CPNRE Exam Prep

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75 yr old pt with tuberculosis, and has been placed on isolation precautions since being admitted to the hospital. What would offer the best protection to the PN when providing direct care to the pt? 1. A mask 2. Sterile gloves 3. A gown 4. Goggles

1. A mask

Mrs. Proud, 32 years old, is pregnant for the third time. Her first pregnancy ended at 17 weeks gestation and her second child was delivered at 36 weeks gestation. Two hours after delivery, Mrs. Proud's fundus is firm, three finger breadths above the umbilicus, displaced to the right side, the size of a large grapefruit and slightly tender. She has a moderate amount of lochia rubra. What is the best action for the PN to take? 1. Ask Mrs. Proud to void and re-assess the fundus 2. Check when Mrs. Proud last received analgesic medication 3. Notify the physician of the findings and monitor closely 4. Massage the fundus until it returns midline

1. Ask Mrs. Proud to void and re-assess the fundus Suggestive of full bladder displacement Only massage fundus to midline AFTER voiding

When should the PN have a replacement IV bag ready to hang? 1. At least 1 hour before needed 2. When the IV bag is empty 3. When the drip chamber is half full 4. As the solution empties into the drip chamber

1. At least 1 hour before needed : prevents finding a bag without having a replacement bag available

Mrs. Mayhew, 72 years old, has been admitted to hospital with chronic obstructive pulmonary disease (COPD). She is accompanied by her daughter, Adrianna, who indicates that her mother's condition has deteriorated. Mrs. Mayhew is to be discharged today. Which activity should the PN suggest to promote Mrs. Mayhew's independence? 1. Be as active as possible without increasing SOB 2. Walk to the corner store once a day 3. Do all housework at one time so she can rest afterward 4. Go to the mall to avoid social isolation

1. Be as active as possible without increasing SOB : this would allow client to do activity as tolerated Walking every day is unrealistic goal Housework too demanding High risk of infection by going to the mall

Mr. Spencer, 52 yr old with schizophrenia,lives in an apartment building. The PN visits daily for med admin and a mental status assessment. Lately, there have been reports from other tenants that Mr. Spencer hammers on the walls and yells for the noises to go away.Mr. Spencer risks being evicted if he does not stop. During today`s visit, Mr. Spencer is pacing,stating that the noises in his head are loud, and he had his hands over his ears. He has not bathed lately and his apartment has garbage on the floor. How should the PN document the visit to Mr. SPencer`s apartment? 1. Client pacing, states noises are loud, unkempt presentation, garbage all over floor.Landlord reports client is yelling and hammering on the walls and could get evicted if behavior does not stop. 2. Client agitated and behaving inappropriately. Landlord reports client yelling and hammering on the wall and may get evicted. Client unkempt and apartment unclean. 3. Client pacing and is hallucinating. Landlord reports that client is yelling loudly, is hammering on the walls and he could get evicted if the behavior does not stop. Apartment is a mess. 4. Landlord states tenants are complaining and client may be evicted due to inappropriate activity in client's apartment. Client is dirty and unkempt.

1. Client pacing, states noises are loud, unkempt presentation, garbage all over floor.Landlord reports client is yelling and hammering on the walls and could get evicted if behavior does not stop.

Mrs. Hart is 39 years old, married with two children aged 10 and 13. She is admitted for mastectomy following a diagnosis of right breast cancer. She is fearful the cancer has spread and is anxious about the future for herself and her family. On the second postoperative day, which action by the practical nurse would be most appropriate when assisting Mrs. Hart with morning care? 1. Encourage Mrs. Hart to brush her hair using her hand on her affected side 2. Suggest to Mrs.Hart that she avoid looking at the incision until the drain is removed 3. Recommend to Mrs. Hart that she wear a hospital gown so as not to soil her clothing 4. Give Mrs. Hart perineal care to avoid strain on her affected arm and hand

1. Encourage Mrs. Hart to brush her hair using her hand on her affected side : exercises the affected arm and promotes independence Inappropriate to encourage self-image issues Psychologically better for breast cancer pt's to wear normal clothing as soon as possible Mrs. Hart should be independent and perform her own care

Mr. Gerald, 82 years old, is a resident of a long-term care facility. He has become quiet and sits alone in his room all day. Which nursing intervention would best assist the PN in identifying the reason for his social isolation? 1. Establish whether hearing and vision deficits exist 2. Ask his family to describe his typical behavior 3. Arrange a psychiatric assessment 4. Check his blood work for an electrolyte imbalance

1. Establish whether hearing and vision deficits exist : older clients who have difficulty with hearing or vision will often isolate themselves. Asking family should involve identifying the primary care contact Assessment of client required first

Ms. May, 78 years old, is admitted to the palliative care unit. What information would help the PN best determine Ms. May's spiritual needs? 1. Her sources of strength and meaning of life 2. Her level of knowledge regarding her prognosis 3. Her pre-planned funeral preferences 4. Her resuscitation status and advance directives

