should contact my doctor." C. "I need to wear sunscreen outdoors while taking this medication." D. "I can stop this medication when I feel better." E. "I should take this medication on an empty stomach."

A, D These statements are incorrect and require follow-up. ➢ Premature discontinuation of antibiotics leads to therapeutic failure. Therefore, all antibiotics must be continued for the entire course, not when the symptoms abate. ➢ Doxycycline absorption may decrease when the client takes it with calcium. ➢ The client should be instructed not to take this medication with calcium-rich foods, dairy products, or antacids containing calcium. The client should take this medication on an empty stomach.

The nurse is reviewing the client's intake and output for the twelve-hour shift The client consumed three eight-ounce cups of water. The client received 0.9% saline at 70 mL/hr. The client received 250 mL of azithromycin for a bacterial infection. The client received 2 mL of 4 mg morphine sulfate that was diluted with 5 mL of saline. When calculating the total intake for the client, the nurse should document how many mL? A. 1817 mL B. 1815 mL C. 1810 mL D. 1800 mL

A. 1817 mL One cup = 240 mL x 3 cups = 720 mL 70 mL/hr x 12 hours = 840 mL Azithromycin = 250 mL Morphine = 2 mL + 5 mL saline = 7 mL 1817 mL total fluid intake

The nurse is caring for assigned clients. Which of the following clients should the nurse identify is at the highest risk for falling? A. 88-year-old admitted with a chest tube secondary to pneumothorax and has a history of dementia. B. 44-year-old admitted with heart failure, has a peripheral IV, and receiving IV furosemide. C. 33-year-old admitted with cholecystitis, has a peripheral IV, and is receiving IV hydromorphone. D. 28-year-old admitted with bacteremia, is receiving intravenous fluids via central line, and is diaphoretic.

A. 88-year-old admitted with a chest tube secondary to pneumothorax and has a history of dementia. This client has advanced age, has a medical device that impedes their mobility, and has cognitive impairments (delirium and dementia). Thus, all these risk factors make this client at a very high risk for falls.

The nurse is observing a newly hired nurse insert a nasogastric tube (NGT). Which action by the newly hired nurse requires follow-up? A. Advances the tube during the client's inspiration. B. Hands the client a cup of water and straw. C. Positions the client's head-of-bed at 90 degrees. D. Washes the client's bridge of nose with soap and water.

A. Advances the tube during the client's inspiration. This observation requires follow-up because it will likely enter the respiratory tract if the nasogastric tube ( NGT) is advanced as the client takes a breath. The preferred method is gently advancing the NGT each time the client swallows until the desired length is reached. One can feel the characteristic tug on the tube as the epiglottis closes during swallowing. During the advancement of the tube, if the client begins coughing or becomes cyanotic, the nurse should pull the tube back until the client breathes normally again. Cyanosis and severe coughing during tube insertion can indicate accidental positioning of the tube in the respiratory tract ( trachea and bronchi).

The nurse is reviewing laboratory data for a client with epilepsy taking prescribed valproic acid (VPA). The client's VPA level is 40 mcg/mL. Which action should the nurse take next? A. Evaluate the client for non-adherence. B. Instruct the client to skip the next scheduled dose. C. Assess the client for VPA toxicity. D. Document the result as within normal limits.

A. Evaluate the client for non-adherence. The therapeutic VPA level is 50-125 mcg/mL. A VPA level of 40 mcg/mL is considered sub-therapeutic and requires follow-up as the client is at risk of seizure. VPA is indicated in preventing seizures, treatment for bipolar disorder, and migraine headache prevention. The most common adverse effects of VPA include nausea, vomiting, blood dyscrasias, hair loss, and metabolic syndrome. The liver enzymes should be monitored while a client takes VPA as hepatic injury may occur.

