Comprehensive 2013A

A nurse is assessing a client every 15min during the immediate postpartum period. Which of the following findings requires immediate action by the nurse? 1. bright red lochia 2. elevated temp 3. boggy uterus 4. perineal edema

1. bright red lochia (Rationale: Lochia rubra is expected.) 2. elevated temp (Rationale: elevated temp in the first 24hr after childbirth is expected.) Ans. 3. boggy uterus (Rationale: boggy uterus indicates this client risk for uterine atony; therefore, the nurse should immediately massage the fundus to prevent blood loss.) 4. perineal edema (Rationale: expected finding immediately after childbirth.)

A nurse is caring for a group of clients in a community mental health clinic. Which of the following therapy groups is appropriate for the nurse to lead? 1. Alcoholic anonymous 2. psychodrama group 3. medication education group 4. dialectical behavior treatment

1. Alcoholic anonymous (Rationale: a member og the group, rather than a nurse leads AA, a self-help group). Ans 3. medication education group (Rationale: Teaching the use and SE of meds is a nursing responsibility; therefore, it is common for nurse to lead this type of group). A nurse must have graduate education lead these groups: 2. psychodrama group 4. dialectical behavior treatment

A nurse is teaching home wound care to the family of a child who has a large wound. Which of the following interventions is appropriate for the nurse to recommend? 1. Avoid foods that have a high Vitamin A content 2. Clean the wound twice a day with povidone-iodine 3. Apply heat to the wound for 10min, four times a day 4. Provide a diet high in protein

1. Avoid foods that have a high Vitamin A content (Rationale: Child should eat foods high in Vitamin A to promote healing). 2. Clean the wound twice a day with povidone-iodine (Rationale: Povidone-iodine should not be used for cleaning the wound because it is toxic). 3. Apply heat to the wound for 10min, four times a day (Rationale: Heat is contraindicated for wound therapy). Ans. 4. Provide a diet high in protein (Rationale: Child should eat a high protein diet because protein is required for tissue repair).

A nurse is caring for an older adult client who is experiencing anorexia and is receiving enteral tube feedings. Which of the following lab values indicates that the client needs additional nutrients added to the feeding? 1. Serum Cr level of 1.1 mg/dL 2. serum albumin level of 2.8 g/dL 3. a triglyceride level of 100 mg/dL 4. an alkaline phosphatase level of 118 u/L

1. Serum Cr level of 1.1 mg/dL 2. serum albumin level of 2.8 g/dL (Rationale: A serum albumin less than 3.5 g/dL indicates malnutrition and a need for nutritional supplementation.) 3. a triglyceride level of 100 mg/dL Ans. 4. an alkaline phosphatase level of 118 u/L (Rationale: While alkanine phosphatase level is outside the expected reference range, it is not an indicator of nutritional status.)

A nurse is preparing a teaching plan for a client who has thrombocytopenia. the nurse should instruct the client to avoid which of the following? 1. large groups of people 2. quickly changing positions 3. eating fresh fruits 4. nose blowing

A client who has thrombocytopenia does not need to avoid: 1. large groups of people 2. quickly changing positions 3. eating fresh fruits 4. nose blowing (Rationale: increases the risk for bleeding or hemorrhaging.)

According to the principles of triage, which of the following clients requires immediate nursing interventions during a mass casualty disaster? 1. A child whose thigh is impaled with glass 2. an adolescent client who is paralyzed from the waist down. 3. a middle adult client who has a sucking chest wound 4. an older adult who has agonal breathing.

In triage situation, these clients is considered urgent and, therefore, can wait a short time for care: 1. A child whose thigh is impaled with glass 2. an adolescent client who is paralyzed from the waist down. Ans. 3. a middle adult client who has a sucking chest wound (Rationale: emergent and has life threatening injuries that need immediate medical attn.) 4. an older adult who has agonal breathing. (Rationale: client has injuries that make survival unlikely; therefore, a nurse provides comfort measures as time permits.)

A client has weakness of the left leg due to a CVA. the client has been given a quad cane to assist with walking. Which of the following actions by the client requires correction by the nurse? 1. places the cane 6 to 12 inches in front of the body prior to stepping forward 2. places the cane on the affected side of the body 3. steps forward with the affected leg first 4. steps forward with the unaffected leg, placing the foot past the cane.