1. Her sources of strength and meaning of life

Derek, a 17 yr old is admitted to the surgical unit following a skiing accident. He has two fractured ribs, a fractured left wrist and a fractured left femur. Be has a cast on his wrist. After the PN assesses the pt injuries, what will require immediate action? 1. Left fingers have some movement with a capillary refill of 4 seconds 2. Left foot has a palpable pedal pulse and is slightly cooler than the right 3. Left fingers are slightly swollen and bruised 4. Left foot is warm with some pain on movement

1. Left fingers have some movement with a capillary refill of 4 seconds

Mrs. Mayhew, 72 years old, has been admitted to hospital with chronic obstructive pulmonary disease (COPD). She is accompanied by her daughter, Adrianna, who indicates that her mother's condition has deteriorated. When taking Mrs. Mayhew's vital signs, the practical nurse assesses her respiration at 24 breaths/min. Which action should the practical nurse take first? 1. Obtain further information prior to reporting the findings 2. Report the findings immediately to the nurse-in-charge 3. Inform the physician during the next visit 4. Document the respiration rate on the vital signs record

1. Obtain further information prior to reporting the findings : Full chest assessment should be done prior to reporting and documenting

A pt, 68 years old, has chronic renal failure. She has been on peritoneal dialysis for the past 2 years. Her daughter brought her to the Emergency Department last night with a fever. Infection of her peritoneal dialysis catheter is suspected. The PN checks her blood test results. NA and creatinine are elevated and her potassium is 6mmol/L. When health teaching which food should the PN encourage her to avoid consuming? 1. Orange juice 2. Green beans 3. Breads 4, Pineapple

1. Orange juice

Mr. Spencer, 52 yr old with schizophrenia,lives in an apartment building. The PN visits daily for med admin and a mental status assessment. Lately, there have been reports from other tenants that Mr. Spencer hammers on the walls and yells for the noises to go away.Mr. Spencer risks being evicted if he does not stop. During today`s visit, Mr. Spencer is pacing,stating that the noises in his head are loud, and he had his hands over his ears. He has not bathed lately and his apartment has garbage on the floor. The PN needs to advocate for the client. What is the best way to accomplish this? 1. Request that a social worker meet with Mr. Spencer about his situation. 2. Go to the landlord, apologize on behalf of the client and propose a new plan of care. 3. Ask the landlord to allow more time before evicting Mr. Spencer 4. Inform Mr. Spencer that he must apologize to the landlord immediately

1. Request that a social worker meet with Mr. Spencer about his situation.

Mr. Goldwing, 68 years old, has Parkinson's disease. He has been admitted to an acute care unit, accompanied by his wife. Laboratory results indicate that Mr. Goldwing's hemoglobin is 80g/dL. The physician orders 2 units of packed cells. What should the PN do first? 1. Take his temperature, blood pressure, pulse and respiration rate. 2. Prime the blood administration set with D5W 3. Have the physician contacted to verify the order 4. Ensure that the emergency cart is in the room

1. Take his temperature, blood pressure, pulse and respiration rate Baseline vitals are always necessary before a transfusion D5W should NOT be used for blood transfusions; only normal saline

Mrs. Mayhew, 72 years old, has been admitted to hospital with chronic obstructive pulmonary disease (COPD). She is accompanied by her daughter, Adrianna, who indicates that her mother's condition has deteriorated. Mrs. Mayhew goes for a walk down the hallway. What is correct documentation by the PN? 1. Walking in hallway with no shortness of breath 2. Mrs. Mayhew up walking in hallway 3. Tolerating activities well 4. Activites of daily living completed this morning

1. Walking in hallway with no shortness of breath : most detailed documentation is the most accurate DO NOT include name in clients charting. Obviously about client

Mrs. Wong, 74 years old, has been admitted to a medical unit with a diagnosis of tuberculosis (TB). She has an order for oxygen 3L/min via nasal cannula prn Mrs. Wong is in an isolation room and has airborne precautions in place. Because Mrs. Wong does not speak English, her daughter visits frequently. The PN sees MRs. Wong's daughter in the hall. She approaches the daughter, who states that she finds it difficult to speak with her mother while wearing a mask. What is the most appropriate response for the PN to make? 1. "Hospital policy states that all clients with TB must be placed in isolation" 2. "It's very important for you to wear the mask for your own protection." 3. "It will be okay. It is dangerous for you to be exposed to your mother's disease." 4. "It must be very frustrating. Try speaking loudly so she can hear you."

