CAT2DB

The nurse receives report for a group of adult clients. Which client will the nurse see first? 1. The client receiving treatment for osteomyelitis of the lumbar spine, with a white blood cell count of 22,000/mm3 (22 x 109/L).2. The client diagnosed with right-sided heart failure and 4+ pitting edema of the legs, ankles, and feet.3. The adult client with a pneumonia diagnosis, rhonchi clear with coughing, and oxygen saturation level of 93%.4. The client diagnosed with failure to thrive lying supine with a nasogastric tube feeding infusing.

1) The client's white blood cell count is elevated, which indicates an active infection from the osteomyelitis. There is no immediate airway, breathing, or circulation concerns. 2) There is no indication of acute distress in the client diagnosed with heart failure. 3) The client diagnosed with pneumonia clears rhonchi with coughing, and the oxygen saturation level is within normal limits. 4) CORRECT - The client diagnosed with failure to thrive and receiving a nasogastric tube feeding in the supine positions is at risk for aspiration. The head of the bed needs to be elevated 30 to 45 degrees during the tube feeding to reduce the risk of reflux and pulmonary aspiration. The position should be maintained for at least 1 hour post intermittent tube feeding and at all times for continuous tube feedings.

The nurse reviews care needs for assigned clients. Which client will the nurse assess first? 1. Client who had a vaginal hysterectomy 2 days ago and is reporting that the right calf is warm to touch.2. Client who received a dose of prescribed warfarin while receiving a heparin infusion.3. Client with chronic obstructive pulmonary disease who is using pursed-lip breathing.4. Client who had an abdominal aortic aneurysm repaired 10 hours ago and has bronchial breath sounds over the trachea.

The correct answer is 1 . You answered 1. 1) CORRECT - A warm calf might indicate a deep vein thrombosis. Having a hysterectomy is a risk factor for this health problem, which is a priority since it can be life-threatening if it becomes an embolus. 2) Oral warfarin is appropriate to provide to a client whose heparin infusion is being discontinued in a few days. There is no reason to assess this client first. 3) Pursed lip breathing prolongs exhalation and increases airway pressure. It is an appropriate breathing technique for a client with chronic obstructive pulmonary disease. There is no reason to assess this client first. 4) Bronchial breath sounds are considered normal over the trachea. There is no reason to assess this client first.

The nurse provides care to several clients. Which client will the nurse assess first? 1. Client with heart failure and reports substernal pain.2. Client who had laparoscopic bariatric surgery 1 hour ago and is sleeping in a semi-Fowler position.3. Client who had a left pneumonectomy 14 hours ago and is positioned on the left side.4. Client who had an appendectomy 10 hours ago and has vesicular breath sounds over peripheral lung fields.

The correct answer is 1 . You answered 1. 1) CORRECT - Clients with heart failure are at risk for a myocardial infarction, of which substernal pain is a symptom. Chest pain should be considered cardiac in origin until another cause can be ruled out. This client would be the priority. 2) The client recovering from bariatric surgery is in no acute distress and is in an appropriate position to improve breathing and decrease the risk for sleep apnea or other pulmonary complications, such as pneumonia or atelectasis. 3) The client recovering from a pneumonectomy is in no acute distress and is appropriately positioned to allow fluids to fill in the space formerly taken up by the lungs. 4) Vesicular breath sounds are considered normal.

The nurse evaluates the care provided to a client being treated for adrenal crisis. Which finding indicates to the nurse that treatment was successful? 1. Blood pressure of 115/86 mm Hg.2. Weight loss of 1 lb.3. 1+ pretibial edema.4. Urine output of 500 mL in the last 3 hours.

The correct answer is 1 . You answered 1. 1) CORRECT - Hypotension is a sign of adrenal insufficiency. This blood pressure is within normal limits, indicating that the client has responded successfully to treatment. 2) Weight loss indicates continuing loss of water and lack of adrenal hormones. 3) Edema is not seen in adrenal crisis. 4) The client is voiding slightly more than 166 mL/hour. At this rate, the client will lose 4000 mL of fluid in a 24-hour period. Elevated urine output indicates continuing lack of hormones. Urine output should decrease with treatment.

The nurse provides care for a client diagnosed with diabetic ketoacidosis (DKA). The nurse receives a prescription to transition the client from a regular insulin infusion to insulin glargine. Which action does the nurse take first? 1. Continue the insulin infusion for 1 to 2 hours after the glargine is started.2. Check the client's blood glucose every 30 minutes for 24 hours.3. Discontinue the insulin infusion as soon as the glargine is administered.4. Monitor the client closely for signs of seizure activity.

The correct answer is 1 . You answered 1. 1) CORRECT - Insulin glargine is a long-acting insulin that is given subcutaneously (SC). The onset of insulin glargine is 1 to 1.5 hours. Continuing the insulin infusion for 1 to 2 hours after the SC glargine has been administered allows for the long-acting insulin to begin to take effect before discontinuing the short acting (regular) insulin infusion and prevents hyperglycemia. 2) A client with DKA who is transitioning to insulin glargine will require less frequent blood glucose checks. This new prescription is a 24-hour insulin with no peaks. 3) Discontinuing the regular insulin infusion before the long-acting insulin glargine can take effect will lead to hyperglycemia. Insulin glargine has an onset of 1 to 1.5 hours. 4) A client with DKA who is transitioning to insulin glargine is stable and does not require monitoring for seizure activity.

The nurse delegates vital sign measurement to the nursing assistive personnel (NAP). Which statement provides the best information for the nurse to give when delegating this task? 1. "Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Let me know if anyone's systolic blood pressure is <100 or >160, heart rate <60 or >100, respiratory rate <12 or >20, temperature >100.50F (40.60C), or pulse oximetry <95%."2. "Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Report any readings outside the normal ranges."3. "Please obtain blood pressure, heart rate, respiratory rate, temperature, pain rating, and pulse oximetry. Let me know if anyone's systolic blood pressure is <100 or >160, heart rate <60 or >100, respiratory rate <12 or >20, temperature >100.50F (40.60C), pain level >5/10, or pulse oximetry <95%."4. "Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Let me know if anyone's blood pressure is <100 or >160, heart rate <50, respiratory rate <12, temperature >100.50F (45.60C), or pulse oximetry <93%."

The correct answer is 1 . You answered 1. 1) CORRECT - Safe principles of delegation include giving specific instructions including reporting parameters to ensure clear communication. 2) The nurse needs to provide details about the task. 3) The NAP should not perform pain assessments. 4) Parameters are given, but 'blood pressure' does not specify systolic or diastolic. Additionally, a heart rate of <60 should be reported, there is no upper limit provided for the heart rate, and there is no upper limit provided for the respiratory rate.

The nurse plans to delegate a simple dressing change to nursing assistive personnel (NAP). The nurse checks with the charge nurse before delegating the task. Which right of delegation does the nurse follow in this situation? 1. Right task.2. Right circumstance.3. Right person.4. Right direction.

The correct answer is 1 . You answered 1. 1) CORRECT - The nurse needs to determine first if the task is in the NAP's scope of practice before delegating. 2) Right circumstance is ensuring the client is stable to have a task delegated. 3) Right person is ensuring the NAP has the skills and ability to perform the delegated task. 4) Right direction is ensuring the nurse has provided appropriate communication to the NAP.

The nurse provides care for a client diagnosed with diabetes mellitus who is hospitalized with acute pyelonephritis. Which collaborative problem is a priority for the team to address? 1. Urosepsis.2. Hydronephrosis.3. Hyperglycemia.4. Flank pain.

The correct answer is 1 . You answered 1. 1) CORRECT — Acute pyelonephritis is an upper urinary tract infection that can rapidly lead to urosepsis and septic shock. This is a priority. There is a high mortality rate if not caught early. 2) Hydronephrosis is commonly associated with obstructive renal conditions, such as renal calculi, and is not priority. 3) Hyperglycemia can result from acute infections and needs continued assessment, but it is not the priority. 4) Flank pain may occur with acute pyelonephritis and needs further assessment. It is a symptom and the not priority.

The nurse provides care to a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation will the nurse implement for this client? 1. Contact.2. Droplet.3. Airborne.4. Reverse.

The correct answer is 1 . You answered 1. 1) CORRECT — Contact isolation involves the use of barrier protection (such as gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. 2) Hands of personnel continue to be the principal mode of transmission for MRSA. The organism is limited to the sputum in this example. Precautions are taken if contact with the patient's sputum is expected. 3) Hands of personnel continue to be the principal mode of transmission for MRSA. If the organism is limited to the sputum, precautions are taken if contact with the client's sputum is expected. 4) Reverse isolation is used to protect an immune-compromised client. The client in this example requires isolation to protect others.

The nurse uses a paper-based documentation system to write a client care note. The previous nurse's documentation appears incomplete. Which action should the nurse take next? 1. Draw a line through any empty space and continue documenting.2. Mark out the previous nurse's entry, initial, and continue documenting.3. Complete an incident report for the nurse manager to review.4. Call the previous nurse at home and ask if the documented entry is complete.

The correct answer is 1 . You answered 1. 1) CORRECT — Empty spaces should not be left because it allows others to document in that space in an incorrect manner. 2) The nurse has no reason to delete the other nurse's documentation. 3) Incomplete documentation does not require an incident report. 4) The nurse who did the documenting should come in to complete it as soon as possible, but calling the nurse to ask if the documentation is complete does not solve the issue.

After being told the diagnosis of terminal cancer, a client says "Why is God doing this to me?" Which nursing diagnosis does the nurse include in the plan of care for this client? 1. Spiritual distress.2. Ineffective coping.3. Anticipatory grieving.4. Readiness for enhanced spiritual well-being.

The correct answer is 1 . You answered 1. 1) CORRECT — The client's questions about actions that might have angered God to cause the illness indicate a conflict with spirituality. 2) The client has just learned of the diagnosis. The immediate response to the news is unlikely caused by the inability to cope. 3) Anticipatory grieving is grieving the loss of someone or something before it occurs. The client is not demonstrating this behavior. 4) Readiness for enhanced spiritual well-being is indicated by a sense of peace or contentment and comfort with one's spirituality. The client is not demonstrating this behavior.

The nurse provides care for a client who is experiencing an Addisonian crisis. The nurse anticipates administering which medication? 1. Hydrocortisone.2. Metformin.3. Potassium chloride.4. Glimepiride.

The correct answer is 1 . You answered 1. 1) CORRECT- An Addisonian crisis is characterized by hyposecretion of adrenal hormones (e.g., mineralocorticoids, glucocorticoids, androgens). This condition may lead to hyponatremia, dehydration, decreased blood volume and shock, hyperkalemia, metabolic acidosis, arrhythmias, hypoglycemia, and insulin shock. Administration of corticosteroid medications, such as hydrocortisone, is indicated in the treatment of Addisonian crisis. 2) Hypoglycemia often occurs during Addisonian crisis. Metformin, which is used to lower blood sugar, is contraindicated in the treatment of Addisonian crisis. 3) Hyperkalemia may occur during Addisonian crisis. Administration of potassium chloride is contraindicated in the treatment of Addisonian crisis. 4) Hypoglycemia is expected with Addisonian crisis. Since glimepiride lowers blood sugar, administration of this medication is contraindicated during Addisonian crisis.

The nurse provides care to a client of Asian descent having surgery later in the day. Which action will be most appropriate for the nurse to take when assessing this client? 1. Observe the client's use of eye contact.2. Look directly at the client when interacting.3. Avoid eye contact with the client.4. Ask a family member about the client's cultural beliefs.

The correct answer is 1 . You answered 1. 1) CORRECT— Observation of the client's use of eye contact will be most useful in determining the best way to communicate effectively with the client. 2) Looking directly at the client may be appropriate, depending on the client's individual cultural beliefs. 3) Avoiding eye contact may be appropriate, depending on the client's individual cultural beliefs. 4) The nurse should assess the client, rather than asking family members about the client's beliefs.

The nurse plans to teach an adolescent female, newly diagnosed with systemic lupus erythematosus (SLE), about measures to prevent complications. Which information does the nurse include in the teaching session? 1. Apply sunscreen daily.2. Protect against warm weather by wearing light clothing.3. Take aspirin to control joint pain.4. Avoid intake of calcium-rich foods.

The correct answer is 1 . You answered 1. 1) CORRECT— Sunscreen prevents rashes and photosensitivity in the client with SLE. 2) Clothing should be layered to protect against cold weather. 3) Aspirin is not recommended. Large doses may be required to be effective. 4) Encourage calcium-rich foods, particularly in adolescent females receiving corticosteroid therapy.

The nurse provides care for a client who comes to the clinic for follow-up blood pressure monitoring. The nurse auscultates the client's breath sounds. The nurse hears wheezing over all lung fields. Which medication in the client's current medication list does the nurse suspect as a cause of the wheezing? 1. Atenolol.2. Indapamide.3. Metformin.4. Atorvastatin.

The correct answer is 1 . You answered 2. 1) CORRECT - Beta-adrenergic blocking agents, such as atenolol, may cause bronchospasm (airway narrowing), which produces wheezing on auscultation of the client's breath sounds. 2) Indapamide, a thiazide diuretic used to treat hypertension, has not been associated with wheezing. 3) Metformin, a biguanide antidiabetic agent, has not been associated with wheezing. 4) Atorvastatin, a lipid-lowering agent, has not been associated with wheezing.

The nurse observes a wrench taped to the head of the bed of a client who is currently in surgery. Which device does the nurse expect this client to have when returning to the care area? 1. Halo vest.2. Buck traction.3. External fixation device.4. Passive range of motion device.

The correct answer is 1 . You answered 2. 1) CORRECT — A wrench is needed to open the halo vest in the event the client needs cardiopulmonary resuscitation. 2) A wrench is not used to set up or maintain Buck traction. 3) A wrench is not used to maintain or adjust the pins on an external fixation device. 4) A wrench is not used to set up or maintain a passive range of motion device.

The parent of a 5-year-old client reports to the nurse that the child has difficulty settling down at bedtime. Which intervention should the nurse recommend to the parent? 1. Allow the child to select a stuffed animal to sleep with.2. Push the bedtime back thirty minutes to help the child grow tired.3. Allow the child to read books until tired.4. Turn off the night-light at bedtime.

The correct answer is 1 . You answered 3. 1) CORRECT - Allowing children choices and finding items that allow them to feel more comfortable going to bed can increase comfort. 2) Pushing back a bedtime can lead to sleep deprivation. The parent should maintain a consistent time for bed. 3) The child may not grow tired for several minutes. It is important to set limits on the number of books and be consistent to reduce bedtime stress. 4) A night-light can help increase comfort, especially if the child has a fear of the dark. The night-light should be low wattage.

Prior to the beginning of a site survey, the charge nurse advises the nurse to deny any knowledge of a recent sentinel event if asked by the surveyor. Which action will the nurse take? 1. Notify the unit manager.2. Notify the medical director.3. Tell the charge nurse about being uncomfortable lying to the surveyor.4. Tell the surveyor the nurse is not allowed to talk to them.