Ans. 2. places the cane on the affected side of the body (Rationale: can should always be places on the unaffected side of the body) These are appropriate action by the client: 1. places the cane 6 to 12 inches in front of the body prior to stepping forward. 3. steps forward with the affected leg first 4. steps forward with the unaffected leg, placing the foot past the cane.

A nurse is planning to teach a client to start a new prescription for fluoxetine. For which of the following should the nurse instruct the client to monitor and report to the provider? 1. jaundice 2. pedal edema 3. tremors 4. dysuria

Ans. 3. tremors (Rationale: Fluoxetine can cause serotonin syndrome within 2-72 hr after starting TX. the client can experience tremors, agitation, confusion, anxiety, & hallucination. Report to the provider and client will need to stop taking the medication.) These are not SE of fluoxetine: 1. jaundice 2. pedal edema 4. dysuria

A nurse is discussing the goals of hospice care with a client. Statement indicates an understanding of the information? 1. "I will be eligible to receive experimental therapy in hopes of controlling my disease." 2. "Care will included treatments that might cure my disease." 3. "If the suffering gets too bad, I will be given medication to help me die." 4. "Care and treatment will be provided to control symptoms and keep me comfortable."

Ans. 4. "Care and treatment will be provided to control symptoms and keep me comfortable." (Rationale: the goals of hospice care include symptom management and comfort interventions rather than cure or control of disease process.)

A nurse is admitting a child from the ED who has a fever & fluid-filled vesicles on the trunk and extremities. Nursing intervention is the highest priority? 1. Encourage oral fluids. 2. apply topical calamine lotion 3. administer APAP as an antipyretic 4. implement transmission based precautions

Ans. 4. Implement transmission based precaution. Rationale: child most likely has varicella, an infectious dz, indicates the child is at the greatest risk for transmitting the infectious agent to others. Not the highest priority intervention: 1. Encourage oral fluids. 2. apply topical calamine lotion 3. administer APAP as an antipyretic

A toddler has been diagnoses with hemophilia A. Which of the following activated partial thromboplastin time (aPTT) values should the nurse expect to see in a client with hemophilia A? 1. 11 sec 2. 22 sec 3. 30 sec 4. 45 sec

This is below expected range, indiciating a risk for blood clots: 1. 11 sec 2. 22 sec 3. 30 sec (Rationale: expected reference range.) Ans. 4. 45 sec (Rationale: value above expected reference range, indicating a risk for spontaneous bleeding, which is a mani of hemophilia A.)

A nurse is admitting an adolescent client for TX of depression. The client's parents report that the client has been making jokes about committing suicide. Which of the following questions is appropriate for the nurse to ask the client? 1. "Do you think that you might benefit from an antidepressant?" 2. "I heard you are making jokes about suicide. Do you realize suicide is a very serious subject?" 3. "Do you plan to hurt yourself?" 4. "Are you having trouble at school that is contributing to your depression?"

1. "Do you think that you might benefit from an antidepressant?" (Rationale: provider prescribes an antidepressant, but this not an appropriate ? @ this time.) 2. "I heard you are making jokes about suicide. Do you realize suicide is a very serious subject?" (Rationale: accusatory response and may make a client defensive. It does not address whether or not the client is seriously considering suicide.) Ans. 3. "Do you plan to hurt yourself?" 4. "Are you having trouble at school that is contributing to your depression?" (Rationale: close-ended ? that changes the subject, nontherapeutic communication.)

A nurse is providing education to a parent of a child who has asthma. Which of the following statements by the parents indicates a need for further instruction? 1. "I will be sure my child gets an annual influenza immunization." 2. " I will have my child use his peak flow meter at the same time every day." 3. " I will have my child play inside during cold weather." 4. "I will keep my child from participating in sports."

1. "I will be sure my child gets an annual influenza immunization." (Rationale: children who have asthma are an increased risk for infection; therefore,t hey should have an annual influenza immunization.) 2. " I will have my child use his peak flow meter at the same time every day." (Rationale: child should use a peak flow meter at the same time every day to monitor effectiveness of TX.) 3. " I will have my child play inside during cold weather." (Rationale: Extreme changes in temp. can provoke asthma episode.) Ans. 4. "I will keep my child from participating in sports." (the parent of a child who has asthma should encourage her to stay active. the child may need to use an inhaler prior to exercise.)