2. "It's very important for you to wear the mask for your own protection." : most therapeutic response provides health teaching and a rationale for why. Stating hospital policy is too dismissive Stating it will be okay is false reassurance The issue is not about hearing; it is about protection and ease of communication telling to speak louder is not therapeutic

Mr. Rao, 45 years old, has been admitted following an open cholecystectomy. He has a nasogastric (NG) tube in place connected to suction and an IV. The physician ordered 5,000 units of heparin sodium (Hepalean) subcutaneous twice a day. The vial of heparin sodium contains 10,000 units/1mL. How much sodium should the PN withdraw? 1. 0.2mL 2. 0.5mL 3. 2mL 4. 5mL

2. 0.5mL Remember dose ordered over/ dose on hand

What is max volume that can be injected subcutaneously? 1. 0.5mL 2. 1mL 3. 2mL 4. 3mL

2. 1mL Anything greater is IM split up into two separate injections

The PN arrives to help out on a busy surgical unit. The clerk informs the PN that one client ahs been ringing for a bedpan for 10 minutes, another client has been calling out for pain medication for 5 minutes, and another client has just arrived from the operating room. Also, a visitor a the desk is demanding to speak to someone about her mother. In what order should the PN proceed? 1. Speak to the visitor and then assess the client from the operating room 2. Assess the client form the OR and get the client medication for pain 3. Give the client the bedpan and the other client medication for pain 4. Get the client medication for pain and then assess the client from the operating room

2. Assess the client form the OR and get the client medication for pain : client from OR should be assessed immediately for post-op risks and pain should be addressed ASAP

Before changing an IV container, which action should be taken by the PN first? 1. Review the client's intake/output for the shift 2. Check the physicians orders 3. Gather the necessary equipment 4. Explain the procedure to the client

2. Check the physicians orders : Any time there is a break in the IV line, the physician's orders should be checked. Reviewing client intake/output is important but FIRST check the order is correct Dr's orders should be checked before gathering equipment The PN should be aware of the Dr's orders before explaining procedures

2. Dry Skin : hypothyroid-like state manifested by dry skin More likely to experience hypothermia; lanugo (baby-like fine hair) of the face, extremities and trunk may occur, and hypotension.

Derek, a 17 yr old is admitted to the surgical unit following a skiing accident. He has two fractured ribs, a fractured left wrist and a fractured left femur. Be has a cast on his wrist. What should be included when teaching Derek about decreasing the risk of respiratory complications? 1. Splint chest with both hands when coughing 2. Encourage the use of an incentive spirometer 3. Alternate position frequently from side to side 4. Use the overhead trapeze to facilitate mobility

2. Encourage the use of an incentive spirometer

Ms. O'Connor, 67 years old, has been living alone in her family home. She has just been admitted by ambulance to an acute care facility. She has acute osteoarthritis and this has made self-care impossible. Upon admission, the physician has ordered Ms. O'Connor to be on complete bed rest for 48 hours. Ms. O'Connor's condition has been slowly improving over the past 5 days and she is now allowed to ambulate with the use of a walker. What should the PN do to promote Ms. O'Connor's safety when she is assisted from the bedside to the walker? 1. Assess Ms. O'Connor's motivation for ambulating with a walker. 2. Ensure that Ms. O'Connor is wearing well-fitting, non-skid shoes 3. Instruct Ms. O'Connor to place her feet about 5cm apart 4. Encourage Ms. O'Connor to hold her back straight and to look ahead

2. Ensure that Ms. O'Connor is wearing well-fitting, non-skid shoes : lessen the risk of slipping during the transfer Clients with arthritis should be assessed for their fatigue level, not their motivational level Ms. O'Connors feet should be placed 15-20 cm apart to provide a wide base of support This action will be maintain good posture but not safe transfer

When using a mechanical lift to transfer Mr. Gosselin, 42 years old, from bed to chair, what should the PN do first? 1. Place the bed in the lowest horizontal position 2. Ensure that the brakes are locked on his bed 3. Place Mr.Goselin in high-Fowler's position 4. Lower both side rails for good body mechanics

2. Ensure that the brakes are locked on his bed: promotes client safety and should be done before starting transfer Bed should be raised to comfortable working height optimal for body Sling must be applied while the client is in supine position Only side rail on the side that the lift is happening should be lowered at first

A pt, 68 years old, has chronic renal failure. She has been on peritoneal dialysis for the past 2 years. Her daughter brought her to the Emergency Department last night with a fever. Infection of her peritoneal dialysis catheter is suspected. The pt is started on IV therapy what complication is most likely to occur bc of renal failure? 1. Infiltration 2. Fluid Overload 3. Dehydration 4. Urinary retention

2. Fluid Overload

Mr. Rao, 45 years old, has been admitted following an open cholecystectomy. He has a nasogastric (NG) tube in place connected to suction and an IV. Mr. Rao's dressing is saturated with serosanguineous drainage. How should the PN cleanse the wound? 1. From distal to proximal 2. From proximal to distal 3. From medial to proximal 4. From proximal to medial

2. From proximal to distal - most preventive of organisms entering the wound Distal to proximal encourages debris to enter the wound because of dragging across medial Cleaning medial first encourages debris from dirty sides to enter the wound * When cleaning wounds or drain sites, clean from the least to most contaminated area, away from wound edges