The correct answer is 1 . You answered 3. 1) CORRECT - Always follow the direct chain of command. If asked about the event by the surveyor prior to speaking with the unit manager, do not lie. Nurses have a professional and ethical responsibility to tell the truth in all situations. 2) The medical director is not the nurse's direct supervisor. 3) Confronting the charge nurse will not resolve the issue and will likely increase the tension of an already stressful situation. 4) If asked about the event by the surveyor prior to speaking with the unit manager, do not lie. Nurses have a professional and ethical responsibility to tell the truth in all situations.

While preparing medications, the nurse documents that a client is allergic to penicillin. Which medication will the nurse question before administering to this client? 1. Cefazolin.2. Doxycycline.3. Ciprofloxacin.4. Clarithromycin.

The correct answer is 1 . You answered 3. 1) CORRECT - Cefazolin is a cephalosporin that is contraindicated in clients who have an allergic reaction to penicillin. 2) Doxycycline is a tetracycline antibiotic and is safe to give to a client with an allergy to penicillin. 3) Ciprofloxacin is a quinolone antibiotic and is safe to give to a client with an allergy to penicillin. 4) Clarithromycin is a macrolide antibiotic and is safe to give to a client with an allergy to penicillin.

The nurse provides care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which finding indicates to the nurse that the client is experiencing cor pulmonale? 1. Jugular vein distension.2. Whitish frothy sputum.3. Finger clubbing.4. Chest tightness.

The correct answer is 1 . You answered 3. 1) CORRECT — Jugular vein distention indicates cor pulmonale (right-sided heart failure). 2) A whitish frothy sputum may indicate left-sided, not right-sided, heart failure. 3) Finger clubbing is not a specific sign of cor pulmonale. This finding may be seen in COPD, indicating chronic hypoxemia. 4) Chest tightness is not a specific sign of cor pulmonale.

The nurse provides care for a client diagnosed with chronic obstructive pulmonary disease (COPD). The client is having difficulty clearing lung secretions. Which technique is best for the nurse to teach the client to perform? 1. Huff cough.2. Postural drainage.3. Chest physiotherapy.4. Pursed-lip breathing.

The correct answer is 1 . You answered 3. 1) CORRECT — The huff cough is a forced expiratory technique that mobilizes secretions from the small airways for easier expectoration. 2) Postural drainage is a series of body positions used to drain accumulated fluid from the different lung lobes. 3) Chest physiotherapy includes percussion and vibration to loosen pulmonary secretions. 4) Pursed-lip breathing is a technique to control dyspnea.

The nurse provides care to a client of Native American descent who has traditional beliefs about health and illness. Which action is most appropriate for the nurse to take? 1. Ask if cultural healers should be contacted.2. Avoid asking questions unless initiated by the client.3. Obtain further information about the client's cultural beliefs from the family.4. Explain the usual hospital routines for mealtimes, care, and family visits.

The correct answer is 1 . You answered 3. 1) CORRECT— Because the client has traditional Native American health care beliefs, it is appropriate for the nurse to ask whether the client would like a visit by a shaman or other cultural healer. 2) There is no cultural reason for the nurse to avoid asking the client questions because they are necessary to obtain health information. 3) The client, rather than the family, should be consulted about personal cultural beliefs. 4) Hospital routines should be adapted, as much as possible, to the client's preferences rather than expecting the client to adapt to the hospital schedule.

The nurse notes that at 2200, a client is scheduled to receive 10 units of insulin glargine. The client also has a "now" prescription of 7 units of regular insulin. Which approach will the nurse use to administer these medications? 1. Prepare two separate injections.2. Administer the regular insulin first.3. Mix the medications in one syringe.4. Administer the insulin glargine first.

The correct answer is 1 . You answered 3. 1) CORRECT— Insulin glargine should not be mixed with any other insulin. This client will need two separate injections. 2) There is no evidence to support that the regular insulin should be administered before insulin glargine. 3) Insulin glargine should not be mixed with any other medication. 4) There is no evidence to support that insulin glargine should be administered before the regular insulin.

A client of Italian descent reports pain. The client falls asleep before the nurse can complete a pain assessment. Which conclusion will the nurse make about the client's pain? 1. The client has a low threshold for pain.2. Someone else gave the client medication.3. The client is faking pain to seek attention.4. The pain resolved without medication.

The correct answer is 1 . You answered 4. 1) CORRECT - People of this culture tend to verbalize discomfort and pain. The pain is real to the client, and the client may need medication upon waking up. 2) The nurse would check the medical record to verify whether any medication had been given to the client for pain prior to drawing conclusions. 3) Believing that the client is faking pain to seek attention is an inappropriate conclusion. 4) It would be appropriate to wait until the client wakes up to see if there is still a report of pain.

The nurse provides care for a client who reports waking up with heartburn every night. Which client statement requires the nurse to provide further education to the client? 1. "I eat 3 meals a day."2. "I do not eat 2 hours before going to bed."3. "I will work on losing weight."4. "I will elevate the head of my bed 6 to 12 inches."

The correct answer is 1 . You answered 4. 1) CORRECT - The client should eat smaller, more frequent meals to prevent over distention of the stomach. The client needs further teaching. 2) The client should avoid eating 2 to 3 hours before bed. 3) Weight loss can help reduce reflux. 4) Lifting the head of the bed can help reduce reflux. The use of additional pillows can also help.

The nurse provides care to a school-age child suspected of being sexually abused. Which assessment data best supports this suspicion? 1. Difficulty walking.2. Bald spots on scalp.3. Fear of parents.4. Welts on buttocks.

The correct answer is 1 . You answered 4. 1) CORRECT - This finding, along with bloody or stained underclothes and pain, itching, or swelling in the genital area, are indicators of sexual abuse. 2) Bald spots on the scalp are more likely associated with physical abuse. 3) Fear of a parent is more likely associated with physical abuse. 4) Welts or bruises are more likely associated with physical abuse.

The nurse provides care for a client who was in a car accident as the result of falling asleep at the wheel. The client reports only being able to sleep 3 to 4 hours a night over the past month, due to stress. The client reports waking up frequently during the night. Which outcome is most appropriate for the nurse to include in the client's plan of care? 1. Client will verbalize a plan to implement a sleep promoting program within the next week.2. Client will fall asleep with less difficulty over the next 2 weeks.3. Client will achieve a more normal sleep pattern within 2 to 4 weeks.4. Client will achieve an improved sense of adequate sleep over the next 4 weeks.

The correct answer is 1 . You answered 4. 1) CORRECT - This measurable outcome requires the client to make specific adjustments more quickly to deal with the stress that is causing the disturbed sleep patterns. The client needs a shorter deadline to make the changes. 2) This outcome is not measurable because it does not provide a specific plan for the client to follow over the 2 weeks. Because the insomnia resulted in a car accident, a more aggressive approach is needed. 3) This outcome is not measurable because it does not provide a specific plan for the client to follow over the 2 to 4 weeks. Because the insomnia resulted in a car accident, a more aggressive approach is needed. 4) This outcome is not measurable because it does not provide a specific plan for the client to follow over the 4 weeks. Because the insomnia resulted in a car accident, a more aggressive approach is needed.

The nurse provides care for a client diagnosed with a seizure disorder. Which client care activity does the nurse delegate to a nursing assistive personnel (NAP)? (Select all that apply.) 1. Place respiratory equipment at the bedside.2. Remove harmful objects from the client's reach.3. Apply foam padding around the bed rails.4. Time the duration of seizure activity.5. Teach the client about antiseizure medications.

The correct answer is 1, 2, 3 . You answered 1, 2, 3. 1) CORRECT — Settting up essential supplies and equipment at the bedside is within the scope of practice for NAPs. 2) CORRECT — Assisting the nurse in maintaining a safe care environment is within the scope of practice for NAPs. 3) CORRECT — Applying padding around the bedside is within the scope of practice for NAPs. 4) Only the nurse can do assessments such as timing the duration of a seizure activity. 5) Teaching about medication is the nurse's responsibility.

The nurse educator plans an educational program to review transmission-based precautions with unit staff. Which substance is included on the list of potential sources of infection as outlined by the Centers for Disease Control and Prevention (CDCP)? (Select all that apply.) 1. Blood.2. Vaginal secretions.3. Sputum.4. Non-intact skin.5. Sweat.

The correct answer is 1, 2, 3, 4 . You answered 1, 2, 3, 4. 1) CORRECT - Blood is considered potentially infectious as outlined by the CDCP. 2) CORRECT- Vaginal secretions are considered potentially infectious as outlined by the CDCP. 3) CORRECT- Sputum is considered potentially infectious as outlined by the CDCP. 4) CORRECT - Non-intact skin, whether or not blood is visible, is considered potentially infectious as outlined by the CDCP. 5) Sweat is the only bodily secretion that is not considered infectious as outlined by the CDCP.

The nurse notes that a client diagnosed with Parkinson disease moves slowly, has difficulty dressing, and experiences bowel and urinary incontinence. Which intervention is appropriate for this client? (Select all that apply.) 1. Provide an elevated toilet seat.2. Make modified clothing without buttons available.3. Transfer to a skilled nursing facility.4. Arrange for gait training.5. Lower the dose of Parkinson medications.

The correct answer is 1, 2, 4 . You answered 2, 3, 4. 1) CORRECT — An elevated toilet seat makes it easier to get on and off the toilet. 2) CORRECT — Modified clothing that does not use buttons helps facilitate timely toileting. 3) There is no indication that a transfer to a skilled nursing facility is needed at this time. 4) CORRECT — Gait training assists with mobility and may help the client reach the bathroom on time. 5) It is not within the scope of practice for a nurse to change the dose of a client's medication.

A client may be developing side effects from an anticholinergic medication. Which question does the nurse ask the client to further assess for side effects to this medication? (Select all that apply.) 1. "Do you have blurred vision?"2. "Does your mouth feel dry?"3. "Do you have needles and pins sensation?"4. "When was the last time you voided?"5. "When was your last bowel movement?"

The correct answer is 1, 2, 4, 5 . You answered 1, 2, 3, 4, 5. 1) CORRECT - Anticholinergics cause dilatation of pupils and vision may be blurred. 2) CORRECT - Anticholinergics cause xerostomia or dryness of mouth. 3) Anticholinergics do not cause paresthesia. 4) CORRECT - Anticholinergics can cause urinary hesitancy and retention. 5) CORRECT - Anticholinergics can reduce bowel tone and motility and constipation may occur.

Which activities can the nurse delegate to a nursing assistive personnel (NAP) for a client in the postanesthesia unit (PACU)? (Select all that apply.) 1. Obtaining vital signs.2. Assisting with positioning.3. Suctioning the oropharynx.4. Accompanying client transfer.5. Measuring urine output.

The correct answer is 1, 2, 4, 5 . You answered 1, 2, 3, 4, 5. 1) CORRECT — NAPs can obtain vital signs in PACU and report the findings to the nurse. 2) CORRECT— NAPs can help the nurse turn and reposition clients. 3) Oropharyngeal suctioning is the responsibility of the nurse. 4) CORRECT — NAPs can accompany and assist in the transfer of clients from PACU. 5) CORRECT — NAPs can measure urine output and report the findings to the nurse.

The nurse reviews care required for assigned clients. Which task will the nurse delegate to nursing assistive personnel (NAP)? (Select all that apply.) 1. Empty a client's indwelling urinary catheter bag.2. Adding up intake and output for each client.3. Adding 'acute pain' nursing diagnosis to the care plan.4. Check and document vital signs.5. Set up a client's supper tray.

The correct answer is 1, 2, 4, 5 . You answered 1, 2, 4, 5. 1) CORRECT - Emptying a catheter bag is an appropriate task for NAP. 2) CORRECT - Adding up and documenting intake and output is an appropriate task for NAP. 3) NAP cannot complete tasks associated with the nursing process. The care plan needs to be addressed by the nurse. 4) CORRECT - Obtaining and documenting vital signs is an appropriate task for NAP. 5) CORRECT - Setting up the client's supper tray is an appropriate task for NAP.

The nurse provides care for a client diagnosed with head trauma. The client experiences a seizure. Which actions will the nurse implement? (Select all that apply.) 1. Keep the client in a side-lying position.2. Monitor the client's ability to maintain a patent airway.3. Arouse the client frequently to assess neurological status.4. Provide environmental stimuli to help the client awaken.5. Place suction equipment and an oral airway at the client's bedside.

The correct answer is 1, 2, 5 . You answered 2, 3, 5. 1) CORRECT — Placing the client in a side-lying position allows drainage of oral secretions while the client regains the ability to swallow, cough, and gag. 2) CORRECT — The client has lost the ability to protect the airway and is at risk of aspiration. 3) The client needs to be allowed to rest in the postictal state of seizure activity. Continuous arousal will agitate the client and may cause complications. 4) Noise, lights, and disruptions are harmful to the client who has head trauma and to the client with seizures. This client requires a reduction of stimuli for healing. 5) CORRECT — The client is currently at risk for aspiration and loss of airway, as well as being at risk for additional seizure activity.

The nurse plans for the discharge of a client with Parkinson disease. Which outcome is appropriate for collaboration between the nurse and the physical therapist? (Select all that apply.) 1. Maintain physical strength and mobility.2. Bladder training to increase bladder capacity.3. Optimal use of extremities in performing activities.4. Proper use of ambulatory assistive devices.5. Monitor skin for alterations in integrity.

The correct answer is 1, 3, 4 . You answered 1, 2, 3, 4. 1) CORRECT - A physical therapist can design a personal exercise program to strengthen and stretch specific muscles. 2) Bladder training does not increase bladder capacity. 3) CORRECT - A physical therapist can help optimize independence with activities. 4) CORRECT - A physical therapist can provide expert advice on the proper use of ambulatory assistive devices. 5) Monitoring for skin breakdown is a nursing assessment.

The nurse provides care for a client receiving chemotherapy and radiation who has several bruises. Which nursing intervention will be part of the care plan to prevent further injury? (Select all that apply.) 1. Shave with an electric razor.2. Allow the client to be up without supervision as tolerated.3. Avoid enemas and suppositories.4. Administer stool softeners.5. Place an indwelling catheter.

The correct answer is 1, 3, 4 . You answered 1, 2, 4. 1) CORRECT — An electric razor reduces the risk of being cut. 2) Supervise out of bed activity to prevent injury. 3) CORRECT — Avoid inserting objects into body to reduce the risk of trauma to rectal mucosa. 4) CORRECT — Stool softeners reduce the risk of trauma to rectal mucosa and anal tears from hard stool. 5) Avoid inserting objects into the body. If catheterization is essential, use the smallest catheter possible.