As part of the discharge instructions for the parent of a newborn, the nurse is receiving information about measure to prevent SIDS. Which of the following statements by the parent indicates a need for further instruction? 1. "I wont allow anyone to smoke in our house or car." 2. " Because I am breastfeeding my baby, I am helping to reduce the risk of SIDS." 3. "My baby should not have the DTP vaccine because of the risk for SIDS." 4. "It is best for my baby to sleep on her back on a firm crib mattress."

1. "I wont allow anyone to smoke in our house or car." (Rationale: Research indicates a strong correlation between maternal smoking prenatally, exposure to smoke postnatally, and the occurrence of SIDS. the greater the exposure to tobacco smoke, the greater the risk of SIDS.) 2. " Because I am breastfeeding my baby, I am helping to reduce the risk of SIDS." (Rationale: Studies indicate that breastfed newborns have a lower risk for SIDS than formula-fed newborns. Breast milk decreases the occurrence of respiratory and GI infections by enhancing the newborn's immune system.) Ans. 3. "My baby should not have the DTP vaccine because of the risk for SIDS." (Rationale: Many parents may believe there is a risk for SIDS r/t DTP vaccine. However, the correlation between SIDS and the DTP vaccine has been disproved.) 4. "It is best for my baby to sleep on her back on a firm crib mattress." (Rationale: the incidence of SIDS is greater for newborns who sleep on their stomach vs. those who sleep on their back. Soft mattresses and heavy covering are associated with the risk for SIDS.)

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification? 1. Check the client's type and crossmatch against the primary care provider's orders. 2. ask the client to state her blood type prior to beginning blood administration 3. compare information on the blood product to the informed consent form. 4. verify the client and blood product information with another licensed nurse.

1. Check the client's type and crossmatch against the primary care provider's orders. (Rationale: this action validates the provider's orders, but does not ensure proper client identification.) 2. ask the client to state her blood type prior to beginning blood administration (Rationale: client may not know her blood type, and many clients have the same blood type. therefore, this is an inappropriate method to ensure proper client identification.) 3. compare information on the blood product to the informed consent form. (Rationale: nurse should validate that the client has given informed consent; however, comparing the information on the blood product to the informed consent is not an appropriate method to ensure proper client identification.) Ans. 4. verify the client and blood product information with another licensed nurse.

A nurse is developing a client education program about men's health. Which of the following points should the nurse include regarding early detection of prostate cancer? 1. Males should perform monthly testicular self-examination starting at age 16. 2. Digital rectal examinations should be included in biannual physical examinations for men beginning at age 60. 3. Prostate biopsies should be performed every 5 years for men starting at age 55. 4. Annual measurement for prostate specific antigen (PSA) levels should be perforemd for men over 50.

1. Males should perform monthly testicular self-examination starting at age 16. (Rationale: Testicular examinations do not reveal abnormalities in the prostate.) 2. Digital rectal examinations should be included in biannual physical examinations for men beginning at age 60. (Rationale: Male client should have a DRE annually starting @ the age 50 & are an integral part of early detection of prostate cancer.) 3. Prostate biopsies should be performed every 5 years for men starting at age 55. (Rationale: Male clients do not have biopsies routinely unless indicated by lab data and palpation of the prostate that reveals an abnormality.) Ans. 4. Annual measurement for prostate specific antigen (PSA) levels should be perforemd for men over 50. (Rationale: the PSA is a good screening for prostate cancer and is recommended annually for men over 50, PSA levels greater than 4 ng/ml indicates further diagnostic evaluation.)

A nurse is caring for a client who requests pain medication. The nurse notes that morphine 1mg is prescribed IV every 2 to 4 hr. the medication is available in a prefilled syringe dose of 2mg/ml. During preparation of the medication, which of the following is correct action by the nurse? 1. Place the unused portion in the client's medication drawer. 2. Dispose the unused portion in the sharps container 3. Return the unused portion to the pharmacy 4. Have another nurse observe wasting the unused portion

1. Place the unused portion in the client's medication drawer. (Rationale: nurse should not return the unused portion to the medication drawer). 2. Dispose the unused portion in the sharps container (Rationale: nurse should not discard the unused portion it sharps container). 3. Return the unused portion to the pharmacy (Rationale: nurse shouldnt not return unused portion to the pharmacy). Ans. 4. Have another nurse observe wasting the unused portion

An infection control nurse is determining whether infection rates have decreased following a policy revision withing the facility. which of the following types of audits is the nurse performing? 1. process 2. prospective 3. structure 4. outcome

1. process (Rationale: a process audit examines how nursing care is provided.) 2. prospective (Rationale: prospective audit provides prediction about performance in the future based on a new intervention.) 3. structure (Rationale: structure audit includes the evaluation of the availability resources, such as staffing ratios.) Ans. 4. outcome (Rationale: Outcome audit examines data to determine the results from a specific NI.)