75 yr old pt with tuberculosis, and has been placed on isolation precautions since being admitted to the hospital. While in the pt room doing routine care, what is the most crucial health information about TB that the practical nurse should provide to the pt? 1. His contacts do not need to worry about contracting TB 2. He must comply with medication protocol on discharge 3. He should follow a well-balanced diet 4. His fluid intake should ensure adequate hydration

2. He must comply with medication protocol on discharge

Ms. Roach, 41 years old, asks the practical nurse why his IV must be checked after he has been out of bed. How should the PN respond? 1. Moving can affect reaction to the IV infusion 2. Moving may change the rate of flow 3. Moving is likely to dislodge the needle 4. Moving can disturb the regulation clamp

2. Moving may change the rate of flow Pt will react the same to IV infusion regardless of movement Unlikely for IV to become dislodged Regulation clamp wouldn't be disturbed

Mr. Dixon, 91 years old, has glaucoma. The Dr has ordered opthalmic drops. Which factor should the PN take into consideration following the administration of the eye drops? 1. Instruct Mr. Dixon to squeeze his eyelid shut 2. Press on the nasolacrimal duct for several seconds 3. Gently wipe excess fluid from outer to inner canthus 4. Teach Mr. Dixon to hyperextend his head for 5 minutes

2. Press on the nasolacrimal duct for several seconds : prevents medication from running out of the eye and down the duct Client should gently close eyes to avoid squeezing medication out From outer to inner canthus is wrong way; excess fluid wiped from inner to outer canthus Hyperextending head not necessary

A 10 month old lives on a busy family farm where pesticides are used. Her father, who handles pesticides, changed his clothes following a spray but left his boots by the back door. Later in the day, the baby is found playing near the back door. She quickly shows signs of illness and is rushed to the hospital. The PN is acting as a liaison between the inter-professional team and the family, and provides frequent updates on the babies condition. What environment would be most appropriate for the PN to use to communicate with Emily's family? 1. Hospital waiting room 2. Private room 3. Hospital chapel 4. Babies room

2. Private room

Mr. Rao, 45 years old, has been admitted following an open cholecystectomy. He has a nasogastric (NG) tube in place connected to suction and an IV. Mr. Rao pulls his IV out. What should the PN do first? 1. Put on sterile gloves and elevate the extremity 2. Put on clean gloves and apply pressure 3. Apply pressure to the site and notify the nurse-in-charge 4. Stop the IV and prepare for reinsertion

2. Put on clean gloves and apply pressure : follow standard precautions, client will be bleeding so need to prevent hemorrhaging Elevating the extremity won't be effective; and notifying another HCP isn't necessary right now; re-insertion isn't the priority.

Mrs. Peterson, 72 years old, is receiving a blood transfusion. Two hours later, the practical nurse notices that the client has become dyspneic and her heart rate has increased from 76 to 104 beats/min. What should the PN do first? 1. Auscultate the clients chest 2. Stop the transfusion 3. Verify the clients O2 saturation levels 4. Take the clients temperature

2. Stop the transfusion : client is having adverse blood reaction most likely due to circulatory overload. Circulatory volume too high for client's heart to manage Auscultation of chest and O2 stats would occur after stopping transfusion Pyrexia can occur with circulatory overload but stopping the transfusion is most important

Ms. O'Connor, 67 years old, has been living alone in her family home. She has just been admitted by ambulance to an acute care facility. She has acute osteoarthritis and this has made self-care impossible. Upon admission, the physician has ordered Ms. O'Connor to be on complete bed rest for 48 hours. Which action by the PN would be most helpful in assisting Ms. O'Connor to use the bedpan? 1. Warm Ms. O'Connor's metal bedpan by rinsing it with warm water 2. Turn Ms. O'Connor on her side and then roll her onto a fracture (slipper) bedpan 3. Raise Ms. O'Connor to high-Fowler's position and have her lift her pelvis 4. Leave Ms. O'Connor with the privacy drapes pulled and allow 15 minutes before returning

2. Turn Ms. O'Connor on her side and then roll her onto a fracture (slipper) bedpan : Rolling takes less energy than lifting. Therefore, it is much easier for a client with arthritis. In addition, the fractured bedpan is more comfortable for the client to use due to it's shallow depth. Metal bedpans are not helpful to clients with osteoarthritis High fowler's is too high for this client Leaving a client with arthritis on the bedpan for 15 minutes could promote joint discomfort and pain. The PN needs to ensure the call bell is within reach

Mrs. Sopczak, 65 years old, had back surgery. What would the PN use to logroll her in bed? 1. Trapeze 2. Turning sheet 3. Trochanter Roll 4. Sliding board

2. Turning sheet : maintains spinal alignment Trapeze encourages spinal twisting Trochanter rolls used to prevent external rotation of the hip not used for logrolling Sliding board doesn't help people turn

2. Upper arm

Mrs. Hutmacher, 67 years old, received teaching regarding changing his colostomy appliance. How could the PN best assess Mr. Hutmacher's learning? 1. Ask what problems he has had with the appliance 2. Watch him change his appliance 3. Check if the appliance is properly attached 4. Look at his appliance site