The nurse in the ICU is using the Critical-Care Pain Observation Tool (CPOT) to evaluate the patient's pain. The patient was in a motor vehicle accident two days ago; he sustained a flail chest and fractured femur. He is intubated and on a mechanical ventilator. When using the CPOT, the nurse understands that the best indicator of the patient's pain is: A. Facial expression B. Body movements C. Compliance with the ventilator D. Muscle tension

A. Facial expression Facial expression is the best indicator of the patient's pain since this is often the first change the nurse might notice and is least likely to be under the control of the patient. Muscle tension is the second-best indicator of the patient's pain. In the Critical Care unit, anxiety is one of the most common issues and the evaluation of pain is often problematic. The CPOT allows the critical care nurse to evaluate a patient who may not be verbal or unable to identify their level of pain consciously. The nurse assesses each of the behaviors in the CPOT with a score of 0 to 2. The "best" score that indicates minimal pain is 0 and a maximum score of 8 equals the worst pain. C. Gelinas developed this pain scale in 2006.

The nurse in the surgical ward cares for a client who has just undergone a procedure for a Kock pouch as a treatment for his bladder cancer. The initial nursing interventions for this patient would include: A. Monitor urine output through the pouch; checking the ostomy pouch for leaks; taking note of the size, shape, and color of the stoma. B. Talking to the client's family and updating them about the client's status. C. Teaching the client about stoma care and skincare. D. Irrigating the ureteral catheters as needed.

A. Monitor urine output through the pouch; checking the ostomy pouch for leaks; taking note of the size, shape, and color of the stoma. The nurse should monitor the urine output and report if the volume is less than 0.5 ml/kg/hr or no output for more than 15 minutes. Checking for leaks makes sure that the skin under the pouch is not irritated. Noting the characteristics of the stoma gives baseline information regarding the stoma's appearance. Following the procedure, a stoma site is usually hyperemic (red or pink). Any changes in the stoma site's color from reddish/pink to cyanotic/dusky may indicate impairment of arterial blood supply (ischemia). If cyanosis is noted, the nurse must notify the physician immediately. A cyanotic stoma is a medical emergency and, if not addressed, can lead to necrosis.

Which of the following are potential complications of dexamethasone administration? Select all that apply. A. Risk of infection B. Hypotension C. Hyperlipidemia D. Hypoglycemia

A. Risk of infection C. Hyperlipidemia Like with any steroid, when a patient is receiving dexamethasone, they are at higher risk for infection. They should be monitored closely to evaluate for WBCs trending upwards, increased CRP, becoming febrile, and other indicators of disease (Choice A). Hyperlipidemia is a side effect of dexamethasone. Dexamethasone causes the development of cholesterol and can increase triglycerides as well as low-density lipoproteins (LDLs) (Choice C).

In the ICU, the low-pressure ventilator alarm goes off. The nurse attends to the patient, checks the ventilator, and attempts to determine the cause of the signal. She is unable to identify the cause. Which action would the nurse initiate next? A. Give oxygen to the patient. B. Assess the client's vital signs. C. Ventilate the client manually. D. Start CPR immediately.

B. Assess the client's vital signs. Checking the client's vital signs is the priority action among the options given. If the patient is unstable and struggling for air and if no problem has been found with a ventilator, the nurse needs to disconnect the patient from the ventilator and manually ventilate until the problem can be identified. The nurse should assess the patient's level of consciousness, use of accessory muscles, and chest wall movements; determine whether bilateral breath sounds are present as well as evaluate the heart rate and SpO2.

Which of the following is the first nursing action for a patient experiencing dyspnea? A. Remove pillows from under the patient's head B. Elevate the head of the bed C. Elevate the foot of the bed D. Take the patient's blood pressure

B. Elevate the head of the bed Elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm more room and facilitating lung expansion. Dyspnea is difficult or labored breathing. A dyspneic patient usually has rapid, shallow respirations. Because of this "shallow" breathing, ventilation is affected, and Co2 accumulates. Dyspneic clients can often breathe better in an upright position. When standing or sitting, gravity pulls the abdominal organs down and away from the diaphragm, creating more space in the thoracic cavity. This allows the lungs more room for expansion and allows the client to take more air with each breath ( better ventilation).