A nurse is caring for a client who requires an alternative communication method. Appropriate intervention by the nurse? 1. Use sign language for a client with receptive aphasia 2. suggest that a postoperative laryngectomy client use a pad and pencil to write out her requests 3. use a high-pitched tone when speaking with a hearing impaired client 4. provide a visually impaired client with a communication board to request pain medication.

1. Use sign language for a client with receptive aphasia (Rationale: client w/ receptive aphasia is unable to understand and process language). Ans. 2. suggest that a postoperative laryngectomy client use a pad and pencil to write out her requests (Appropriate intervention) 3. use a high-pitched tone when speaking with a hearing impaired client (Rationale: high pitched sounds are more difficult to hear than low pitched w/ hearing impairment). 4. provide a visually impaired client with a communication board to request pain medication.

A nurse manager is reviewing a newly licensed nurse's performance. Which of the following methods should the nurse manager to evaluate the nurse's time management skills? 1. compare the nurse's time management skills to the skills of her co-workers 2. maintain regular notes about the nurse's time management skills. 3. ask another staff nurse to evaluate the nurses's time management skills. 4. review the client satisfaction reports about how the nurse is performing.

1. compare the nurse's time management skills to the skills of her co-workers. (Rationale: nurse manager should evaluate nurse's time mgmt skills based on est. standards.) Ans. 2. maintain regular notes about the nurse's time management skills. (Rationale: Maintaining notes over a period of time provides a comprehensive view of the nurse's abilities.) 3. ask another staff nurse to evaluate the nurses's time management skills. (Rationale: It's not the responsibility of other staff nurses to provide evaluative data about the nurse's level of time mgmt proficiency to the nurse manager.) 4. review the client satisfaction reports about how the nurse is performing. (Rationale: It is not appropriate to use client satisfaction reports to evaluate an individual nurse's time mgmt performance.)

A nurse is evaluating a client who is taking chlorpromazine. Which of the following findings indicates the medication is effective? 1. decreased BP 2. decreased hallucinations 3. decreased cholesterol 4. decreased esophageal reflux

1. decreased BP (Rationale: Adverse effect: orthostatic hypotension.) Ans. 2. decreased hallucinations This is not a therapeutic effect of chlorpromazine: 3. decreased cholesterol 4. decreased esophageal reflux

A nurse is caring for a client who is experiencing a hemolytic transfusion reaction and is receiving mannitol. the nurse should monitor for which of the following therapeutic effects? 1. decreased wheezing 2. increased diuresis 3. resolution of rash 4. prevention of infections

1. decreased wheezing (Rationale: Nurse should monitor for decreased wheezing for a client who is being treated for an anaphylactic transfusion rxn). Ans. 2. increased diuresis (Rationale: Mannitol casuses osmotic diuresis for the TX of a hemolytic transfusion rxn). 3. resolution of rash (Rationale: Nurse should monitor for resolution of rash for a client who is being treated for an anaphylactic transfusion rxn). 4. prevention of infections (Rationale: nurse should monitor for prevention of infection with a bacterial infection rxn).

A nurse observes a client's urine output is 15ml/hr. Which of the following additional assessment data is indicative of fluid volume deficit? 1. elastic skin turgor 2. bradycardia 3. decreased BUN levels 4. orthostatic hypotension

1. elastic skin turgor (Rationale: poor skin turgor indicates FVD.) 2. bradycardia (Rationale: tachycardia indicates FVD) 3. decreased BUN levels (Rationale: increased BUN indicates FVD.) Ans. 4. orthostatic hypotension

A nurse recognizes that a provider's Rx is inappropriate for a client. the nurse ?s the provider about the Rx, but the provider insists that the nurse follow the order as written. Action should the nurse take? 1. follow through on the Rx written 2. contact the on-call provider 3. establish a common goal with the provider 4. bring the issue to the charge nurse's attn.