2. Watch him change his appliance : client demonstration best indication of learning Asking to state problems may result in pt saying nothing Checking the appliance only shows what it should look like not the right technique Site does not determine changing abilities

Jared 4 years old is diagnosed with acute bronchial asthma. Jared's mother states, " The physician told me that smoking makes his asthma worse. Is this true? I want to quit, but I just don't know how to." What is the best response for the PN to make? 1. "You should discuss this with your physician who can recommend the best plan for you to stop smoking." 2. "You will need to stop smoking for the welfare of your child. Would you like to contact the lung association?" 3. "Cigarette smoke can cause an asthmatic episode. If you would like to quit, I can help you create a plan." 4. "It is dangerous for children with asthma to be exposed to cigarette smoke. You need to quit right away."

3. "Cigarette smoke can cause an asthmatic episode. If you would like to quit, I can help you create a plan." : acknowledges mothers concern and offers assistance Referral to dr and lung association doesn't address issues Stating its dangerous sounds judgmental

Joan is a 17 yr old, 155cm tall female, who normally weights 48kg. She lost 9kg in the past 3 months and has ammenorrhea. Joan describes an intense fear ofgaining weight and is preoccupied with food. She is admitted with a diagnosis of anorexia nervosa and is confined to the unit. After 8 weeks, Joan has gained 5kg. She expresses concern about the weight gain and observes that her "thighs seem huge." Which response would be most therapeutic for the PN to make? 1. "It must seem like that to you. Let's stand side-by-side and look in the mirror.You'll see your thighs aren't that big." 2. "It must be frightening for you to have gained so much weight. Let's talk about that with the psychologist." 3. "I hear your concerns. You are uncomfortable with how you see yourself and eating." 4. "You have gone through a great deal. Perhaps shopping for clothes that don't emphasize your weight gain would help you feel better."

3. "I hear your concerns. You are uncomfortable with how you see yourself and eating." : most honest and empathetic answer Standing side-by-side is non therapeutic Stating that she has gained weight is only re-affirming fears Wearing clothing suggests she should hide herself and feel ashamed

Mrs. Wong, 74 years old, has been admitted to a medical unit with a diagnosis of tuberculosis (TB). She has an order for oxygen 3L/min via nasal cannula prn Mrs. Wong is in an isolation room and has airborne precautions in place. Because Mrs. Wong does not speak English, her daughter visits frequently. Mrs. Wong is preparing for discharge. She asks whether she should continue taking her TB medications at home. What would be the best response by the PN? 1. "Here are some written discharge instructions. If you have any questions, you can contact your physician." 2. "Contact your pharmacist who will provide instructions on how the medication should be taken." 3. "You must follow the treatment regimen by taking your medication and reporting for follow-up screening." 4. "The public health nurse will visit in a few days and discuss follow up care with you."

3. "You must follow the treatment regimen by taking your medication and reporting for follow-up screening." : adherence to the prescribed treatment regimen is very important and can lead to a cure Written directions are not enough; it is the PN's responsibility to provide discharge instructions not a pharmacist.

Mr. Manne, 45 years old, is admitted with weight loss not yet diagnosed. He reports a loss of appetite and a general feeling of fatigue. MR. Manne tells the PN that his father died at the age of 50 from colon cancer and states "I am going to end up like my father." How should the PN respond to Mr. Manne? 1. "You are not your father. You were diagnosed early." 2. "You think you are going to die, don't you?" 3. "You seem upset. Tell me what the physician has told you" 4. "Let's discuss getting you home. That will cheer you up, don't you think?"

3. "You seem upset. Tell me what the physician has told you" : open ended questions help to express the pt's feelings False reassurance doesn't help genetic inclination Leading questions don't acknowledge the pt's true feelings Avoiding the topic is not helpful

Mrs. Proud, 32 years old, is pregnant for the third time. Her first pregnancy ended at 17 weeks gestation and her second child was delivered at 36 weeks gestation. Mrs. Proud spontaneously delivers a living female. At 1 minute age, the newborn is pink, has acrocyanosis, flexed tone, an apical pulse rate of 140 beats/min and responds with a vigorous cry to a tap on the sole of her foot. Which Apgar score would the baby receive? 1. 7 2. 8 3. 9 4. 10

3. 9 Appearance {skin color} Pulse {heart rate} Grimace {reflex irritability} Activity {muscle tone} Respiration {breath rate/effort}

Mr. Spencer, 52 yr old with schizophrenia,lives in an apartment building. The PN visits daily for med admin and a mental status assessment. Lately, there have been reports from other tenants that Mr. Spencer hammers on the walls and yells for the noises to go away.Mr. Spencer risks being evicted if he does not stop. During today`s visit, Mr. Spencer is pacing,stating that the noises in his head are loud, and he had his hands over his ears. He has not bathed lately and his apartment has garbage on the floor. Which plan of care would be most appropriate for the PN to implement for Mr. Spencer? 1. Notify the physician of Mr. Spencer's behavioral changes and request immediate hospitalization. 2. Suggest to Mr. Spencer that he move to an assisted living facility before he gets evicted. 3. Advocate for a psychiatric assessment and increased daily visits by an appropriate health-care provider 4. Advise Mr. Spencer that if he does not improve, he may be discharged form the program