The nurse reviews care needs for a shift assignment. Which client task will the nurse delegate to newly hired nursing assistive personnel (NAP)? (Select all that apply.) 1. Client diagnosed with a fractured hip being discharged tomorrow.2. Client receiving blood after a total abdominal hysterectomy that was admitted to the care area 10 minutes ago.3. Client diagnosed with a fractured tibia who had surgery 2 days ago.4. Client diagnosed with cellulitis to the lower leg.5. Client who had a resection of the prostate this morning with a 3-way indwelling urinary catheter for irrigation.

The correct answer is 1, 3, 4 . You answered 3, 4. 1) CORRECT - The client being discharged in a day is stable enough for NAP to provide care. 2) Recovering from major abdominal surgery and receiving blood are not characteristics of a stable client and should not be assigned to NAP. 3) CORRECT - The client recovering from surgery two days ago is stable and can be assigned to NAP. 4) CORRECT - The client with a leg wound is stable and can be assigned to NAP. 5) The client recovering from prostate resection with bladder irrigation is not stable and should not be assigned to NAP.

The nurse provides care for a client in the end stages of dying. The family asks the nurse how they can provide comfort to the client in the client's final hours. Which intervention will the nurse recommend the family implement? (Select all that apply.) 1. Reading to the client.2. Encouraging the intake of fluid.3. Giving a gentle massage.4. Holding the client's hand.5. Talking to the client.

The correct answer is 1, 3, 4, 5 . You answered 1, 3, 4, 5. 1) CORRECT — Reading to the client can provide comfort. 2) Pushing food and fluid is not recommended at the end of life. It is a normal part of dying for the client to stop eating and drinking. 3) CORRECT — Gentle massage can provide comfort for the client. 4) CORRECT — Holding the client's hand so the client knows someone is there can be comforting to the client. 5) CORRECT — Talking to the client, even if the client can no longer respond, can be comforting to the client.

The nurse teaches a class on suicide prevention to high school students. Which risk factor is accurate with regard to suicide in adolescent clients? (Select all that apply.) 1. Possessions that are given to friends.2. A low grade point average.3. Statements like, "I may not be around anymore."4. Access to a gun at home.5. Frequent thoughts of suicide.

The correct answer is 1, 3, 4, 5 . You answered 3, 4, 5. 1) CORRECT - There is a correlation between this action and a high risk of suicidal tendencies or thoughts. 2) There is no specific correlation between a low grade point average and an increased risk for suicide. 3) CORRECT - There is a correlation between these types of statements and a high risk of suicidal tendencies or thoughts. 4) CORRECT - There is a correlation between easy access to a gun and an increased risk for suicide. 5) CORRECT - There is a correlation between frequent thoughts of suicide and an increased risk for suicide.

The nurse provides care to a client with an epidural catheter for pain control with fentanyl after spinal fusion surgery. Which action will the nurse include when providing post-operative care to this client? (Select all that apply.) 1. Perform peripheral neurovascular checks every 2 hours.2. Ambulate the client around the hallway.3. Assess for bowel and bladder distention.4. Keep the client at nothing by mouth status.5. Monitor client for nausea and vomiting.

The correct answer is 1, 3, 5 . You answered 1, 2, 3, 5. 1) CORRECT - Frequent neurovascular assessment is essential for clients with an epidural catheter, as it allows for early detection of sensory-motor impairment. 2) Ambulation is inappropriate for a client with an epidural catheter because of a risk for catheter displacement. 3) CORRECT - Assessment of bowel and bladder function is part of best practice guidelines for clients with epidural catheters. 4) It is not necessary to keep the client at nothing by mouth status because of an epidural catheter. 5) CORRECT - Nausea and vomiting are common side effects of opioids such as fentanyl.

The nurse works with an LPN/LVN on a team nursing unit. Which task is most appropriate for the nurse to delegate to the LPN/LVN? (Select all that apply.) 1. Administering an intramuscular injection.2. Administering a blood pressure medication intravenously.3. Administering oral medications.4. Referring a client to a long-term care facility.5. Obtaining a capillary blood glucose.

The correct answer is 1, 3, 5 . You answered 1, 2, 3, 5. 1) CORRECT — An LPN/LVN can administer an intramuscular injection. 2) The nurse will need to administer an intravenous blood pressure medication because these drugs require close monitoring after administration. 3) CORRECT — An LPN/LVN can administer oral medications. This is an appropriate task for the LPN/LVN. 4) The nurse oversees the client's care and should be making the referral to the long-term care facility. 5) CORRECT— An LPN/LVN can obtain a capillary blood glucose.

The nurse teaches the client about skin care during radiation therapy. The nurse includes which teaching point? (Select all that apply.) 1. Use lukewarm water and gentle soap to bathe.2. Rub the affected skin with lotion as needed.3. Wear loose-fitting clothing made from natural fibers.4. Shave the area using non-alcohol-based products.5. Wear sunblock when engaging in outdoor activities.

The correct answer is 1, 3, 5 . You answered 1, 2, 3, 5. 1) CORRECT — Hot water and harsh or fragrant soaps irritate skin; therefore, the nurse teaches this client to use lukewarm water and a gentle soap when bathing. 2) Friction and use of typical lotions can be irritating; therefore, this is not recommended. 3) CORRECT— Tight clothing and artificial fibers can cause skin damage; therefore, the nurse recommends the use of loose-fitting clothing made with natural fibers. 4) The nurse should teach the client to avoid shaving the irradiated area. 5) CORRECT — Damaging effects of radiation are compounded by the effects of sun; therefore, the nurse teaches the client to use sunblock when engaging in outdoor activities.

The home health nurse documents that the client with osteoarthritis understands proper inclusion of assistive devices when the client makes which statement? (Select all that apply.) 1. "I started using an electric can and jar opener."2. "There is a counter near the tub that I grab for balance."3. "I just bought the television remote with large keys."4. "I purchased a pair of shoes with larger laces."5. "We converted the doorknobs in the house to levers."

The correct answer is 1, 3, 5 . You answered 1, 3, 5. 1) CORRECT - Use of an electric can and jar opener saves the joints from excessive force caused by a regular can opener or opening a jar by hand. 2) The client needs to install a bathtub grab bar for stability. A counter top cannot be fully grasped and may be a slick surface. 3) CORRECT - A remote with larger keys is good for those with diminished eyesight, but is also great for people with difficulty with fine motor movements of the hands and fingers. 4) Shoes with larger laces still require the fine motor movements of tying, which can be difficult with osteoarthritis. A better choice would be shoes with velcro or shoes that slip on. 5) CORRECT - Changing the door knobs to levers allows the client to push the handle up or down without having to grab and twist a knob.

The nurse plans to teach a local community group about chronic obstructive pulmonary disease (COPD). Which information does the nurse include? (Select all that apply.) 1. Uncontrolled COPD can lead to cardiac disease.2. Asthma in childhood leads to COPD later in life.3. Cigarette smoking is the leading COPD risk factor.4. More females are affected by COPD than males.5. Co-existing illness may cause COPD exacerbation.

The correct answer is 1, 3, 5 . You answered 1, 3, 5. 1) CORRECT — Right-sided heart failure results from uncontrolled COPD. 2) There is no evidence that childhood asthma leads to COPD in adults. 3) CORRECT — Cigarette smoking is a major risk factor for COPD. 4) More males than females are affected by COPD. 5) CORRECT — Heart failure, gastroesophageal reflux disease (GERD), and pneumonia may lead to COPD exacerbation.

The nurse educator teaches a group of staff nurses about measures to prevent the transmission of healthcare-associated infections when providing care for clients. Which intervention does the nurse educator include in the teaching? (Select all that apply.) 1. Clean stethoscopes between clients.2. Empty bedpans as soon as possible.3. Limit fresh flowers in client rooms.4. Use personal protective equipment (PPE)5. Perform handwashing and alcohol-based sanitizing.

The correct answer is 1, 4, 5 . You answered 1, 2, 3, 4, 5. 1) CORRECT - Cleaning stethoscopes between clients is a practical method for preventing infections. 2) Although this is a good practice, emptying bedpans as soon as possible does not prevent healthcare-associated infections. 3) Although this is a good practice, limiting fresh flowers in client rooms does not prevent healthcare-associated infections. 4) CORRECT - Using personal protective equipment (PPE) is part of standard precautions, when warranted, and helps prevent infections. 5) CORRECT - Performing handwashing and alcohol-based sanitizing is a major method for preventing infections.

The nurse provides care to an older adult client in the hospital. Which factor increases this client's risk of falling? (Select all that apply.) 1. Glare from bright lights.2. Hypertension.3. Obesity.4. Medication interactions.5. Previous falls.

The correct answer is 1, 4, 5 . You answered 1, 3, 4, 5. 1) CORRECT - Vision changes associated with aging can be exacerbated by the glare from bright hospital lights. This can cause difficulty differentiating things that can create tripping hazards. 2) Orthostatic hypotension, not hypertension, increases the risk for falling. 3) Obesity is not identified as a reason for increased falls. 4) CORRECT - Medication interactions can cause drowsiness, decreased coordination, and orthostatic hypotension, which increase the risk of falling. 5) CORRECT - Previous falls can lead to fear and a loss of confidence when walking.

The nurse instructs a client being discharged about home oxygen therapy. Which client statement indicates that further teaching is needed? (Select all that apply.) 1. "I know I can turn up the rate of oxygen flow if I get short of breath."2. "I have a fire extinguisher and smoke detector in my home."3. "My family has posted several signs that say 'Oxygen is in use'."4. "My family members who smoke promise not to smoke in my room."5. "We have a gas fireplace so I won't be breathing smoke from burning logs."

The correct answer is 1, 4, 5 . You answered 4, 5. 1) CORRECT - The client should not adjust the flow rate on the oxygen concentrator. Oxygen is a medication and only the health care provider can adjust the rate. 2) It is important for the client to have a fire extinguisher and smoke detectors in the home. 3) Signs that explain that oxygen is in use are important to post in the home. 4) CORRECT - Smoking is not allowed anywhere in the home of a client receiving home oxygen. 5) CORRECT - Gas stoves or heaters are a fire hazard in the home of a client receiving oxygen.

The nurse provides care for a client in bilateral limb restraints. Which action does the nurse take to ensure proper use? (Select all that apply.) 1. Provide education to the client before applying the restraints. 2. Obtain an as-needed prescription from the health care provider.3. Assess for skin breakdown under the restraints every shift.4. Tie a quick release knot to the fixed portion of the bed frame.5. Remove restraints every 2 hours or as needed.

The correct answer is 1, 5 . You answered 2, 3, 4. 1) CORRECT - The nurse needs to provide education to both the client and client's family before applying restraints. They need to understand why restraints are being used and for how long they may be used for. 2) When writing an order for restraints, the health care provider must identify specifically why the restraint is being used, along with a specific time frame. Writing an as-needed order for restraints is prohibited. 3) The nurse needs to assess for skin breakdown under restraints at least every 2 hours. 4) Restraints should be tied using a quick-release knot. However, the knot should never be tied to a fixed portion of the bed frame. 5) CORRECT - Restraints should be removed every 2 hours to assess for skin breakdown and to allow the client to eat and/or drink.

The nurse assesses a client who is in labor. Which assessment findings does the nurse tell the client to expect in the latent phase of the first stage of labor? 1. Contractions occur at 2- to 4-minute intervals, lasting 50 to 60 seconds.2. Contractions occur at 5- to 30-minute intervals, lasting 10 to 30 seconds.3. Contractions occur at regular intervals, lasting 1 to 2 minutes.4. Contractions occur at 2- to 3-minute intervals, lasting 2 minutes.

The correct answer is 2 . You answered 1. 1) Contractions occurring at 2- to 4-minute intervals and lasting 50 to 60 seconds are seen in the active phase of labor. 2) CORRECT - Contractions occurring at 5- to 30-minute intervals and lasting 10 to 30 seconds are seen in the latent phase. 3) Contractions occurring at regular intervals and lasting 1 to 2 minutes are seen in the transition phase. 4) Contractions occurring at 2- to 3-minute intervals and lasting 2 minutes are seen in the transition phase.

The nurse encourages clients in a community population to attend a diabetes screening event scheduled at a local community center. Which level of intervention is the nurse advocating? 1. Primary prevention.2. Secondary prevention.3. Tertiary prevention.4. Health risk assessment.

The correct answer is 2 . You answered 1. 1) Primary prevention focuses on health promotion and prevention of illness or disease, not disease screening. 2) CORRECT— Secondary prevention focuses on screening to ensure early disease detection and prompt intervention. 3) Tertiary prevention focuses on preventing deterioration associated with disease and improving the client's quality of life, not disease screening. 4) Health risk assessment plays an important role in primary prevention, not disease screening.

A parent asks the nurse about the best time to begin toilet training a 22-month-old child. Which nursing response is most appropriate? 1. "When your child turns 2 years old."2. "When your child expresses interest in toilet training."3. "When you are ready to begin toilet training."4. "When your child turns 3 years old."

The correct answer is 2 . You answered 2. 1) A child's readiness is key to toilet training. The most common age of readiness is 2 1/2 to 3 years old. 2) CORRECT - Toilet training should begin when a child expresses interest. Physical readiness is determined by the child's recognition that urination or defecation just occurred. 3) Toilet training begins when the child is ready, not the parent. However, the parent has to be willing to spend the time with the child for success. 4) A child's readiness is key to toilet training. The most common age of readiness is 2 1/2 to 3 years old.

The nurse teaches a client about how yoga can control pain. Which client statement indicates to the nurse that the client understands the teaching? 1. "I will learn how to visualize images that can help me relax."2. "I will learn how to perform exercises to improve my circulation."3. "I will learn to control my physiological responses to pain."4. "I will use sound to help relieve my distress."

The correct answer is 2 . You answered 2. 1) A client can use guided imagery to visualize images and focus on relaxing to reduce pain. 2) CORRECT - A client can use yoga to learn how to perform exercises that will improve circulation, promote relaxation, and alleviate pain. 3) A client can use biofeedback to control physiological responses of the body, such as pain, using electronic equipment to evaluate specific responses. 4) A client can use music or other forms of sound to induce distraction and relaxation, thus reducing pain.

The visiting nurse notes that a client diagnosed with asthma is in the "red zone" of the peak flow meter system. Which action does the nurse take first? 1. Take a detailed medical history.2. Call the health care provider.3. Do a medication reconciliation.4. Repeat the peak flow meter test.

The correct answer is 2 . You answered 2. 1) A detailed history is not the priority. 2) CORRECT— The red zone (50% or below peak flow) of the peak flow meter system signals an emergent situation. 3) Medication reconciliation is not the priority. 4) If done correctly, the peak flow meter reading is accurate. Repeating it will waste time in an emergent situation.

The nurse assesses a client diagnosed with gestational hypertension (GH). Which finding is the priority for the nurse to report to the health care provider? 1. 1+ protein in the urine.2. A continuous headache.3. 2+ ankle edema.4. A weight gain of 2 lb. (0.9 kg) in the past week.