1. follow through on the Rx written (Rationale: nurse can be held liable for carrying out a Rx that is unsafe.) 2. contact the on-call provider (Rationale: does not follow nurse's chain of command.) 3. establish a common goal with the provider (Rationale: while establishing a common goal is a conflict resolution technique, there is nothing for the nurse to negotiate. the nurse's goal is to ensure safe care.) Ans. 4. bring the issue to the charge nurse's attn. (Rationale: nurse should follow the chain of command to resolve this conflict and to ensure safe client care; therefore, speaking with the charge nurse about the Rx is an appropriate action.)

A nurse is caring for a client in the ED who is being transported to surgery when the nurse realizes the consent form has not been signed. The client speaks Spanish and does not understand the nurse when she speaks. Which of the following actions is appropriate for the nurse to take? 1. have the client sign a consent form that has been translated in Spanish 2. have an official interpreter provide translation 3. ask a coworker who speaks Spanish to translate 4. Ask a bilingual family member to act as an interpreter.

1. have the client sign a consent form that has been translated in Spanish (Rationale: Not the nurse's scope of practice to obtain informed consent. This action implies the nurse is providing the information.) Ans. 2. have an official interpreter provide translation 3. ask a coworker who speaks Spanish to translate (Rationale: Speaking the client's language s not the only criteria for acting as an interpreter. The coworker must have specific training to provide translation.) 4. Ask a bilingual family member to act as an interpreter (Rationale: Family members are not medically trained and may not convey accurate interpretation of procedures & risks.)

A nurse is caring for a client following an esophagogastroduodenoscopy (EGD). Which of the following findings should the nurse report to the provider? 1. hoarse voice 2. hypoactive bowel sounds 3. cool, clammy skin 4. low grade fever

1. hoarse voice (Rationale: Following an EGD, a hoarse voice is an expected finding.) 2. hypoactive bowel sounds (Rationale: the client have been NPO for at least 6 hr prior to the procedure so it's an expected finding.) Ans. 3. cool, clammy skin (Rationale: It's a clinical manifestation of hypovolemic shock which can occur with perforation of the bowel and is a complication of EGD.) 4. low grade fever (Rationale: the client may be dehydrated from being NPO causing a low grade fever.)

A 23 y.o. female client has been admitted to the ED following MVA. A portable x-ray is ordered of the left femur. Interventions should nurse take before the procedure? 1. hold the client's leg to prevent movement 2. support the client's leg with a pillow and sand bags 3. cover the client's pelvic area with a lead shield. 4. assist the client to lie on the unaffected side.

1. hold the client's leg to prevent movement (Rationale: nurse hand will interfere with the x-ray) 2. support the client's leg with a pillow and sand bags (Rationale: pillow and sandbags could distort x-ray). Ans. 3. cover the client's pelvic area with a lead shield. (Rationale: clients is female and child bearing age. the lead shield will protect the uterus from x-ray exposure). 4. assist the client to lie on the unaffected side. (Rationale: this position will not provide an adequate view of the femur).

A nurse is assessing a client after administering epinephrine for an anaphylactic rxn. the nurse should monitor the client for which of the following adverse effects of this medication? 1. hypotension 2. report of tinnitus 3. report of chest pain 4. ecchymosis

1. hypotension (Rationale: Epi is a sympathetic (adrenergic) agent that stimulate the heart, thereby, increasing HR & raising BP.) 2. report of tinnitus (Rationale: Epi does not cause tinnitus.) Ans. 3. report of chest pain (Rational: Epi is a sympathetic (adrenergic) agent that stimulate the heart. This increases cardiac work load and oxygen demand, which can result in angina.) 4. ecchymosis (Rationale: Epi does not cause ecchymosis.)

A nurse is preparing to transfer a client who is postoperative following a pneumonectomy and was recently weaned from mechanical ventilation and transferred from the ICU to the medical-surgical unit. Which of the following is necessary to include in the transfer report? 1. last time the provider visited the client 2. ventilator settings the client had in the ICU 3. the client's last does of pain medication 4. how frequently the client uses the call light

1. last time the provider visited the client (Rationale: nurse does not need to know in order to plan and implement care for the client.) 2. ventilator settings the client had in the ICU (Rationale: not necessary for the transfer report b/c the client is no longer receiving mechanical ventilation.) Ans. 3. the client's last does of pain medication (Rationale: nurse needs to know when the client last received medication in order to plan and implement care.) 4. how frequently the client uses the call light (Rationale: nurse does not need to know in order to plan and implement care for the client.)

A nurse is caring for a client who has active TB and is admitted to the unit. Which of the following precautions should the nurse implement to prevent the transmission of the disease? 1. maintain contact precaution 2. restrict visitors from visiting the client 3. wear a surgical mask during contact with the client 4. have the client wear a mask while being transported outside the room.