3. Advocate for a psychiatric assessment and increased daily visits by an appropriate health-care provider

3. An inflammatory and possibly infectious process : an elevation in the number and types of WBC's indicates possible infection Dehydration is not common to hyperthermia High number of antibody titres is a part of agglutination testing that confirms immunity to disease; not for high WBC Hypervolemia and liver failure are not shown by high WBC

The PN observes that a client with COPD Mr. Sanjeev, 74 years old, is dyspneic, restless and reporting chest discomfort. Expiratory wheezes are audible and he is diaphoretic. The bedding is saturated from urinary incontinence. What should the PN do first? 1. Auscultate his chest 2. Change his bed linens 3. Apply O2 at 1-2 L/min 4. Assess vital signs

3. Apply O2 at 1-2 L/min : PN CAN administer 1-2L/min of O2 at their discretion w/o a Dr order. Adequate oxygenation always first consideration

Mr. Goldwing, 68 years old, has Parkinson's disease. He has been admitted to an acute care unit, accompanied by his wife. Mr. Goldwig has tremors and is unsteady while walking. What should the PN do? 1. Hold the client's hand while walking down the hallways 2. Give the client a walker when he is walking around the unit 3. Ask the client if he needs any assistance for walking 4. Ask the client's wife to assist him while walking

3. Ask the client if he needs any assistance for walking : promotes pt autonomy Holding hand is a risk for falling A walker encourages dependence Asking wife to assist places undue stress on family

Mrs. Hart is 39 years old, married with two children aged 10 and 13. She is admitted for mastectomy following a diagnosis of right breast cancer. She is fearful the cancer has spread and is anxious about the future for herself and her family. Which action is most important for the PN to perform on the morning of Mrs. Harts first postoperative day? 1. Ask Mrs. Hart if she has been passing any flatus 2. Encourage Mrs. Hart to do deep breathing and coughing exercises every 4 hours 3. Assess Mrs. Hart's right mastectomy dressing for drainage 4. Teach Mrs. Hart how to do wall-walking exercises

3. Assess Mrs. Hart's right mastectomy dressing for drainage : hemorrhaging is postoperative risk and should be assessed on the first postop day First postoperative day is too soon to be passing flatus Deep breathing exercises should be done more often than every 4 hours Fist post-operative day is too soon to begin wall-walking exercises

A 68 yr old in the medical unit following an MI has a history of type 2 diabetes mellitus and has orders for IV 0.9% NaCl at 30mL/h, oxygen PRN, oral hypoglycemic daily, nitroglycerin transdermal patch (Nitro-Dur) 0.4mg daily and nitroglycerin 0.3mg sublingual PRN for chest discomfort. On the fourth day on the medical unit, the pt reports that he has chest discomfort and SOB. The PN notes that he is pale, and his skin is cool and clammy . Most appropriate sequence of interventions? 1. Assess vital signs & blood glucose, then apply oxygen 2. Apply oxygen, assess vital signs and then assess blood glucose 3. Assess vital signs, apply oxygen, and then give sublingual nitroglycerin 4. Apply oxygen, assess vital signs and provide a warm blanket

3. Assess vital signs, apply oxygen, and then give sublingual nitroglycerin

A 2 year-old client has an IV infusing through an infusion control device. Which action by the PN is most appropriate when the device is being used? 1. Monitor the infusion control device every 15 minutes 2. Attach a mini-drop administration set to the infusion control device 3. Check that the infusion control device rate is set properly 4. Monitor the infusion control device every 2 hours

3. Check that the infusion control device rate is set properly : promotes safe delivery of fluid at correct rate Nurse should check device first before monitoring

Mrs. Bates, 68 years old, has rheumatoid arthritis and is being admitted to a nursing home. She has recently been diagnosed with early stage Alzheimers disease. Her son manages her finances and her daughter has been responsible for personal care. From whom should the PN obtain consent? 1. Son 2. Daughter 3. Client 4. Son and daughter

3. Client : No indication that Mrs. Bates isn't competent to make her own decisions. Clients with early stage Alzheimer's can still retain decision making skills

Mr. Manne, 45 years old, is admitted with weight loss not yet diagnosed. He reports a loss of appetite and a general feeling of fatigue. Mr. Manne is experiencing bloody diarrhea. What diagnostic tests would be ordered if colorectal cancer is suspected? 1. Upper GI series and electrolytes 2. Colposcopy and stool for occult blood 3. Colonoscopy and hemoglobin 4. Lower GI series and creatinine