The nurse is caring for a client with an ectopic pregnancy. The primary healthcare provider (PHCP) recommends medical treatment over surgical treatment. The nurse anticipates a prescription for which medication? A. Terbutaline B. Methotrexate C. Methylergonovine D. Nifedipine

B. Methotrexate Methotrexate (MTX) may be used to medically treat an ectopic pregnancy that has not ruptured, and the woman is hemodynamically stable. Methotrexate is a folic acid antagonist and may be given a variety of routes. Terbutaline and nifedipine are tocolytics employed in the prevention of preterm labor. Methylergonovine is an ergot alkaloid indicated in the treatment of postpartum hemorrhage. None of these medications are indicated for an ectopic pregnancy.

The nurse cares for an infant undergoing a surgical repair of a total anomalous pulmonary venous return tomorrow. The doctor has talked to the parents and obtained consent. The mother tells the nurse, "I'm not so sure about this. What if my baby dies?" The nurse's most appropriate response is: A. Explain the procedure to the mother. B. Notify the surgical team and have them come back to speak with the mother again. C. Reassure the mother that everything will go as planned. D. Tell the mother that because she has already signed the consent, she cannot change her mind now.

B. Notify the surgical team and have them come back to speak with the mother again. The nurse has identified that the mother has concerns about the surgery, so it is her responsibility to notify the surgical team and have them come back to speak with the mother.

You are caring for a client with a terminal disease and this person has asked for a curandero. What should you do? A. Refer the family to a religious shop with Bibles and other holy books. B. Refer the family and the client to a member of the clergy who may be able to help. C. Give the client a candle then close all of the shades and blinds to darken the room. D. Arrange for the client to go to a religious service to get this special blessing.

B. Refer the family and the client to a member of the clergy who may be able to help. You would refer the family and the client to a member of the clergy who may be able to help. A curandero is a healer who is believed to have supernatural powers that can cure the sick. These powers are derived from the fact that many believe that illnesses and diseases occur as the result of evil spirits and a curse from God.

A 23-year-old college student seeks medical help at the infirmary complaining of severe fatigue. She reports exertional dyspnea, and her skin appears pale. Aplastic anemia is suspected. Laboratory values reflect anemia, and the client is advised for a bone marrow biopsy. The client refuses to sign the consent and states, "Come on, just get the doctor to give me a transfusion and let me go. Spring break begins this weekend, and I'm leaving for Florida." The nurse's most significant concern at this time would be: A. The possibility that the client may contract an infection from being exposed to large crowds during spring break. B. The client does not understand the full impact of her condition. C. The client may need a transfusion before leaving for spring break. D. The causative agent needs to be identified and the treatment should be started.

B. The client does not understand the full impact of her condition. The most significant concern at this point is the fact that the client does not fully grasp the gravity of her condition. She must be educated and be allowed to verbalize her feelings about her situation.

A patient admits that he thinks he has a problem with drinking too much alcohol. The nurse talks with the patient about substance abuse and the adverse effects of alcoholism. Which best describes how personal engagement with a patient is an active method of change? A. The patient will understand the information more than if it were presented electronically. B. The patient will be less likely to be litigious toward the healthcare facility. C. The patient will more likely desire change after connecting with another person. D. The patient will feel as if he has made a new friend.

C. The patient will more likely desire change after connecting with another person. Feeling connected to another person gives a sense of belonging and acceptance. The patient will be more likely to change after joining with another person. Change is necessary when a patient is exhibiting behaviors that are harmful to himself or others. Change can be implemented in many ways, but personal engagement, or talking, working with, and spending time with another person, can be useful in getting the message across about the high-risk behavior. With personal engagement, the patient is more likely to desire change because he feels a connection with another person.

The nurse is caring for a 14-year-old who is scheduled to go to the OR for an appendectomy later in the day. What is the nurse's role in obtaining informed consent before surgery? SATA A. Explain the procedure to the patient in terms they can understand. B. Review the risks and benefits of the surgery. C. Validate that the parents are competent to provide consent for the patient. D. Witness the signature on the informed consent

C, D Since the patient is 14-years-old, they are a minor and their parents will be responsible for signing informed consent. The nurse is accountable for validating that the parents are competent to provide consent for the patient (Choice C). The nurse will serve as the witness for the informed consent. This is one of the primary responsibilities of the nurse when a patient is getting a procedure and signing a consent. The other primary responsibility will be to serve as the patient's advocate and ensure that the parents have received sufficient information to make an informed decision. If they have not, the nurse must call the surgeon to return and speak further with the parents (Choice D).