The correct answer is 2 . You answered 2. 1) A finding of 1+ protein in the urine needs further evaluation, but it is not as significant as a continuous headache. 2) CORRECT— A continuous headache, drowsiness, or mental confusion would indicate worsening of GH. These signs indicate poor cerebral perfusion and may be precursors of generalized seizures. It is a priority to report this finding to the health care provider. 3) Edema of feet and legs is common during pregnancy. However, edema above the waist does suggest GH. 4) A general recommendation is that women gain up to 4.4 lb. (2 kg) during the first trimester and approximately 1 lb. (0.44 kg) per week during the rest of the pregnancy. Although this weight gain exceeds the recommended amount, it would require further evaluation and is not as concerning as the continuous headache.

The nurse assists with a cardiac arrest for a client in ventricular fibrillation. Cardiopulmonary resuscitation is in progress and 1 mg of epinephrine was just given. The nurse is likely to give which medication next? 1. Magnesium.2. Amiodarone.3. Vasopressin.4. Atropine.

The correct answer is 2 . You answered 2. 1) Magnesium IV is given in torsades de pointes, not in v-fib. 2) CORRECT - Give amiodarone, an antiarrhythmic, after epinephrine in v-fib and v-tach. 3) Vasopressin is no longer indicated in cardiac arrest. 4) Atropine is no longer indicated in cardiac arrest, only in symptomatic bradycardia.

The nurse provides care for a client diagnosed with type 2 diabetes mellitus. The nurse anticipates that the client will be prescribed a second-generation sulfonylurea. Which medication in the hospital formulary belongs to this class of drugs? 1. Metformin.2. Glipizide.3. Repaglinide.4. Miglitol.

The correct answer is 2 . You answered 2. 1) Metformin, a biguanide, controls blood glucose levels in type 2 diabetes by inhibiting glucose production in the liver and increasing insulin sensitivity in body tissues. 2) CORRECT - Glipizide, a second-generation sulfonylurea, controls blood glucose levels in type 2 diabetes by stimulating pancreatic beta cells to secrete insulin. 3) Repaglinide, a meglitinide, controls blood glucose levels in type 2 diabetes by stimulating pancreatic insulin secretion. 4) Miglitol, an alpha-glucosidase inhibitor, controls blood glucose levels in type 2 diabetes by delaying absorption of complex carbohydrates in the intestine. This delays carbohydrate digestion after meals slowing glucose entry into the systemic circulation.

The nurse plans to delegate a task to a new nursing assistive personnel (NAP). The nurse discovers that the NAP has never performed the task and changes the assignment. Which right of delegation does the nurse follow in this scenario? 1. Right supervision.2. Right person.3. Right circumstance.4. Right direction.

The correct answer is 2 . You answered 2. 1) Right supervision is providing appropriate monitoring, intervention if needed, and follow-up. The scenario indicates the NAP is not the right person for this task due to lack of experience. 2) CORRECT— The right person is choosing the correct personnel to complete the task. The NAP had not performed the task before, so the nurse decided to not delegate that task to the NAP. 3) Right circumstance is using the appropriate client and the setting to determine if the delegated task is appropriate. This scenario indicates the NAP is not the right person for this task due to lack of experience. 4) Right direction is giving a clear, concise description of the delegated task. This scenario indicates the NAP is not the right person for this task due to lack of experience.

The nurse provides care for a client diagnosed with emphysema. The client becomes anxious and confused. What is the first action the nurse should take? 1. Increase the client's oxygen flow rate to 4 liters per minute.2. Encourage the client to do pursed-lip breathing.3. Assess the client's sodium level.4. Take the client's blood pressure.

The correct answer is 2 . You answered 2. 1) The client should receive low-flow oxygen (less than 3 liters per minute) to prevent carbon dioxide narcosis. 2) CORRECT — This prevents the collapse of the alveoli and helps the client control the depth and rate of breathing. 3) The confusion most likely is related to decreased oxygenation, not an electrolyte imbalance. 4) The confusion most likely is related to decreased oxygenation. Taking the blood pressure is not warranted.

Before delegating tasks to nursing assistive personnel (NAP), a new nurse asks the manager to explain "the right circumstance" of delegation. Which response will the manager make to the nurse? 1. "Delegating the right circumstance is ensuring the person you delegate to is capable of handling the delegated task."2. "Delegating the right circumstance is ensuring the client is stable."3. "Delegating the right circumstance is intervening when the person the task was delegated to is not doing the delegated task correctly."4. "Delegating the right circumstance is asking the person delegated if they completed the task assigned."

The correct answer is 2 . You answered 2. 1) The right circumstance is not ensuring that the person is capable of handling the delegated task. This statement describes the right person. 2) CORRECT - Client stability is a factor that nurses should consider when delegating tasks. If the client is not stable, the nurse should be monitoring the client more closely and minimize the number of tasks delegated for this client. 3) The right circumstance is not intervening when the task is being completed incorrectly by the person delegated to complete it. This statement describes the right supervision. 4) The right circumstance is not asking the person delegated to complete a task if the task was completed. This statement describes the right evaluation/follow up.

The nurse auscultates heart sounds in a school-age client. Where does the nurse place the stethoscope to listen to the aortic area of the heart? 1. Second left intercostal space.2. Second right intercostal space.3. Fifth intercostal space, left midclavicular line.4. Fifth right and left intercostal spaces.

The correct answer is 2 . You answered 2. 1) The second left intercostal space is the location of the pulmonic area of the heart. 2) CORRECT - The second right intercostal space is the location for auscultating the aortic area. 3) The fifth intercostal space at the left midclavicular line is the mitral area. 4) The fifth right and left intercostal spaces make up the tricuspid area.

The nurse ambulates the client using a four-point cane. The client is to ambulate the length of the hallway, but reports dizziness only a few steps from the bed. Which is the nurse's best action? 1. Perform an assisted fall with the client.2. Assist the client to sit back on the bed.3. Ask the client to take a few more steps.4. Call another nurse to bring a walker to the client.

The correct answer is 2 . You answered 2. 1) There is no indication that the client has had a syncopal episode, such as knee buckling, or is otherwise unable to continue moving as directed. 2) CORRECT - The client should be assisted back to bed and encouraged to take deep breaths until the dizziness passes. The nurse might also obtain a set of orthostatic blood pressures to include laying, sitting, and standing prior to attempting ambulation again. 3) The client may be on the verge of syncope and should not be pushed to take additional steps. 4) A walker will not help the client avoid a syncopal episode. The client may benefit from a walker with the next ambulation attempt, in addition to dangling the legs prior to standing.

The new graduate nurse notices that one of the other nurses has been sleeping on the unit during the night shift. The other staff members seem to have seen this nurse asleep, but they have said nothing. Which action does the new graduate nurse take? 1. Tell the nurse manager in the morning.2. Contact the nursing supervisor.3. Tell the nurse you have seen the sleeping and it needs to stop.4. Tell the nurse if you see the sleeping again, you will report it.

The correct answer is 2 . You answered 2. 1) Waiting to speak with the manager potentially puts clients at risk during the remainder of the shift. 2) CORRECT — Following the vertical chain of command without delay reduces client risk. 3) This action is confrontational and inappropriate. 4) This action is threatening and inappropriate.

A client who is pregnant asks the nurse what an elevated serum alpha-fetoprotein (AFP) level indicates. Which information does the nurse provide to the mother? 1. Gestational diabetes.2. A neural tube defect.3. Trisomy 21 (Down syndrome).4. Lack of lung maturity.

The correct answer is 2 . You answered 3. 1) A glucose tolerance test is used to diagnose gestational diabetes. 2) CORRECT— An elevated AFP level may indicate a neural tube defect, which is the most common birth defect in the United States. 3) A low AFP level may indicate Trisomy 21 (Down syndrome). 4) An amniocentesis is used to determine lung maturity.

The nurse reviews the daily lab results of four clients. Which client does the nurse delegate to the LPN/LVN to provide care? 1. Client with a brain natriuretic peptide (BNP) level of 300 pg/mL.2. Client with an erythrocyte sedimentation rate of 10 mm/h.3. Client with a C-reactive protein (CRP) level of 4 mg/L.4. Client with an international normalized ratio (INR) level of 8.0.

The correct answer is 2 . You answered 3. 1) An elevated BNP level indicates congestive heart failure and requires observation by the nurse. The normal value is less than 100 pg/mL. This client requires frequent assessment of breathing and circulation. 2) CORRECT - An elevated sedimentation rate indicates an inflammatory process. The normal value for males under 50 years is less than 15 mm/h. For males over 50 years, it is less than 20 mm/h. For females under 50 years, it is less than 25 mm/h. For females over 50 years, it is less than 30 mm/h. This client can be delegated to the LPN/LVN. 3) An elevated CRP indicates inflammation, tissue injury, infection, or atherosclerosis and follow up by the nurse. The normal CRP level is less than 1 mg/L. 4) The INR level monitors the effectiveness of warfarin. The therapeutic range is 2 to 3.5, based on the diagnosis and the reasons for taking warfarin. An elevated INR indicates that the warfarin dose is not therapeutic. The client is at high risk for bleeding and should be monitored by the nurse.

The nurse prepares discharge instructions for a client who speaks very little English and is recovering from an emergency appendectomy. Which nursing action best helps this client understand wound care instructions? 1. Asking if the client understands the instruction.2. Demonstrating the procedure and having the client return the demonstration.3. Asking an interpreter to replay the instructions to the client.4. Writing out the instructions and having a family member read them to the client.

The correct answer is 2 . You answered 3. 1) Clients may claim to understand discharge instructions when they do not actually understand. 2) CORRECT — When the client can repeat the action that was taught by the nurse, that best ensures that the client can perform wound care correctly at home. 3) An interpreter or family member may communicate verbal or written instructions inaccurately. 4) Family members are not considered appropriate and objective interpreters for clients.

The nurse provides care for a child who ingested an unknown substance. The client is unconscious with a respiratory rate of 10 breaths/min, pulse oximeter reading is 88%, and the heart rate is 160 beats/min. The nurse determines which nursing diagnosis is the highest priority for this client? 1. Decreased cardiac output.2. Ineffective breathing pattern.3. Ineffective tissue perfusion.4. Impaired cerebral tissue perfusion.

The correct answer is 2 . You answered 3. 1) Decreased cardiac output is not the highest priority in the scenario. Airway and breathing are higher priorities. 2) CORRECT—Ineffective breathing pattern is the highest priority and needs to be addressed first. 3) Ineffective tissue perfusion is not the highest priority in the scenario. The client must breathe effectively to have tissue perfusion. 4) Impaired cerebral tissue perfusion is not the highest priority in the scenario. Breathing is a higher priority than circulation.

The nurse notes that a client's heart rate decreases from 55 to 45 beats/min. Which action does the nurse take first? 1. Notify the health care provider (HCP).2. Determine if the client is lightheaded.3. Administer 0.5 mg of intravenous (IV) atropine. 4. Prepare for transcutaneous pacing.

The correct answer is 2 . You answered 3. 1) First determine if the client is symptomatic before notifying the HCP. 2) CORRECT - The priority action is for the nurse to determine if the client is symptomatic. 3) If the client is symptomatic, atropine 0.5 mg through the intravenous route is administered every 3 to 5 minutes up to a maximum dose of 3 mg. However, this is not the first action the nurse takes. 4) Pacing may be considered if bradycardia continues despite atropine therapy.

The nurse provides care for a client who takes digoxin for heart failure. Which finding is a priority for the nurse to communicate to the health care provider (HCP)? 1. Presence of 1+ edema in the ankles.2. Intermittent nausea and loss of appetite.3. Serum potassium level 3.8 mEq/L.4. Weight gain of 2 pounds in one week.

The correct answer is 2 . You answered 3. 1) The presence of 1+ edema in the ankles does not require immediate attention; however, this finding indicates the need for further assessment. 2) CORRECT - Nausea, anorexia, and vomiting are early signs of digitalis toxicity. It is a priority to communicate this data to the HCP. 3) A serum potassium level of 3.8 mEq/L is within the normal range of 3.5 to 5.0 mEq/L. 4) A weight gain of 2 lbs. in one week does not require immediate attention; however, this finding indicates the need further assessment.

The nurse notes that a client's T-tube has drained 425 mL of dark green thick fluid. Which action does the nurse take next? 1. Clamp the tube for the next 8 hours.2. Document the amount on the output sheet.3. Notify the health care provider immediately.4. Irrigate the tube with 30 mL of normal saline.

The correct answer is 2 . You answered 3. 1) This is an expected amount of T-tube drainage. The tube should not be clamped. 2) CORRECT - This is an expected amount of T-tube drainage. The volume should be documented on the client's output record. 3) This is an expected amount of T-tube drainage. The health care provider does not need to be notified immediately. 4) The T-tube is draining appropriately. T-tubes are not irrigated.

The nurse assesses a client admitted for the evaluation of acute onset of seizures. Which diagnostic test does the nurse expect to be performed first? 1. Electromyogram.2. Electroencephalogram.3. Magnetic resonance imaging.4. Cerebral angiography.

The correct answer is 2 . You answered 3. 1) This test evaluates the activity of muscles. It is not the appropriate test to determine the cause of seizures. 2) CORRECT - This test records the electrical activity of the brain. A seizure is an uncontrolled discharge of electrical activity of the brain. 3) This test is utilized to obtain detailed pictures of a body part, but will not evaluate the electrical activity in the brain. 4) This test provides images of blood vessels in and around the brain, allowing detection of abnormalities, such as arteriovenous malformations and aneurysms. However, it does not evaluate the electrical activity of the brain.

A client's IV alarm sounds. A nurse states, "I'll get it! That alarm has been beeping all shift. Maybe it's broken." During client rounds, the charge nurse finds the IV pump alarm button covered with a heavy layer of tape. Which immediate action by the charge nurse is appropriate? 1. Report evidence of "alarm fatigue" among staff to the unit manager.2. Replace the pump, label the current pump, and send it for repairs.3. Fill out an incident report, citing the behavior that endangered a client.4. Approach the nurse and discuss how to handle broken equipment.

The correct answer is 2 . You answered 4. 1) "Alarm fatigue" describes how nurses may respond to overexposure to multiple alarm systems. It may be a valid reason in this case, but it would not be the immediate action. 2) CORRECT - Focus the immediate action on the client and the safe use of equipment. Arrange for the replacement or repair of the pump that is alarming continuously. 3) Do not document the behavior of the nurse on an incident report. This behavior is handled directly by the charge nurse. 4) As long as a professional attitude is maintained, the charge nurse should approach the nurse about how the malfunctioning pump was handled.

The nurse provides care for a client with an oral temperature of 90 °F (32 °C). Which nursing diagnosis will the nurse use first to guide this client's care? 1. Risk for impaired cognition.2. Risk for cardiac dysrhythmia.3. Risk for acid-base imbalance.4. Risk for shivering and spasm.