1. maintain contact precaution (Rationale: nurse should initiate airborne precaution, mycobacterium TB is transmitted by air in nuclei smaller than 5 microns.) 2. restrict visitors from visiting the client (Rationale: unnecessary if proper transmission precautions are taken.) 3. wear a surgical mask during contact with the client (Rationale: nurse should wear an N95 or HEPA respirator when caring for a client who has active TB.) Ans. 4. have the client wear a mask while being transported outside the room.

A nurse is assessing a client who is near the end of her first trimester during a routine prenatal exam. When checking to determine if the FHR can be detected, the nurse should 1. move the doppler stethoscope around the area at the level of the umbilicus until the FHR is heard 2. count the FHR and note its quality and rhythm in conjunction with uterine activity 3. place the scope midline just above the symphysis pubis and apply firm pressure. 4. perform Leopold's maneuver to palpate the fetal position and determine the location of the FHR

1. move the doppler stethoscope around the area at the level of the umbilicus until the FHR is heard (Rationale: During 1st trimester, the FHR is not located at the level of umbilicus.) 2. count the FHR and note its quality and rhythm in conjunction with uterine activity (Rationale: Evaluation of uterine activity requires toco. Nurse cannot measure uterine activity during 1st trimester.) Ans. 3. place the scope midline just above the symphysis pubis and apply firm pressure. 4. perform Leopold's maneuver to palpate the fetal position and determine the location of the FHR (Rationale: Leopold not appropriate for 1st trimester.)

A nurse is performing an assessment on a 12 y.o. child who has bacterial meningitis. Which of the following findings should alert the nurse that the child may be experiencing increased intracranial pressure (IICP)? 1. nuchal rigidity 2. petechial rash 3. memory loss 4. kernig's sign

1. nuchal rigidity (Rationale: Manifestation of bacterial meningitis; not a sign of IICP.) 2. petechial rash (Rationale: specific to meningococcal meningitis C.) Ans. 3. memory loss 4. kernig's sign (Rationale: Manifestation of bacterial meningitis; not a sign of IICP.)

A nurse is caring for a client who is taking valproic acid for seizure control. Which side effects should the nurse monitor and report? 1. peripheral edema 2. jaundice 3. bradycardia 4. polyuria

1. peripheral edema (Rationale: can result with an OD of this medication) Ans. 2. jaundice (Rationale: Clients who take valproic acid are @risk for liver damage --> jaundice. Not an adverse effect of this medicaion: 3. bradycardia 4. polyuria

A nurse is caring for a client with a closed-head injury who has been placed on seizure precautions. Which of the following situations should the nurse make in the client's environment? 1. place a padded tongue blade at the bedside 2. maintain side rails in a lowered position 3. remove unused peripheral IV catheters 4. set up suctioning equipment at the bedside

1. place a padded tongue blade at the bedside (Rationale: nurse should not place anything in the mouth of client who is experiencing seizure --> damage to the the teeth and present a risk for aspiration of tooth fragments.) 2. maintain side rails in a lowered position (Rationale: nurse should keep the side rails up at all times to prevent injuring from falling out of bed.) 3. remove unused peripheral IV catheters (Rationale: If the client has any unused peripheral IV catheters in place, the nurse should not remove them as the client may need to receive IV medication if a seizure occurs.) Ans. 4. set up suctioning equipment at the bedside

An RN has delegated movement of a client up in bed to a licensed practical nurse (LPN) and an assistive personnel (AP). RN should intervene if she makes which of the following observations? 1. the side rails are lowered before lifting the client up in the bed 2. prior to lifting the client, the bed is put in high position 3. the AP and the LPN grasp the client under the arms to lift him up in the bed 4. the LPN asks the clients to flex his knees and push his heels into the bed as he is lifted.

1. the side rails are lowered before lifting the client up in the bed (Rationale: LPN and AP should lower the side rails to avoid reaching over the rails to lift the client) 2. prior to lifting the client, the bed is put in high position Ans. 3. the AP and the LPN grasp the client under the arms to lift him up in the bed (Rationale: LPN and AP SHOULD NOT grasp the client under the arms when lifting the client --> result in shoulder dislocation). 4. the LPN asks the clients to flex his knees and push his heels into the bed as he is lifted.