A nurse is conducting pre-operative teaching to a client who will undergo surgery in 1 week. Which response by the client would prompt the nurse to give additional teaching? A. "Aspirin can possibly cause bleeding even after surgery." B. "Aspirin can adversely affect my clotting ability" C. "I should stop aspirin one day prior to my surgery." D. "It is important that I talk to my physician about the possibility of stopping aspirin before the surgery."

C. "I should stop aspirin one day prior to my surgery." Stopping Aspirin one day before surgery is not usually appropriate since platelet function would not recover enough in 1 day. Aspirin is an anti-platelet drug and can alter the platelet's ability to aggregate and may increase the risk of bleeding after surgery. usually stopped 5 to 7 days before the scheduled surgery but should be done as directed by the physician.

The nurse is teaching a client about the newly prescribed medication, epoetin alfa. Which of the following should the nurse include in the teaching? A. This medication will decrease your risk for infection. B. You may notice black tarry stools while on this medication. C. This medication may raise your blood pressure. D. Take this medication with food rich in Vitamin C.

C. This medication may raise your blood pressure. Epoetin alfa is an effective treatment for anemia secondary to chronic kidney disease. ➢ This medication is given parenterally, and the nurse should expect a therapeutic response of an increase in hemoglobin and hematocrit. ➢ Once the hemoglobin reaches 11 g/dl, the nurse should question further administration as higher hemoglobin levels have been implicated in causing myocardial infarction or stroke. ➢ The priority vital sign to monitor during the course of therapy is blood pressure.

The nurse is teaching a client about storing their prescribed insulin. Which statement, if made by the client, would indicate a correct understanding of the teaching? A. Opened vials of insulin may be kept in the freezer." B. "My opened vial of insulin is good for 45 days." C. "If I travel, I can keep a vial of insulin in my car." D. "Unopened vials of insulin may be stored in the refrigerator."

D. "Unopened vials of insulin may be stored in the refrigerator." Extra vials (unopened) of insulin may be stored in the refrigerator. Insulin should never be frozen or administered cold. Insulin should never be stored in the freezer. Insulin may be kept on ice but should not be allowed to freeze. Insulin should be discarded 28-days after it has been opened. Keeping a vial of insulin in the car is not recommended. Car temperatures vary greatly and will damage the effects of insulin. Do not inject insulin that is cold

A client is brought to the emergency department after a severe car accident. They need immediate surgery if their life is to be preserved. However, they are unconscious and unable to consent to the operation. Which of the following is the best action? A. Ask a friend who was with the client to sign the consent form. B. Attempt calling a family member to obtain consent. C. Call the on-staff nursing supervisor and request a court order for the surgery. D. Immediately transport the client to the operating department without obtaining consent.

D. Immediately transport the client to the operating department without obtaining consent. When delaying treatment to a client would result in severe injury or death, consent is not needed. The only other circumstance where treatment of adults does not require approval is if the client declines treatment.

The Registered Nurse is preparing a patient for a pneumonectomy. What teaching should the nurse discuss with the patient? A. Instruct patient to lie on the non-operative side following the procedure. B. Expect the remaining lung to return to normal function within 2-6 hours. C. Advise the patient to avoid coughing and make sure the nurse will use wall suction to clear secretions. D. Keep head of bed elevated at 30-45 degree angle post-procedure.

D. Keep head of bed elevated at 30-45 degree angle post-procedure. Keeping the head of the bed between 30-45 degrees will minimize respiratory efforts and facilitate recovery post-pneumonectomy. This intervention will also prevent post-pneumonectomy pulmonary edema. The patient should lie on the operative side and should have the head of the bed raised to 45 degrees as soon as awake. These positions minimize the gravitational effect on capillary pressure in the remaining lung.