The correct answer is 2 . You answered 4. 1) A low body temperature will probably impair cognition; however, this is not a priority. 2) CORRECT - Severe hypothermia can lead to cardiac arrest. 3) Acid-base imbalance will most likely occur; however, this is not a priority. 4) The client will most likely shiver and experience spasms; however, this is not a priority.

The nurse assess a client who is in the 24th week of gestation. Which finding is a priority for the nurse to follow-up? 1. Fetal heart rate of 130 to 140 beats/min. 2. Fundal level at 3 fingers below the umbilicus.3. Fetal movements felt faintly on lower part of abdomen.4. Client reports backache and leg cramps when sleeping.

The correct answer is 2 . You answered 4. 1) The normal range for fetal heart rate at term is 110 to 160 beats/min. This rate is higher earlier in gestation and slows as the time of delivery approaches. 2) CORRECT - Fundal height should be at the level of the umbilicus at 20 weeks. Three fingers below this height indicates a fetal problem. 3) Fetal movement is first perceived as faint fluttering in the lower abdomen. 4) Pressure of the uterus on blood vessels impairs circulation to the legs. This causes muscle strain, fatigue, and leg cramps.

The nurse notes that an older client is hearing impaired. Which action is the most appropriate for the nurse to use when communicating with this client? 1. Raise voice volume.2. Lower voice pitch.3. Use exaggerated lip movements.4. Turn down the volume of the television.

The correct answer is 2 . You answered 4. 1) When conversing with a hearing-impaired older adult, it is best to maintain a normal voice volume. 2) CORRECT— Age-related presbycusis leads to difficulty hearing sounds or a voice with higher pitches. A lower voice pitch by the nurse may make it easier for the client to hear. 3) Exaggerated lip movements do not improve hearing and may cause embarrassment. 4) Noise distractions, such as a radio or television, should be turned off and not down.

The nurse assesses a client being considered for thrombolytic therapy. Which question is most appropriate for the nurse to ask? (Select all that apply.) 1. "When was the last time you had a bowel movement?"2. "Can you tell me the exact time your chest pain began?"3. "Are you taking any medications to thin your blood?"4. "Did you have the flu and pneumonia vaccination?"5. "When was the last time you ate?"

The correct answer is 2, 3 . You answered 1, 2, 3, 4. 1) The last time the client had a bowel movement does not impact the decision to use thrombolytic therapy. 2) CORRECT - Establishing the exact time of onset of chest pain is essential in thrombolytic therapy screening because the medicine is ideally given within 6 hours of a coronary event. 3) CORRECT - Concurrent use of anticoagulants such as warfarin is a relative contraindication for thrombolytic therapy. 4) Flu and pneumonia vaccination status does not impact the use of thrombolytic therapy. 5) Timing of client's last meal does not impact the use of thrombolytic therapy.

The nurse provides cares for a client with a wound. The client's wound culture is positive for vancomycin-resistant Staphylococcus aureus (VRSA). Which personal protective equipment (PPE) does the nurse don before entering the client's room? (Select all that apply.) 1. Mask. 2. Gown. 3. Gloves. 4. Face shield. 5. N-95 respirator mask.

The correct answer is 2, 3 . You answered 2, 3. 1) Organisms spread by respiratory droplets, such as influenza, require a mask. A client diagnosed with VRSA requires contact precautions. 2) CORRECT - A client diagnosed with VRSA, a resistant organism, requires contact precautions (in addition to standard precautions) to prevent the spread of infection. Contact precautions require the use of gloves and a gown when entering the client's room to protect against contamination with the resistant organism. 3) CORRECT - A client diagnosed with VRSA, a resistant organism, requires contact precautions (in addition to standard precautions) to prevent the spread of infection. Contact precautions require the use of gloves and a gown when entering the client's room to protect against contamination with the resistant organism. 4) A face shield or goggles is required when splashing with blood or body fluids is likely; it is not required for contact precautions. 5) Airborne precautions require an N-95 respirator mask. Airborne precautions are required for organisms that are spread by droplet nuclei, such as pulmonary tuberculosis.

The nurse provides care to a client with severe anemia related to peptic ulcer disease. Which intervention is most appropriate for the nurse to include in the client's plan of care? (Select all that apply.) 1. Administering vitamin B12 injections.2. Monitoring stools for guaiac.3. Measuring vital signs every 4 hours.4. Instructing about a high-iron diet.5. Teaching self-injection of erythropoietin.

The correct answer is 2, 3, 4 . You answered 1, 2, 4, 5. 1) A vitamin B12 (cobalamin) deficiency is a common cause of macrocytic or pernicious anemia. It is much less common in anemia related to recurrent peptic ulcer disease. 2) CORRECT - This test measures loss of blood in stools, which occurs in peptic ulcer disease. 3) CORRECT - Assessing vital signs every 4 hours provides indicators of the severity of anemia, such as tachycardia and hypotension. 4) CORRECT - The client with severe anemia related to peptic ulcer disease requires increased dietary iron to replace red blood cells, which carry oxygen to all parts of the body. 5) Erythropoietin is used for the maintenance of hemoglobin levels in anemia of chronic renal failure.

The nurse provides care to a client prescribed long-term prednisone for the treatment of chronic obstructive pulmonary disease (COPD). Which side effect of prednisone does the nurse expect to observe? (Select all that apply.) 1. Loss of appetite.2. K+ 3.1 mEq/L (3.1 mmol/L).3. Weight loss.4. Blood sugar 180 mg/dL (9.99 mmol/L).5. BP 140/90 mmHg.

The correct answer is 2, 4, 5 . You answered 1, 3, 4, 5. 1) Hunger is a side effect of prednisone. 2) CORRECT — Potassium depletion is a side effect of prednisone. 3) Weight gain is expected due to sodium and water retention. 4) CORRECT — Elevated blood glucose level is a side effect of prednisone. 5) CORRECT — Hypertension is a side effect of prednisone.

The nurse cares for a group of assigned clients. Which action constitutes negligence? (Select all that apply.) 1. Administering furosemide 40 mg orally followed by potassium chloride 20 mEq orally.2. Transcribing a health care provider's telephone prescription for digoxin 0.5 mg to be given twice daily.3. Using a nasogastric tube (NGT) to administer oral contrast dye prior to a computerized tomography scan.4. Performing a baseline neurological assessment on a post-craniotomy client 4 hours after surgery.5. Checking post-cardiac catheterization distal pulses on a client 2 hours after the procedure.

The correct answer is 2, 4, 5 . You answered 1, 3, 4. 1) Administering a loop diuretic with potassium is an expected action. 2) CORRECT - Digoxin is normally prescribed only once a day. The normal dosage range is 0.125 mg to 0.5 mg daily. The nurse is expected to clarify the frequency of this maximum dose. The nurse also should not accept a telephone order except in the case of an emergency. And the nurse should ensure that a route of administration (e.g. orally) is specified for each medication order. 3) Using an NGT to administer a contrast dye for a client who cannot swallow or is nauseated is acceptable practice. 4) CORRECT - The nurse assesses the neurological status of a post-craniotomy client as soon as the client returns from surgery and at least every hour thereafter. 5) CORRECT - Pulses after a cardiac catheterization are checked every 15 minutes for the first hour, every 30 minutes for the second hour, and hourly for the next 4 hours.

The nurse provides care for a client at risk for urinary incontinence. Which client care activity does the nurse delegate to a nursing assistive personnel (NAP)? (Select all that apply.) 1. Perform a bladder scan with nurse supervision.2. Clean the client after an episode of incontinence.3. Teach the client to perform pelvic floor exercises.4. Determine the type of incontinence the client has.5. Assist the client in using the bathroom or commode.

The correct answer is 2, 5 . You answered 1, 2, 5. 1) Performing a bladder scan is the role of the nurse. 2) CORRECT — NAPs can provide or assist incontinent clients with personal hygiene. 3) Teaching pelvic floor exercises is within the nurse's scope of practice. 4) Assessment of the type of incontinence is initially a nursing assessment but is the health care provider's responsibility. 5) CORRECT— NAPs can assist clients with activities of daily living (ADLs), such as using the commode or bathroom.

The nurse provides care for a client taking warfarin for a mechanical prosthetic heart valve. The client has an international normalized ratio (INR) of 3.1. Which is the correct interpretation by the nurse of this finding? 1. The next dose of warfarin needs to be stopped.2. The result indicates a sign of warfarin toxicity.3. The client's treatment goal has been achieved.4. The client may require a plasma transfusion.

The correct answer is 3 . You answered 1. 1) The client's INR is within the desired goal for warfarin therapy (2.5 to 3.5); therefore, there is no reason to withhold the next dose of warfarin. 2) An INR of 3.1 is appropriate. Bleeding is the typical sign of toxicity. 3) CORRECT — The desired goal for warfarin therapy is an INR of 2.5 to 3.5. 4) A plasma transfusion is not indicated unless the client's INR is over the therapeutic range and bleeding occurs.

The nurse teaches a client who had a radical retropubic prostatectomy about potential complications of the surgery. Which client statement indicates the teaching was successful? 1. "I will limit my fluid intake."2. "I need to self-catheterize."3. "I will perform Kegel exercises."4. "I will need opioids for pain relief."

The correct answer is 3 . You answered 2. 1) A client is advised to increase fluid intake after a radical prostatectomy. 2) Self-catheterization is not indicated after a radical prostatectomy. 3) CORRECT — Pelvic floor exercises (Kegel) prevent or reduce the severity of urinary incontinence after a radical retropubic prostatectomy. 4) Opioids are not ideal for post-prostatectomy clients as they might cause constipation. Other medications are available to manage post-op pain.

A client takes a beta 2 adrenergic agonist. Which finding indicates to the nurse that the client is experiencing an adverse reaction? 1. Drowsiness.2. Dysphagia.3. Palpitation.4. Paresthesias.

The correct answer is 3 . You answered 2. 1) Drowsiness is not an adverse reaction of a beta 2 adrenergic agonist. 2) Dysphagia is not an adverse reaction of a beta 2 adrenergic agonist. 3) CORRECT — Cardiovascular adverse effects of a beta 2 adrenergic agonist include palpitations, tachycardia, and hypertension. 4) Beta 2 adrenergic agonists do not cause paresthesias.

The nurse auscultates a client's lungs during a comprehensive assessment. Which finding will the nurse consider to be normal? 1. Dullness above the 10th left intercostal space.2. Tympany over the right upper lobe.3. Resonance over the left upper lobe.4. Hyperresonance over the left lower lobe.

The correct answer is 3 . You answered 2. 1) Dullness would normally be heard below, rather than above, the 10th intercostal space. Dullness cannot be auscultated. 2) Tympany is normally heard over the stomach. Tympany cannot be auscultated. 3) CORRECT - Resonance is a normal sound over lung tissue. 4) Hyperresonance is never a normal finding.

The nurse uses research findings to improve client care. Which technique of care is the nurse using? 1. Nurse-sensitive indicators.2. Care management.3. Performance improvement.4. Utilization review.

The correct answer is 3 . You answered 2. 1) Nurse-sensitive indicators are client outcomes and nursing workforce characteristics that are directly related to nursing care, such as changes in clients' symptom experiences, functional status, safety, total nursing hours per client day, and costs. 2) Case management encompasses the oversight and education activities conducted by health care professionals to help clients with chronic diseases and health conditions learn to understand their condition and live successfully with it. 3) CORRECT — Performance improvement typically involves clinical projects conceived in response to identified clinical problems and designed to use research findings to improve clinical practice. 4) A utilization review identifies and eliminates the overuse of diagnostic and treatment services prescribed by health care providers caring for clients on Medicare.

A client receives an antibiotic every 8 hours. The antibiotic has an onset of action of 2 hours and a duration of action of 8 hours. The client is prescribed a peak blood level. If the medication is provided at 1000, at which time will the nurse schedule the peak level to be drawn? 1. 1100.2. 1200.3. 1400.4. 1800.

The correct answer is 3 . You answered 2. 1) Peak concentration does not occur before the onset. 2) Peak concentration does not occur before the onset. 3) CORRECT— Peak concentration occurs after the onset but before the end of the duration. 4) The medication concentration is too low at 1800.

The nurse inserts a heparin lock in a client prescribed intravenous enalapril 0.625 mg for hypertension. What action will the nurse take next? 1. Look up the frequency of medication in a medication manual.2. Administer the medication intravenously.3. Contact the health care provider.4. Contact the pharmacist.

The correct answer is 3 . You answered 2. 1) The frequency of the medication needs to be ordered. 2) The medication should not be given until there is a full order. 3) CORRECT - The health care provider should be contacted to provide the frequency of the medication. 4) There is no reason to contact the pharmacy.

A young adult military veteran who served time in the Gulf War reports headache, sore throat, shortness of breath, a rash, and nausea when exposed to paint and certain air fresheners. Which condition does the nurse suspect is most likely causing the client's symptoms? 1. Post-traumatic stress disorder.2. Allergy-induced asthma.3. Multiple chemical sensitivities.4. Claustrophobic reaction.

The correct answer is 3 . You answered 2. 1) The group of symptoms reported are not consistent with post-traumatic stress disorder. 2) The group of symptoms reported are not consistent with asthma. 3) CORRECT - Multiple chemical sensitivities are commonly seen with scented products and paint fumes. These occur in Gulf War veterans. 4) The group of symptoms reported are not consistent with a claustrophobic reaction.

The nurse directs the nursing assistive personnel (NAP) to provide a back massage to a client. Which action does the nurse emphasize when giving these directions? 1. Warm the lotion in the microwave before use.2. Wear clean gloves while performing the massage.3. Place the bed in the lowest position after the massage.4. Start the massage at the shoulders and work toward the buttocks.

The correct answer is 3 . You answered 2. 1) The lotion is warmed in the hands. Warming the lotion in the microwave could cause the client or NAP to experience a burn. 2) Hand hygiene is performed before the massage. The use of gloves is required only if there is a risk of contact with body fluids. Otherwise, the massage is given without wearing gloves. 3) CORRECT — The NAP raises the bed to facilitate ease of performing the back massage and provide good body mechanics for the NAP. Afterward, the bed is placed in the lowest position for safety of the client. 4) The massage should start at the buttocks and progress toward the shoulders.

The nurse performs a pelvic exam on a client admitted in labor to determine the station of the presenting part. The client asks the nurse, "What does the term station mean?" Which explanation does the nurse give to the client? 1. The relationship of the presenting fetal parts to the perineum.2. The relationship of the presenting fetal parts to the true pelvis.3. The relationship of the presenting fetal parts to the ischial spines.4. The relationship of the fetal parts to the external cervical os.

The correct answer is 3 . You answered 2. 1) This is not the definition of station. The station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. 2) This is not the definition of station. The station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. 3) CORRECT — The station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. It is a measure of the degree of descent of the presenting part of the fetus through the birth canal. The station of the presenting part is determined when labor begins so the rate of descent of the fetus during labor can be determined accurately. 4) This is not the definition of station. The station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines.