A nurse is assessing an older adult client who has delirium. Expected finding? 1. unaware of cognitive changes 2. gradual decline in memory 3. fluctuating LOC 4. level of agitation remains constant throughout the day

1. unaware of cognitive changes (Rationale: Client who has delirium is often aware of cognitive changes.) 2. gradual decline in memory (Rationale: Client who has delirium usually has an acute memory deficit.) Ans. 3. fluctuating LOC 4. level of agitation remains constant throughout the day (Rationale: Client's level of agitation becomes more pronounced in the evening.)

A nurse is caring for a client who is undergoing radiation therapy. The nurse notes a large area of dry, shiny red skin over the client's neck and clavicular area. Which of the following instructions regarding skin care should the nurse give the client? 1. use a soft washcloth to gently exfoliate the area 2. cover the area with an occlusive dressing 3. apply an antihistamine cream to area of redness 4. wash the area with mild soap and water

1. use a soft washcloth to gently exfoliate the area 2. cover the area with an occlusive dressing 3. apply an antihistamine cream to area of redness 4. wash the area with mild soap and water

A nurse is providing teaching about self-administration of insulin to a client who has a new Rx for a short-acting and active intermediate-acting insulin. Action by the client indicates teaching is effective? 1. withdraws the intermediate-acting insulin before the short-acting insulin 2. injects the insulin into the deltoid muscle 3. pinches the skin prior to injecting the insulin 4. inserts the needles at a 30deg angle

1. withdraws the intermediate-acting insulin before the short-acting insulin (Rationale: when mixing insulin, short-acting first before intermediate. this prevents contaminating the short-acting with the protein in the intermediate.) 2. injects the insulin into the deltoid muscle (Rationale: inject insulin in to the subQ tissue) Ans. 3. pinches the skin prior to injecting the insulin 4. inserts the needles at a 30deg angle (Rationale: Should be 45 to 90 deg angle to access subQ tissue)

A nurse is caring for a school-age who is taking valproic acid. the nurse should expect the provider to order which of the following diagnostic tests? 1. CXR 2. serum liver enzyme levels 3. ABG 4. Urine C&S

Ans. 2. Serum liver enzyme levels (Rationale: Valproic acid may cause hepatic toxicity.) It is not necessary to assess: 1. CXR 3. ABG 4. Urine C&S

A nurse is preparing to administer ranitidine 50mg intermittent IV bolus. Available is ranitidine 50mg in 100ml D5W to infuse over 30 min. The nurse should set the IV infusion pump to deliver how many ml/hr? (Round to the nearest whole number.)

200 ml/hr

A newly licensed nurse reports to his preceptor concerns about his ability to complete assignments. Which of the following time-management strategies is appropriate for the preceptor to suggest? SATA 1. Group activities together that should be performed on the same client. 2. Ensure that all equipment has been gathered for a procedure before entering a client's room. 3. document NI @ the end of the shift 4. delegate selected tasks to an assistive personnel. 5. develop a schedule that prioritize client care

Ans. 1, 2, 4, 5 1. Group activities together that should be performed on the same client. (Rationale: grouping eliminates the time lost moving from client's room to another). 2. Ensure that all equipment has been gathered for a procedure before entering a client's room. (Rationale: Gathering equipment ensure that all equipment is available and eliminates time lost). 3. document NI @ the end of the shift (Rationale: Nurse should document NI all throughout the day as she provides nursing care. Otherwise, the nurse may spend time trying to recall info re care provided earlier or may recall it inaccurately) 4. delegate selected tasks to an assistive personnel. (Rationale: Appropriate use of AP relieves the nurse of tasks that other staff members can complete) 5. develop a schedule that prioritize client care (Rationale: helps organize her day and make decisions about the timing of care)

A nurse is caring for a newborn whose parents ask why her baby is receiving Vitamin K. the nurse should explain to the parent that the medication will prevent which of the following? 1. bleeding 2. potassium deficiency 3. infection 4. hyperbilirubinemia

Ans. 1. bleeding (Rationale: Vitamin K is routinely given to newborn to prevent bleeding) Vitamin K does not prevent: 2. potassium deficiency 3. infection 4. hyperbilirubinemia

A nurse is caring for a client who is in active labor and receiving oxytocin. the FHR pattern shows variability with accelerations. Appropriate nursing response? 1. document and continue to monitor. 2. administer oxygen 8-10 L/min via a mask 3. Place client in a side-lying position 4. discontinue the infusing oxytocin