3. Colonoscopy and hemoglobin : Colonoscopy used to view the rectum and lining for growths to diagnose rectal cancer and hemoglobin should be monitored because of blood loss For colon cancer upper GI series is unnecessary Colposcopy is not required and neiter is an occult stool test if stools are obviously bloody Creatinine is used to assess kidney function and is not relevant if colorectal cancer is suspected

A pt, 68 years old, has chronic renal failure. She has been on peritoneal dialysis for the past 2 years. Her daughter brought her to the Emergency Department last night with a fever. Infection of her peritoneal dialysis catheter is suspected. She reports swelling in her ankles. Yesterday she had an intake of 1000mL and an outake 400mL. When assessing her respiratory status what would the PN most likely expect to find? 1. Inspiratory stridor bilaterally 2. Fine crackles in the bases bilaterally 3. Course crackles on auscultation 4. Vesicular breath sounds

3. Course crackles on auscultation

Mrs. Block, 75 years old, has been admitted with congestive heart failure and is receiving an IV infusion of D5W at 125mL/h. When the PN is performing routine morning care, Mrs. Block reports a pounding headache, chills and difficulty breathing. her pulse and BP are elevated. What should the PN do initially? 1. Have the physician informed of her symptoms 2. Help her to a sitting position on the side of the bed 3. Decrease the IV rate of flow 4. Obtain an oxygen saturation level

3. Decrease the IV rate of flow : manifesting signs of fluid overload Physician can be informed after Change of position would not address cause of fluid overload O2 levels not main priority

Mr. Ross, 75 years old, is having a bowel resection. When peri-operative teaching should the PN emphasize initially? 1. Modification of diet 2. Care of an ostomy 3. Deep breathing exercises 4. Postoperative positioning

3. Deep breathing exercises : after any surgery client will have reduced lung volume and need greater efforts to breathe. Deep breathing exercises will improve Mr. Ross' ability to cough and breathe Diet would be dependent on post op Dr orders Not known if client will have ostomy No specific positioning restrictions for bowel resection

Joan is a 17 yr old, 155cm tall female, who normally weights 48kg. She lost 9kg in the past 3 months and has ammenorrhea. Joan describes an intense fear ofgaining weight and is preoccupied with food. She is admitted with a diagnosis of anorexia nervosa and is confined to the unit. At the third weekly inter-professional conference, Joan states that her preoccupation with food and exercise has greatly diminished. The PN has observed Joan discussing recipes with other clients and lengthening her daily exercises. What should the PN do? 1. Confirm for Joan and her family that she appears to be making progress and that her progress has been noted in her treatment plan 2. Discuss the observations with Joan's family, noting specific changes in Joan's behavior from the previous planning conference 3. Encourage Joan to reflect on her behaviour and explore if she is less preoccupied with food and weight gain 4. Introduce the need to begin discharge planning for Joan that includes referral to a local self-help group

3. Encourage Joan to reflect on her behaviour and explore if she is less preoccupied with food and weight gain : Most therapeutic response Joans preoccupations are still significant Discussing with her family is not beneficial for Joan Group therapy will not address her specific issues

A 10 month old lives on a busy family farm where pesticides are used. Her father, who handles pesticides, changed his clothes following a spray but left his boots by the back door. Later in the day, the baby is found playing near the back door. She quickly shows signs of illness and is rushed to the hospital. After several months, the physician determines that the baby is palliative. The difficult decision to terminate life support is made. How can the PN help support the family? 1. Encourage the family to withdraw from their babies care 2. Encourage the family to advocate for a private nurse 3. Encourage a plan of care that involves the family's participation 4. Encourage the family to make funeral arrangements in advance

3. Encourage a plan of care that involves the family's participation

A 10 month old lives on a busy family farm where pesticides are used. Her father, who handles pesticides, changed his clothes following a spray but left his boots by the back door. Later in the day, the baby is found playing near the back door. She quickly shows signs of illness and is rushed to the hospital. The baby goes into respiratory arrest and is resuscitated. The Dr. speaks with the family about the babies progress but they find it difficult to understand the information. How could the PN help the family understand the info the Dr has provided? 1. Suggest that the family contact the Poison Control Center 2. Provide the family with poison control literature 3. Encourage the family to ask questions and continue to clarify 4. Have a social worker speak with the family

3. Encourage the family to ask questions and continue to clarify

13 yr old female hospitalized with vomiting and generalized stomach pain. Her parents worry about recent changes in behavior and depressed mood. Pt tells PN her stomach hurts because she is making herself vomit. Asks PN not to tell parents, how should PN respond? 1. Tell the pt that the PN is only obliged to report vomiting if it occurs during her hospitalization 2. Remind the pt that clients have the right to determine what information is documented and reported 3. Explain to the pt that information is shared with the health care team to provide appropriate care 4. Reassure the pt that her stomach pains will subside if she stops vomiting and her condition improves