The graduate nurse attends an orientation to the oncology unit. Which statement indicates that the graduate nurse understands the teaching? 1. "Angiogenesis is only accomplished by malignant cells."2. "Everyone diagnosed with cancer will die from it."3. "Cancers metastasize through lymphatic spread to organs."4. "Cell mutations cannot be managed by the body's immune system."

The correct answer is 3 . You answered 3. 1) Angiogenesis is the creation of a blood supply. The human body does this for many reasons; it is not unique to tumors. 2) Cancer is not always lethal. Most cancers, when detected early, are treatable for cure or remission. 3) CORRECT - Cancers metastasize primarily by spreading cancerous cells through the lymph system. 4) Normally, the body can manage and destroy cell mutations.

A nurse who is in Generation X, works the night shift and requests more time off than other staff nurses. Which statement best explains a characteristic of this generation? 1. Believes that there are enough other nurses to fill the staffing needs.2. Prefers to work the day shift, but hesitates to ask for the schedule change.3. Wants to increase leisure time to balance work time.4. Wants to be rewarded for the time spent at work.

The correct answer is 3 . You answered 3. 1) Believing that there are enough nurses to fill staffing needs is not a characteristic of this generation. 2) Individuals in this generation would likely request the schedule change. 3) CORRECT - Individuals in this generation have a tendency to want work-life balance. 4) Wanting to be rewarded for time spent at work is a characteristic of a person in Generation Y.

The nurse provides care for a client diagnosed with sickle cell crisis. Which sign or symptom should the nurse immediately report to the healthcare provider? 1. Cyanosis of the tongue.2. Jaundiced skin.3. Slurred speech.4. Slow capillary refill.

The correct answer is 3 . You answered 3. 1) Cyanosis of the tongue is a common finding with sickle cell crisis due to poor profusion. 2) Jaundiced skin is a common finding with sickle cell crisis due to the rapid breakdown of red blood cells. 3) CORRECT - Slurred speech indicates a possible stroke and should be reported immediately. 4) Slow capillary refill is common finding with sickle cell crisis due to poor capillary profusion.

The nurse is assisting in the care of a client with ventricular fibrillation. The "code" leader called to shock the client uses a biphasic defibrillator. The nurse sets the defibrillator at which energy level? 1. 80 to 100 Joules.2. 100 to 110 Joules.3. 120 to 200 Joules.4. 300 to 360 Joules.

The correct answer is 3 . You answered 3. 1) For an initial defibrillation for a client experiencing ventricular fibrillation, the nurse sets the defibrillator at 120 to 200, not 80 to 100, Joules for biphasic machines. 2) For an initial defibrillation for a client experiencing ventricular fibrillation, the nurse sets the defibrillator at 120 to 200, not 100 to 110, Joules for biphasic machines. 3) CORRECT - For an initial defibrillation for a client experiencing ventricular fibrillation, the nurse sets the defibrillator at 120 to 200 Joules for biphasic machines. 4) For an initial defibrillation for a client experiencing ventricular fibrillation, the nurse sets the defibrillator at 120 to 200, not 300 to 360, Joules for biphasic machines.

The nurse provides care to a client at risk for hypercalcemia. Which action is most appropriate for the nurse to take? 1. Encourage strict bed rest.2. Limit dietary fiber.3. Encourage oral fluids.4. Hold prescribed zoledronate.

The correct answer is 3 . You answered 3. 1) Immobility contributes to and exacerbates hypercalcemia. 2) Fiber helps prevent constipation associated with hypercalcemia. 3) CORRECT— Dehydration contributes to and exacerbates hypercalcemia. Fluids containing sodium should be administered, unless contraindicated, because sodium assists with calcium excretion. About 3L of fluids per day or more are encouraged. 4) Zoledronate, a bisphosphonate drug, inhibits the action of osteoclasts and therefore reduces serum calcium levels. The medication should not be held.

The nurse develops a teaching plan to promote optimal cardiac output during pregnancy. Which information is most important for the nurse include? 1. Take frequent rest periods between activities.2. Modify aerobic exercise as pregnancy progresses.3. Avoid resting or sleeping in the supine position.4. Elevate both lower extremities whenever sitting.

The correct answer is 3 . You answered 3. 1) It is important for the client to avoid overexertion, but this is usually not immediately dangerous to mother or fetus. 2) Exercises can be modified to accommodate the growing uterus and changing center of gravity, but this is not an absolute need and can be done gradually. 3) CORRECT— Particularly in second half of pregnancy, the weight of the pregnant uterus compresses the vena cava (which can lead to maternal hypotension syndrome) and aorta (which can lead to fetal hypoxia). It is a priority to prevent compression of these major vessels. 4) It is ideal for the client to elevate the lower extremities to promote venous return, improve cardiac output, and reduce peripheral edema, but it is not a problem if the client does not do this.

The nurse provides care to a client diagnosed with asthma who suddenly develops wheezing. Which class of medications does the nurse give first? 1. Methylxanthines.2. Corticosteroids.3. ß2-adrenergic agonist.4. Anticholinergics.

The correct answer is 3 . You answered 3. 1) Methylxanthine is a sustained release medication that is not the first line drug of therapy for an exacerbation of asthma. 2) Corticosteroids take 1 to 2 weeks for maximum effect. 3) CORRECT— ß2-adrenergic agonists are most effective in relieving acute bronchospasm and are known as rescue medications. 4) Anticholinergics have an onset of action that is slower than ß2-adrenergic agonists.

The nurse provides care for clients in a headache clinic. Which client should the nurse assess first? 1. The client reporting pain and neck stiffness.2. The client reporting abdominal pain and vomiting.3. The client with difficulty speaking to the receptionist.4. The client with a headache of 3 weeks' duration.

The correct answer is 3 . You answered 3. 1) Pain and stiffness are common symptoms of tension headaches. 2) Abdominal pain, nausea, and vomiting are common symptoms for those clients who experience migraine headaches. 3) CORRECT — Difficulty speaking could be a sign of a cerebral vascular accident (CVA), a migraine complication. 4) Although 3 weeks is a long time to have a headache, this is not unusual for a tension headache.

The nurse prepares to insert a peripheral intravenous (IV) catheter in the forearm of a client admitted with dehydration. The nurse applies a tourniquet to the client's right arm, but has difficulty palpating veins distal to the tourniquet. Which action does the nurse take next? 1. Elevate the client's arm slightly above the heart.2. Tighten the tourniquet.3. Apply a warm pack for 10 to 20 minutes.4. Stroke the vein upward.

The correct answer is 3 . You answered 3. 1) Positioning the arm lower than the heart (not above the heart) for several minutes uses gravity to promote vasodilation. 2) A tourniquet should be applied loosely in a manner that impedes venous flow while maintaining arterial circulation. Tightening the tourniquet may compromise the client's arterial circulation. 3) CORRECT - Applying dry heat using a heat pack causes vasodilation, increasing the likelihood of successful peripheral IV catheter insertion. 4) Stroking the vein downward (not upward) promotes vasodilation.

The nurse learns that a client with a seizure disorder has a serum phenytoin level of 35 mcg/ml. Which action does the nurse take first? 1. Ask to repeat the serum phenytoin level in morning.2. Lower the bed and apply foam padding around the bed.3. Inform the health care provider and expect a change in the phenytoin order.4. Ensure suction is at the bedside.

The correct answer is 3 . You answered 3. 1) Repeating the level does not address the current toxic level. 2) Safety measures for seizures do not address the toxic phenytoin level. 3) CORRECT - A serum phenytoin level above 25 mcg/ml is toxic. The priority is to inform the health care provider. 4) A safety measure for a seizure disorder does not address the toxic phenytoin level.

When performing a sterile dressing change, the nurse removes the saturated dressing, notes the wound is clean, applies a new dressing, and discards the used gloves. Which action does the nurse take next? 1. Put on sterile gloves.2. Open the sterile gauze packaging.3. Perform hand hygiene.4. Date and initial the new dressing.

The correct answer is 3 . You answered 3. 1) Sterile gloves are put on after the sterile supplies are opened. If this were a sterile dressing change kit, the nurse would open the kit first and then find sterile gloves inside. 2) Depending on the supplies used, the gauze packaging or the sterile dressing change kit is opened after the nurse has clean hands. 3) CORRECT — After removing and discarding a saturated dressing and then removing the gloves, the nurse performs hand hygiene. 4) Placing a date and initial on the dressing is done last.

The nurse mentors a nursing student. The student asks which organization requires all clients to be assessed for pain. Which response by the nurse is correct? 1. The National Council of State Boards of Nursing (NCSBN).2. The American Nursing Association (ANA).3. The Joint Commission.4. The National League of Nursing (NLN).

The correct answer is 3 . You answered 3. 1) The NCSBN asserts that the scope of nursing includes a comprehensive assessment, but does not specifically identify pain. 2) The ANA developed standards for clinical practice, including those for assessment, but not specifically for pain. 3) CORRECT -The Joint Commission developed assessment standards, including that all clients be assessed for pain. 4) The NLN promotes valid, reliable guidelines and standards for clinical practice, but not specifically for pain.

A preschool-age client experiences a sudden cardiac arrest. Which action will the nurse take when performing cardiopulmonary resuscitation (CPR)? 1. Deliver 12 breaths per minute.2. Compress the sternum with both hands at a depth of 2 inches (4 to 5 cm).3. Use the heel of one hand for sternal compressions.4. Use two fingers for sternal compressions.

The correct answer is 3 . You answered 3. 1) The breathing rate for a small child is 20 breaths per minute. 2) When performing CPR on a child, use the heel of one hand for chest compressions. 3) CORRECT — To perform chest compressions on a child, use the heel of one hand and compress the sternum 2 inches. 4) Using two fingers for chest compressions is recommended for an infant. For a child, use the heel of one hand.

The health care provider prescribes an external urinary catheter for a client with urinary incontinence. Which action does the nurse take after the catheter is rolled onto the penis? 1. Secure the catheter to the tubing.2. Connect the drainage tube system.3. Ensure there is 1 to 2 inches of space at the end of the catheter.4. Observe for urinary drainage to occur within 5 minutes.

The correct answer is 3 . You answered 3. 1) The catheter is attached to the tubing after 1 to 2 inches of space is added to the end of the catheter. 2) The drainage type system is connected after securing the catheter tubing to the thigh. 3) CORRECT - Before securing the catheter, ensure that there is 1 to 2 inches of space for urine to collect in condom catheter. 4) Observing for urinary drainage is done last; however, output may not be immediate. The nurse may have to observe for urine output over the next hour.

The nurse provides care for a client admitted with fever, headache, chills, cough, and malaise. Which personal protective equipment (PPE) does the nurse wear to provide care to the client? 1. Gloves and gown.2. N-95 respirator mask.3. Mask.4. Gloves.

The correct answer is 3 . You answered 3. 1) The client displays signs of influenza, which is spread through respiratory droplets. Therefore, a mask should be worn when caring for the client. A gown and gloves are indicated for contact precautions to prevent the spread of infection through direct contact with the client or the client's environment. 2) An N-95 respirator mask is indicated for airborne isolation precautions. Airborne precautions are indicated to prevent the spread of infection through droplet nuclei. 3) CORRECT - The client shows signs of influenza. In addition to standard precautions, the nurse should institute droplet precautions, which require the use of a mask when in close proximity to the client. 4) Gloves are indicated when contact with blood or body fluids is likely.

The nurse provides care for a client who requires transmission-based precautions to prevent the spread of a resistant organism. Which situation requires the nurse to use soap and water to perform hand hygiene? 1. Before putting on sterile gloves.2. After removing clean gloves.3. When the hands are visibly soiled.4. After contact with objects in the client's environment.

The correct answer is 3 . You answered 3. 1) The nurse may use an alcohol-based hand rub for hand hygiene before putting on sterile gloves, if the hands are not visibly soiled or contaminated with blood or body fluids. 2) The nurse may use an alcohol-based hand rub for hand hygiene after removing clean gloves, if the hands are not visibly soiled or contaminated with blood or body fluids. 3) CORRECT - The nurse must use soap and water for hand hygiene when hands are visibly soiled or contaminated with blood or body fluids. 4) The nurse may use an alcohol-based hand rub for hand hygiene after contact with objects in the client's environment, if the hands are not visibly soiled or contaminated with blood or body fluids.

The nurse makes an error when administering a medication to a client. It is unlikely that anyone else will find out about the error. Which principle does the nurse follow to uphold ethical standards of nursing practice? 1. Fidelity.2. Justice.3. Veracity.4. Confidentiality.

The correct answer is 3 . You answered 3. 1) The nurse uses the ethical principle of fidelity to always keep promises. 2) The nurse uses the ethical principle of justice when providing care fairly to all clients, regardless of age, gender, or ethnic or socioeconomic background. 3) CORRECT — The nurse follows the ethical principle of veracity, which involves telling the truth. Even though the error might go unnoticed, it is the nurse's ethical responsibility to always tell the truth regarding safe practice. 4) The nurse uses the ethical principle of confidentiality to protect client health information.

The nurse provides care for a client recovering from an above the knee amputation. Which is the best intervention for the nurse to include in this client's plan of care? 1. Remind the client to rest the residual limb on a soft surface.2. Elevate the residual limb on a pillow 2 hours every day.3. Assist the client into the prone position for 30 minutes, three or four times a day.4. Encourage the client to sit out of bed in a chair for 2 hours several times a day.

The correct answer is 3 . You answered 3. 1) The residual limb should be on a soft surface at first, but surfaces should gradually become more firm to prepare the limb for a prosthesis. 2) Elevating the limb on a pillow for 2 hours encourages the development of hip contractures. 3) CORRECT — Lying prone for 30 minutes, three or four times a day, prevents the development of hip contractures. 4) Sitting in a chair for greater than an hour encourages the development of hip contractures.

The nurse provides care for a client diagnosed with deep vein thrombosis. The client receives warfarin therapy. Which laboratory test result indicates to the nurse that treatment is successful? 1. International normalized ratio 1 to 2.2. Partial thromboplastin time 1.5 times the control.3. International normalized ratio 2 to 3.4. Partial thromboplastin times 2.5 times the control.

The correct answer is 3 . You answered 3. 1) The warfarin dose is within therapeutic range when the client's international normalized ratio (INR) is 2 to 3. 2) Partial thromboplastin time is used to monitor the therapeutic effects of heparin (not warfarin) therapy; the heparin dose is within therapeutic range when partial thromboplastin time is 1.5 times the control. 3) CORRECT - An international normalized ratio of 2 to 3 is considered within therapeutic range in a client with deep vein thrombosis. 4) Partial thromboplastin time is used to monitor the therapeutic effects of heparin (not warfarin) therapy; the heparin dose is within therapeutic range when partial thromboplastin time is 1.5 to 2 times the control.