Ans. 1. document and continue to monitor. (Rationale: variable accelerations are a reassuring FHR pattern indicating an intact fetal CNS and a placental/fetal exchange of oxygen. nurse should continue to monitor the client. 2. administer oxygen 8-10 L/min via a mask (Rationale: appropriate intervention 4 fetal tachycardia & variable deceleration of FHR) 3. Place client in a side-lying position (Rationale: appropriate intervention 4 fetal bradycardia, late deceleration, decrease or loss of FHR variability & variable deceleration of FHR). 4. discontinue the infusing oxytocin (Rationale: appropriate intervention 4 late deceleration & variable deceleration of FHR)

A nurse is caring for a client who is recovering from a CVA and is being transferred to rehab facility. the client's family is concerned that the client will not receive the appropriate level of care. which of the following actions will address the family's concern? 1. facilitate an interdisciplinary conference at the new facility for the family 2. refer the client and family to social services for counseling and follow-up meeting 3. reassure the client's family that the same provider will provide care at the new facility 4. tell the family that the rehab facility has an excellent record.

Ans. 1. facilitate an interdisciplinary conference at the new facility for the family 2. refer the client and family to social services for counseling and follow-up meeting (Rationale: No indication family needs referral to social services). 3. reassure the client's family that the same provider will provide care at the new facility (Rationale: provides false reassurance). 4. tell the family that the rehab facility has an excellent record. (Rationale: inappropriate and provides false reassurance)

An older client with limited mobility reside in a LTC facility. the client asks the nurse why he has a hand roll in each hand. the nurse explains which of the following as being the purpose of the hand roll? 1. maintains a functional position 2. decrease muscle spasticity 3. increases joint mobility 4. improves hand and grip strength

Ans. 1. maintains a functional position (Rationale: A hand roll keeps the thumb placed slightly inward towards the fingers, maintaining functional position). 2. decrease muscle spasticity (Rationale: TX for spasticity vary based on the cause, & may include PT, OT, & surgery). 3. increases joint mobility (Rationale: nurse can use active & passive ROM to increase joint mobility and prevent contractures) 4. improves hand and grip strength (Rationale: hand and wrist exercises to improved hand and grip strength

A client who has impaired vision is discharged home. Which of the following actions indicates that the client's family understands safety measures to prevent injury? 1. marks step edges with colored tape 2. establishes a TTD phone line 3. encourages an exercise routine to improve balance 4. removes carpeting from the stairs

Ans. 1. marks step edges with colored tape (Rationale: marking step edges with colored tape helps the client see the steps and decreases the risk of falls.) 2. establishes a TTD phone line (Rationale: a client who has a hearing impairment will benefit from a TTD phone.) 3. encourages an exercise routine to improve balance (Rationale: a client who has a coordination impairment will benefit from an exercise routine to improve balance.) 4. removes carpeting from the stairs (Rationale: removing carpeting from the stairs increases the client's risk of falling.)

A nurse is caring for a client who is @risk for developing diabetes insipidus. The nurse should plan to monitor the client for which of the following? 1. polyuria 2. hypglycemia 3. bradycardia 4. hypothermia

Ans. 1. polyuria (Rationale: the nurse shoudl monitor the client for increased urine output, caused by a deficiency of ADH.) 2. hyperglycemia (Rationale: Monitor for HYPOglycemia) 3. bradycardia (Rationale: Monitor for TACHYcardia) 4. hypothermia (Rationale: Monitor for HYPERthermia)

A night shift nurse is giving verbal change of shift report to the oncoming nurse for a client who s scheduled to be discharged in the morning. Which of the following info is the most important for the nurse to communicate to the oncoming nurse? 1. the client needs assistance when transferring from the bed to a wheelchair 2. the client is scheduled to have a visit by a home health nurse tomorrow 3. the client's wife will bring clothes for him to change into prior to discharge 4. the client often needs encouragement in personal hygiene activites

Ans. 1. the client needs assistance when transferring from the bed to a wheelchair (Rationale: greatest risk to this client is injury d/t a fall; therefore, the priority info to communicate is that the client needs assistance during transfer.) These are appropraite information to communicate. However, it does not address the greatest risk to the client and is therefore, not the priority: 2. the client is scheduled to have a visit by a home health nurse tomorrow 3. the client's wife will bring clothes for him to change into prior to discharge 4. the client often needs encouragement in personal hygiene activites