Several clients just arrived at the emergency department at the same time. Which client does the nurse see first? 1. Young adult with a closed leg fracture and a 2+ dorsalis pedis pulse.2. Adolescent with a compound fracture who is bleeding and pale.3. Older adult with confusion and a respiratory rate of 28 breaths/minute.4. Young child with a cut on the forehead who is crying.

The correct answer is 3 . You answered 3. 1) The young adult with a fracture and a strong distal pulse is stable. Assessment is needed, but this client is not the priority. 2) The adolescent is experiencing bleeding. Further assessment of the client's cardiovascular status is required, but there is another client who is a higher priority. 3) CORRECT - This older adult is demonstrating symptoms of hypoxia (confusion) and has an elevated respiratory rate, indicating compromised breathing. Immediate assessment is needed. 4) The child with the forehead cut may need stitches, but is stable. There is another client who is the priority.

The nurse provides care for a group of clients with full term pregnancies who are in active labor. Which client does the nurse assess first? 1. Primigravida, dilated 4 cm, who is reporting nausea and the feeling of pelvic floor pressure.2. Multigravida, in the transitional phase of labor, requesting assistance to use the commode.3. Primigravida, in early labor, with a fetal heart rate of 110 and a variation of 20 beats independent of contractions.4. Multigravida, dilated 9 cm, with a fetal heart rate of 160 and a variation of 5 beats occurring with each contraction.

The correct answer is 3 . You answered 3. 1) This client requires further assessment. However, there is another client who is the priority. 2) Increased pressure during transition and the feeling of needing to urinate is common during the transition phase. This client is stable. 3) CORRECT - Variable fetal decelerations that occur unrelated to the contractions and with significant heart rate changes are due to cord compression and indicate that an urgent assessment is needed. Also, the fetal heart rate is on the lowest end of the acceptable range of 110 to 160. These findings are particularly concerning in the early stages of labor. This client requires immediate intervention to prevent fetal demise. 4) A fetal heart rate of 160 beats per minute with a slight variation during a contraction is an expected early deceleration. This client is stable.

The hospitalized client states to the nurse, "I'm so restless, fatigued, and irritable. I can't concentrate." Which question by the nurse is most appropriate? 1. "Do you take anxiety medicine at home?"2. "Are you thinking about hurting yourself?"3. "How well have you been sleeping since being hospitalized?"4. "Do you worry excessively about your health?"

The correct answer is 3 . You answered 3. 1) This is a closed-ended (yes/no) question that attributes the client's concerns to a pre-existing anxiety disorder. There is no indication of a pre-existing anxiety disorder in the stem of the question. 2. This is a closed-ended (yes/no) question that would be appropriate if there were concern about suicide. However, this question does not address the concern expressed by the client. There is no indication that the client is considering suicide. 3) CORRECT - It is important to gather a sleep history from the client. Hospitalized clients often have difficulty sleeping in an unfamiliar environment due to lack of control over light, noise, and room temperature. Lack of sleep can cause the symptoms expressed by the client and can impact the client's ability to get well. 4) This is a closed-ended (yes/no) question that attributes the client's symptoms to excessive anxiety. There is a better assessment question for the nurse to ask.

The nurse provides care for a client with a small bowel obstruction and stage 4 stomach cancer. The client verbalizes an interest in palliative care and the spouse does not agree. Which statement by the nurse to the client is appropriate? 1. "We need to insert a nasogastric tube."2. "Would you two like to speak in private?"3. "What are your treatment goals?"4. "I know this process is very stressful."

The correct answer is 3 . You answered 3. 1) While a nasogastric tube may be needed if the client has a small bowel obstruction, the nurse needs to clarify the client's wishes for treatment first, and there is no indication this intervention is prescribed. 2) While privacy between the client and spouse is respected, the nurse's priority at this time is to clarify the client's wishes for treatment. 3) CORRECT— The nurse's priority is to advocate for the client by identifying the client's treatment goals, communicating those wishes with the health care provider, and helping the client's family understand and cope with the client's wishes. This statement is both therapeutic and open-ended. 4) This statement is nontherapeutic, focuses on the nurse, and fails to clarify the client's wishes for treatment.

The nurse auscultates the heart of a client experiencing increasing shortness of breath. Which finding causes the nurse the most concern? 1. S1 heart sound.2. S2 heart sound.3. S3 heart sound.4. S4 heart sound.

The correct answer is 3 . You answered 4. 1) An S1 heart sound, a normal finding, occurs when the mitral and tricuspid valves of the heart close. It corresponds with the onset of ventricular contraction. 2) An S2 heart sound, a normal finding, occurs when the aortic and pulmonic valves close. It occurs at the end of ventricular contraction and the onset of ventricular diastole. 3) CORRECT - An S3 heart sound, a significant finding in older adult clients, suggests heart failure. It is heard in early diastole during the period of rapid ventricular filling as blood flows from the atrium into a noncompliant ventricle. 4) An S4 heart sound occurs immediately before the S1 heart sound. It is considered a normal finding in older adult clients.

The nurse prioritizes the needs of several assigned clients. Which client need will the nurse address first? 1. Comforting a client who received a cancer diagnosis.2. Instituting precautions for a client identified at risk for falling.3. Assessing a client with a reported blood glucose level of 60 mg/dL (3.33 mmol/L).4. Implementing precautions for a client identified at risk for aspiration.

The correct answer is 3 . You answered 4. 1) Following Maslow's hierarchy of needs, physiological needs should be addressed before addressing a psychological need, such as comforting a client after receiving a cancer diagnosis. 2) According to Maslow's hierarchy of needs, a client with a physiological need should be addressed before someone with a safety need, such as instituting fall precautions. 3) CORRECT - Addressing a client's physiological needs, such as a blood glucose level of 60 mg/dL takes priority over addressing safety and psychological needs. 4) According to Maslow's hierarchy of needs, a client with a physiological need should be addressed before someone with a safety need, such as instituting aspiration precautions.

The nurse provides care for several assigned clients. Which situation requires an immediate follow-up by the nurse? 1. A client on mechanical ventilation has moisture in the ventilator tubing.2. A client's blood glucose monitor shows a message noting there is insufficient amount of blood to complete the glucose level.3. A client receiving a liter of intravenous fluid at 120 mL/hr has 460 mL remaining after 2 hours.4. A client with a chest tube attached to suction has bubbling in the control chamber of the closed-drainage system.

The correct answer is 3 . You answered 4. 1) Moisture normally occurs in ventilator tubing and does not indicate a mechanical malfunction. Empty ventilator tubing when moisture collects. 2) Accuracy of the blood glucose monitor is ensured when the manufacturer's directions are followed. The most significant source of error in blood glucose measurement is related to the skill of the user and not to errors of the instrument. Common errors in self-monitoring of blood glucose involve failure to obtain a sufficient blood sample. 3) CORRECT — A complication of intravenous therapy is fluid overload from a too-rapid infusion. This is the priority as heart failure can result from fluid overload. 4) The third compartment, the suction control chamber, applies suction to the chest drainage system. Bubbling is an expected finding. If no bubbling is seen in the suction control chamber, (1) there is no suction, (2) suction is not high enough, or (3) the pleural air leak is so large that suction is not high enough to evacuate it.

The nurse caring for a client with an acute myocardial infarction and chest pain delegates 5-minute vital sign assessments to nursing assistive personnel (NAP). The charge nurse intervenes and changes the assignment. Which right of delegation does the charge nurse following in this situation? 1. Right direction.2. Right communication.3. Right circumstance.4. Right supervision.

The correct answer is 3 . You answered 4. 1) Right direction is defined as giving clear and concise direction of the delegated task. The scenario described indicates the client is not stable. 2) Right communication is giving clear directions about the delegated task. The scenario described indicates the client is not stable. 3) CORRECT - This circumstance is not right for NAP delegation. The client's condition is not stable. Therefore, the NAP should not be delegated the task of vital signs until the client is stable. 4) Right supervision is intervening, monitoring, and evaluating the delegated task. The scenario described indicates the client is not stable.

The nurse provides care to a client who is unconscious. In which position will the nurse place the client to provide oral care? 1. Dorsal recumbent.2. Orthopneic.3. Side-lying.4. High Fowler.

The correct answer is 3 . You answered 4. 1) The dorsal recumbent position is not the best to perform oral care in a client who is unconscious. 2) The orthopneic position cannot be used in a client who is unconscious because the client will need to sit up and lean over a table. 3) CORRECT - When performing oral care to an unconscious client, the nurse should place the client in a side-lying or lateral position to facilitate the flow of secretions by gravity to prevent aspiration during the procedure. The nurse can also keep the head of the bed lowered. 4) The high Fowler position is a sitting position with the head of the bed at a 60 to 90 degree angle. This is not the best position to provide oral care to this client.

The nurse provides care for a client who reports difficulty breathing. Which assessment finding requires immediate action by the nurse? (Select all that apply.) 1. Non-productive cough.2. Flushed skin appearance.3. Use of accessory muscles.4. Oxygen saturation of 78%.5. A heart rate of 145/minute.

The correct answer is 3, 4, 5 . You answered 3, 4, 5. 1) A non-productive cough is a benign finding and does not require immediate attention. 2) Flushed skin is not an emergency and could be due to a non-emergency reasons. 3) CORRECT - Use of accessory muscles for breathing signifies air hunger and immediate attention. 4) CORRECT- Severe hypoxia requires emergent action. 5) CORRECT - Tachycardia indicates hypoxia and respiratory distress status, and must be addressed immediately.

The nurse delegates tasks to nursing assistive personnel (NAP). Which statement will the nurse make that indicates adherence to the rights of delegation? (Select all that apply). 1. "I gave Mr. Smith nausea medication 20 minutes ago. Can you go see if he feels better?"2. "I am heading to lunch. Check with Mr. Jones in 15 minutes to see if the enema helped."3. "I placed an indwelling catheter in Mr. John. Empty the urinary bag in 15 minutes and let me know how much he had for urine output."4. "Mr. Jackson can ambulate at 0800 starting in his room with a walker. Once you are done, report to me how he did."5. "I notice Mr. Johnson's temperature is not documented. Can you tell me what it is?"

The correct answer is 3, 4, 5 . You answered 3, 4, 5. 1) It is beyond the scope of practice for NAP to evaluate the effectiveness of medication. 2) It is beyond the scope of practice for NAP to evaluate the effectiveness of nursing interventions. 3) CORRECT - The nurse is delegating an appropriate task and asking NAP to report the amount of urine output to the nurse. 4) CORRECT - The nurse is delegating an appropriate task and asking NAP to report the client's ability to ambulate with a walker to the nurse. 5) CORRECT - The nurse is following up on a task of temperature assessment that was delegated to ensure it was completed by NAP.

The nurse prepares for the admission of a child diagnosed with rubeola. Which isolation precaution does the nurse plan for the child? 1. Enteric.2. Contact.3. Protective.4. Respiratory.

The correct answer is 4 . You answered 2. 1) Enteric isolation is not indicated based on the method of transmission of the rubeola infection. 2) Contact isolation is not indicated based on the method of transmission of the rubeola infection. 3) Protective isolation is not appropriate for this disease process. This is appropriate for a client with neutropenia. 4) CORRECT - Rubeola is transmitted by airborne particles or direct contact with infectious droplets, so respiratory isolation is required.

The nurse provides care for a client with a brain natriuretic peptide (BNP) level of 899 pg/mL. Which priority nursing diagnosis does this finding substantiate? 1. Activity intolerance.2. Electrolyte imbalance.3. Risk for injury.4. Excess fluid volume.

The correct answer is 4 . You answered 3. 1) A BNP level of 899 pg/mL is significantly above normal finding of <100 pg/mL. The finding indicates acute congestive heart failure, which is a potential nursing diagnosis, but not a priority. 2) Electrolyte imbalance is not a priority nursing diagnosis in acute congestive heart failure. 3) Risk for injury is not a priority nursing diagnosis in acute congestive heart failure. 4) CORRECT - A BNP level of 899 pg/mL indicates acute congestive heart failure. There is excess fluid volume related to increased venous pressure and decreased renal perfusion secondary to acute congestive heart failure. This is the priority nursing diagnosis.

The nurse provides care for a client with the following arterial blood gas (ABG) results: pH 7.29, pCO231 mmHg, and HCO3 19 mEq/L. Which electrolyte alteration does the nurse monitor for based on this client data? 1. Hypocalcemia.2. Hypernatremia.3. Hypomagnesemia.4. Hyperkalemia.

The correct answer is 4 . You answered 3. 1) Hypocalcemia is anticipated with alkalotic, not acidotic, processes. 2) Hypernatremia is not typically associated with metabolic acidosis. 3) Hypomagnesemia is not typically associated with metabolic acidosis. 4) CORRECT — Serum potassium levels are often high in metabolic acidosis. As the pH drops, excess hydrogen ions enter the red blood cells, causing potassium to leave the cells, resulting in hyperkalemia.

A client takes a statin as prescribed. Which action does the nurse implement to identify if the client is experiencing any side effects of the medication? 1. Measure height and weight.2. Check recent cholesterol level.3. Inquire about the consistency of stool. 4. Assess for muscle tenderness.

The correct answer is 4 . You answered 3. 1) Statins do not affect height and weight. 2) Monitoring cholesterol evaluates the effectiveness of the medication. It does not assess for side effects. 3) Statins do not effect stool consistency. 4) CORRECT - Myalgia or muscle tenderness may indicate the development of rhabdomyolysis, which is an adverse reaction to statin medication.

The nurse reviews medications prescribed for a client with a gastric feeding tube. For which medication will the nurse need to contact the health care provider? 1. Potassium chloride oral solution.2. Phenytoin oral elixir.3. Enalapril tablet.4. Aspirin E.

The correct answer is 4 . You answered 3. 1) The potassium chloride oral solution is less likely to block the gastric tube. 2) The liquid form of phenytoin oral elixir is less likely to block the gastric tube. 3) An enalapril tablet can be crushed and diluted before administering through the gastric tube. 4) CORRECT - Enteric-coated medication, such as aspirin E, cannot to be crushed.

A client who received ascorbic acid for the treatment of scurvy asks the nurse, "How does ascorbic acid treat my symptoms?" Which response by the nurse is appropriate? 1. "It is responsible for carbohydrate metabolism."2. "It is responsible for protein metabolism."3. "It is responsible for nerve function."4. "It is responsible for collagen synthesis."

The correct answer is 4 . You answered 3. 1) Thiamine (B1), not ascorbic acid, is responsible for carbohydrate metabolism and helps prevent Wernicke-Korsakoff syndrome. 2) Riboflavin (B2), not ascorbic acid, is responsible for protein metabolism and helps prevent ariboflavinosis and tissue inflammation. 3) Cyanocobalamin (B12), not ascorbic acid, is responsible for nerve function and prevents pernicious anemia. 4) CORRECT — Ascorbic acid (vitamin C) is responsible for collagen synthesis and helps prevent scurvy (joint pain, weakness), infant anemia, and oxalate hypersensitivity.

The nurse receives a prescription to provide aspirin to a client with an emergent acute myocardial infarction. What is the best method to administer aspirin to this client? 1. Administer as a rectal suppository.2. Administer with a glass of milk or antacid.3. Give sublingually, times three doses.4. Have the client chew non-enteric coated ASA.

The correct answer is 4 . You answered 3. 1) To maximize immediate antiplatelet action of aspirin across the buccal mucosa, it is best to be chewed. 2) Antacid will reduce absorption of aspirin. 3) In acute myocardial infarction aspirin is given once, not in three doses. 4) CORRECT - To maximize immediate antiplatelet action of aspirin across the buccal mucosa, it is best to be chewed.

The nurse provides care for a client with rhabdomyolysis. Which finding will the nurse determine is most appropriate for the client? 1. Mean arterial pressure >90 mm Hg.2. Bowels sounds in four quadrants.3. Pupils equal and reactive to light.4. Urinary output >60 mL per hour.

The correct answer is 4 . You answered 4. 1) A mean arterial pressure (MAP) >90 mm Hg is not an appropriate outcome in rhabdomyolysis. A MAP of >60 mm Hg is adequate to perfuse vital organs. 2) Establishing the presence of bowels sounds in four quadrants is not a priority outcome. 3) Unless a client has neurological co-morbidity, ensuring the pupils are equal and reactive to light is not a priority outcome. 4) CORRECT - This is an appropriate outcome for rhabdomyolysis. Muscle breakdown can lead to myoglobinuria, which can put the kidneys at risk for acute renal injury. Keep the client hydrated and a urine output of 200 to 300 ml per hour.

The nurse evaluates care provided to a client diagnosed with anorexia nervosa. Which laboratory result indicates to the nurse that further treatment is needed? 1. Arterial pH 7.37.2. Arterial pH 7.48.3. Arterial bicarbonate 24 mEq/L.4. Arterial bicarbonate 19 mEq/L.

The correct answer is 4 . You answered 4. 1) A pH of 7.37 is within normal limits. 2) A pH of 7.48 is elevated and indicates alkalosis. 3) A bicarbonate of 24 mEq/L is within normal limits. 4) CORRECT — A bicarbonate level of 19 mEq/L is low and indicates metabolic acidosis that, in this client's case, is caused by starvation.

The nurse provides care for a client with an enteral feeding tube. The nurse discovers that the client's continuous enteral tube feeding is 100 mL behind the prescribed infusion schedule. Which action should the nurse take first? 1. Flush the tube.2. Reposition the tube.3. Increase the flow rate.4. Measure residual volume.

The correct answer is 4 . You answered 4. 1) After the residual volume is assessed and the tube feeding continues to be sluggish, then the nurse should flush the tube to determine patency. 2) Location of the feeding tube does need to be determined; however, depending on the type of feeding tube used, repositioning the tube may be beyond the nurse's scope of practice. 3) Increasing the flow rate could lead to adverse effects from receiving too much or too rapid of a feeding solution. This action is not recommended. 4) CORRECT — The reason the prescribed amount of tube feeding may not have infused could be due to a high gastric residual volume. Assessing the current residual volume is the first thing that the nurse should do.

The nurse notes that a client is prescribed alendronate. Which instruction will the nurse include when teaching about this medication? 1. "Take the medication at bedtime with a snack."2. "Take the medication in the morning after breakfast."3. "Lie down for 30 minutes after taking the medication."4. "Take the medication with a full glass of water."

The correct answer is 4 . You answered 4. 1) Alendronate is to be taken on an empty stomach. 2) Alendronate can be taken anytime during the day with an empty stomach. 3) The client must remain upright 30 minutes after taking alendronate to prevent esophagitis. 4) CORRECT - Alendronate must be taken with a full glass of water to prevent acid reflux.

While performing an eye assessment, a client asks the nurse what could be the reason for vision to be blurry when looking "straight ahead." For which health problem will the nurser perform an additional assessment? 1. Cataracts.2. Glaucoma.3. Detached retina.4. Macular degeneration.

The correct answer is 4 . You answered 4. 1) Cataracts cause vision to appear cloudy. 2) Glaucoma causes a gradual loss of peripheral vision. 3) With a detached retina, there is a sudden loss of partial or complete vision in one eye. 4) CORRECT - Manifestations of macular degeneration include a change in central vision that is described as blurry or distorted.

The nurse observes a nursing assistive personnel (NAP) prepare to provide mouth care to a client who is comatose. Which action made by the NAP requires the nurse to intervene? 1. The NAP applies clean gloves.2. The NAP activates an oral suction device.3. The NAP places a towel under the client's chin.4. The NAP raises the head of the bed thirty degrees.

The correct answer is 4 . You answered 4. 1) Clean gloves are applied before providing oral care to a client. 2) For a client who is comatose, oral suction may be required to prevent aspiration of fluid and toothpaste used during the mouth care. 3) A towel is placed under the chin to absorb any fluids coming from the mouth. 4) CORRECT- The client who is comatose is placed in a side-lying position with the bed flat. In this position, saliva automatically runs out of the mouth by gravity instead of being aspirated into the lungs.

The nurse provides care for a client recovering from a hysterectomy. The nurse asks the nursing assistive personnel (NAP) to help the client ambulate in the hallway within the next hour. Three hours later the client reports still not being assisted to ambulate. The nurse finds the NAP in the break room shopping on the Internet. Which action will the nurse take next? 1. Tell the NAP to ambulate the client in the hallway now.2. Complete an incident report.3. Tell the NAP to clock out and go home.4. Report the NAP to the nursing supervisor.

The correct answer is 4 . You answered 4. 1) If the NAP did not perform the task when asked the first time, there is reasonable doubt it may be performed when the NAP is asked by the nurse again. 2) There is no valid reason to complete an incident report. 3) The nurse does not have the authority to do this and it does not address the issue. 4) CORRECT — This action appropriately utilizes the nursing chain of command.

The nurse applies the prescribed medication to an adult client diagnosed with scabies. Which body area should the nurse avoid when applying the scabicide? 1. Knees and elbows.2. Fingers and hands.3. Groin and axillae.4. Face and scalp.

The correct answer is 4 . You answered 4. 1) Scabicide can be safely applied to the knees and elbows. 2) Scabicide can be safely applied to the fingers and hands. 3) Scabicide can be safely applied to the groin and axillae. 4) CORRECT — When treating an adult client diagnosed with scabies, the scabicide is applied from the neck down. The drug should not be applied to the face or the scalp of an adult client.

The nurse delivers a kosher lunch to a client who is Jewish. Which nursing action is most appropriate when assisting the client? 1. Moving the food from paper plates to glass plates.2. Unwrapping the eating utensils for the client.3. Replacing the plastic utensils with metal utensils.4. Asking the client to unwrap the eating utensils and to prepare the meal for eating.

The correct answer is 4 . You answered 4. 1) The client must unwrap the utensils and personally prepare to eat the meal in order to comply with religious beliefs. 2) The client must unwrap the utensils. 3) The client will replace the utensils. 4) CORRECT - The client should unwrap the eating utensils. The nurse can prepare the meal for eating. This complies with religious rules.

The nurse teaches a group of nursing students about managed care. Which information will the nurse include in the teaching session? 1. Provides full coverage of health care costs.2. Allows providers to focus on illness care.3. Assumes the financial risk involved.4. Encourages providers to focus on prevention.

The correct answer is 4 . You answered 4. 1) The health care provider or the health care system receives a predetermined capitated (fixed amount) payment for each patient enrolled in the program. 2) The focus of care shifts from individual illness care to prevention, early intervention, and outpatient care 3) The managed care organization (provider) assumes financial risk, in addition to providing patient care. 4) CORRECT - The focus of health care shifts from illness to health and wellness.

The nurse provides care for a client diagnosed with vitamin A deficiency. Which menu selection is most appropriate for the nurse to recommend to the client? 1. Legumes, grains, fish.2. Tomatoes, potatoes, fruit juice.3. Leafy vegetables, eggs, cheese.4. Liver, sweet potato, carrots.

The correct answer is 4 . You answered 4. 1) This menu selection is appropriate for a client with thiamine (B1) deficiency, but these foods are not high in vitamin A. 2) This menu selection is appropriate for a client with vitamin C deficiency, but these foods are not high in vitamin A. 3) This menu selection is appropriate for a client with vitamin K deficiency, but these foods are not high in vitamin A. 4) CORRECT — This menu selection is appropriate for a client with vitamin A deficiency, as all these foods are high in vitamin A.

A 16-year-old client visits the community health clinic. The client tells the nurse, "I think I got an infection from having sex with my boyfriend. I can't tell my parents. They will kill me!" Which is the best response by the nurse? 1. "Since you are a minor, I will have to notify your parents."2. "Your parents will appreciate your maturity in seeking help."3. "Does your boyfriend understand that he will need treatment?"4. "Your parents do not need to know, but will you give me consent for treatment?"

The correct answer is 4 . You answered 4. 1) Unemancipated minors with specific medical conditions, such as a sexually transmitted infection (STI), may consent to medical treatment. Information and treatment can be provided without notification of, or consent from, the parent(s). 2) The nurse does not know if this is true. This response does not address the immediate concern. 3) This question is important, but it does not specifically address the client's concern about informing the parents. 4) CORRECT - The nurse needs to obtain informed consent for treatment from the unemancipated minor. The nurse is not obligated to notify the parents.

The nurse assesses a client with obsessive compulsive personality disorder. Which finding will the nurse expect to observe? (Select all that apply.) 1. Requires excessive support from others when making decisions.2. Believes is able to know what others are thinking.3. Possesses exaggerated feelings of helplessness when alone.4. Demonstrates unwillingness to delegate tasks unless others follow strict rules.5. Imposes perfectionism in own completion of tasks.

The correct answer is 4, 5 . You answered 1, 3, 5. 1) A client with dependent personality disorder has an excessive need for others to take care of them. This leads to clinging behavior and fears of separation. The client must have a great deal of support from others when making important life decisions. 2) A client with schizotypal personality disorder has difficulty establishing close relationships. The client demonstrates perceptual distortions and eccentric behavior, such as believing the ability to know what others are thinking. 3) A client with dependent personality has exaggerated feelings of helplessness when alone because of the fear of not being able to care for self. 4) CORRECT - A client with obsessive compulsive personality disorder is preoccupied in maintaining control in all aspects of life. In order to do so, the client is unwilling to let anyone assist in any tasks unless done exactly in the manner dictated. 5) CORRECT - A client with obsessive compulsive personality disorder attempts to maintain control by imposing standards of perfectionism in all aspects of life. This interferes with the ability to complete tasks and maintain close relationships.

A client receiving 50 mL/hr of continuous bladder irrigation fluid has a total output of 500 mL over 8 hours. Which action does the nurse take? 1. Assess the catheter for kinks.2. Notify the health care provider.3. Manually irrigate the catheter for clots.4. Reduce the rate of the bladder irrigation fluid.

1) It is appropriate to assess the catheter for kinks if the output is less than amount instilled. The amount of output is more than the amount of irrigation instilled. 2) CORRECT- The client received 400 mL of bladder irrigation fluid over 8 hours with an output of 500 mL. The urine output for this time frame is 100 mL (12.5 mL/hr). Normal urine output is at least 30 mL/hr; therefore, the nurse notifies the health care provider. 3) There is no reason to suspect clots in the catheter due to the adequate drainage in the urine bag. 4) The health care provider prescribes the rate of bladder irrigation infusion. Reducing the rate is outside the scope of practice for the nurse.

The nurse plans to teach a group of nursing assistive personnel (NAP) about measures to prevent catheter-associated urinary tract infections. Which measure does the nurse include? (Select all that apply.) 1. Perform meticulous perineal care with soap and water every 48 hours.2. Secure the catheter to prevent movement.3. Maintain a closed drainage system.4. Perform hand hygiene before and after contact with the client.5. Encourage the client to drink 8 to 10 glasses of fluid daily, if permitted.

1) Meticulous perineal care with soap and water should be done daily, not every 48 hours. 2) CORRECT - The catheter should be secured to prevent movement and reduce the risk of catheter-associated urinary tract infections. 3) CORRECT - A closed drainage system should be maintained to prevent contamination from outside organisms and reduce the risk of catheter-associated urinary tract infections. 4) CORRECT - Hand hygiene should be performed before and after contact with the client or the client's environment to prevent the spread of infection. 5) CORRECT - Encourage the client to drink 8 to 10 glasses of fluid daily, if their condition permits, to flush bacteria from the bladder and reduce the risk for catheter-associated urinary tract infections.

The nurse, caring for a client diagnosed with a postoperative ileus, inserts a nasogastric (NG) tube. (Please arrange the steps in the correct order. All options must be used.) Instruct the client to extend the neck backward against the pillow Gently insert the NG tube into a nare Mark the length of the tube to be inserted Assess the client's ability to follow directions Prepare the eq at the bedside,

Correct Answer The nurse assesses if the client is aware and can follow directions to assist in facilitating the passage of the NG tube. The tube is placed in a basin of warm water to facilitate a more flexible and comfortable passage of the tube, while the client is placed in semi-Fowler position. The tube is used to measure from the tip of the nose to earlobe and then to the tip of client's xiphoid for proper distance for insertion to the stomach. Hyperextension of the neck reduces the nasopharyngeal junction. The tube is inserted along the floor of the nostril to avoid the turbinates along the lateral wall. The insertion, while the client takes sips of water to facilitate passage, continues until the measured distance is reached.

The nurse is providing care to a client diagnosed with measles. Which transmission-based precaution does the nurse implement when caring for this client? 1. Airborne.2. Droplet.3. Contact.4. Neutropenic.

The correct answer is 1 . You answered 1. 1) CORRECT - Airborne precautions are implemented when providing care for clients with measles for up to 4 days after the onset of rash. 2) Droplet precautions are used for clients with diphtheria, rubella, streptococcal pharyngitis, pertussis, and mumps, among other conditions. 3) Contact precautions are used for clients diagnosed with multidrug resistant infections and Clostridium difficile. 4) Neutropenic precautions are used specifically for clients with very low white blood cell counts.

The nurse provides care for a client diagnosed with a stage 2 sacral pressure injury. The nurse educates the client's family members about proper positioning. Which statement by the family members indicates a need for further teaching? 1. "We will not keep our parent sitting on the bedpan for too long."2. "We will encourage our parent to change position every few hours."3. "We will use a draw sheet to help position our parent when in bed."4. "We will put our parent on a rubber ring cushion when he is sitting up."

The correct answer is 4 . You answered 4. 1) Sitting on the bed too long puts the client at risk for skin breakdown. 2) Coaching and assisting client to turn to each side relieves pressure. 3) Using a draw sheet prevents shearing. 4) CORRECT — Any type of ring cushion should not be used because it can lead to additional or worsening pressure injuries.