3. Explain to the pt that information is shared with the health care team to provide appropriate care

A 10 month old lives on a busy family farm where pesticides are used. Her father, who handles pesticides, changed his clothes following a spray but left his boots by the back door. Later in the day, the baby is found playing near the back door. She quickly shows signs of illness and is rushed to the hospital. Two weeks later, the baby is transferred to the pediatric unit. Her swallow reflex is diminished and enteral feeding with an indwelling nasogastric tube has been initiated. During the feeding process, the PN has difficulty with the tube clogging. What should the PN do? 1. Elevate the syringe to increase flow rate 2. Use the plunger of syringe to apply more pressure 3. Flush the tubing with tepid tap water 4. Remove the tubing ans reinsert new tubing

3. Flush the tubing with tepid tap water

During an IV assessmen, the PN finds an empty secondary medication bag hanging with a label for dimenhydrinate (Gravol). The client is wearing an arm band that indicates that he has an allergy to dimenhydrinate. What should the PN do first? 1. Document in the clinical record 2. Assess for nausea and vomiting 3. Have the physician contacted 4. Complete an incident report

3. Have the physician contacted : this could be a medical emergency Medical emergency requires immediate action

13 yr old female hospitalized with vomiting and generalized stomach pain. Her parents worry about recent changes in behavior and depressed mood. The pt is concerned about her weight. She exercise and makes food choices based on not wanting to become fat. She says that she does not feel like eating. What should the nurse do? 1. Design a diet in consultation with the dietitian and ensure that it is balanced, contains variety and has the requisite caloric intake. 2. Ask the pt what she likes and dislikes, have her mother bring in food, and obtain and record her daily weight to demonstrate progress. 3. Include the pt in goal-setting for healthy weight, have her maintain a food and fitness journal, and obtain & record her weight weekly. 4. Promote a healthy lifestyle, the importance of stress management and nutritional teaching with peer support groups

3. Include the pt in goal-setting for healthy weight, have her maintain a food and fitness journal, and obtain & record her weight weekly.

Mrs. Hart is 39 years old, married with two children aged 10 and 13. She is admitted for mastectomy following a diagnosis of right breast cancer. She is fearful the cancer has spread and is anxious about the future for herself and her family. Which action would best help Mrs. Hart reduce anxiety on the day she is admitted for her surgery? 1. Show her around the unit 2. Offer her a backrub 3. Listen to her concerns 4. Encourage her to write in a journal

3. Listen to her concerns : emotional support Familiarization with the unit reduces anxiety but emotional concerns are more important A back rub is not appropriate Journaling takes time and would not address immediate concerns

Mr. Rao, 45 years old, has been admitted following an open cholecystectomy. He has a nasogastric (NG) tube in place connected to suction and an IV. On the third post-operative day,Mr. Rao's NG tube has been removed. His IV continues to infuse at 75mL/h, and he is on clear fluids. Over the past 12 hours, his urinary output has been 220mL. What should the PN do first? 1. Palpate the bladder 2. Ensure the physician is notified. 3. Observe for signs of fluid balance 4.Request an order for a diuretic

3. Observe for signs of fluid balance : need to make initial observation first; 220mL/12hr is too low should be at around 700ml/12hrs. Palpation is the second step to assessment Notify the physician ad request diuretic if all assessments point to fluid imbalance.

Ms. O'Connor, 67 years old, has been living alone in her family home. She has just been admitted by ambulance to an acute care facility. She has acute osteoarthritis and this has made self-care impossible. Upon admission, the physician has ordered Ms. O'Connor to be on complete bed rest for 48 hours. The physician has ordered that splints be applied to Ms. O'Connor's hands and wrists at bedtime. What should the PN do before applying these splints? 1. Ensure that Ms. O'Connor has a bedpan available 2. Place Ms. O'Connor's hands in a hyperextended position 3. Obtain Ms. O'Connor's permission to apply these splints 4. Place Ms. O'Connor's hands in a flexed position

3. Obtain Ms. O'Connor's permission to apply these splints A client with splints may not be able to use a bedpan Hyperextending does not secure splints Flexed position is not right for splint appication

Mrs. Wong, 74 years old, has been admitted to a medical unit with a diagnosis of tuberculosis (TB). She has an order for oxygen 3L/min via nasal cannula prn Mrs. Wong is in an isolation room and has airborne precautions in place. Because Mrs. Wong does not speak English, her daughter visits frequently. The practical nurse notes that Mrs. Wong is dyspneic and slightly cyanotic. Her vital signs are T-39.2, HR 112, RR 32 and BP 146/90. In what order should the PN proceed? 1. Administer oxygen, contact Mrs. Wong's daughter, obtain an oxygen saturation level (SpO2) and have the physician notified 2. Have the physician notified, administer an antipyretic, perform a chest assessment and administer oxygen 3. Obtain an oxygen saturation level (SpO2), administer oxygen PRN, perform a chest assessment and have the physician notified 4. Instruct her to perform deep breathing and coughing, administer oxygen, have the physician notified and contact Mrs. Wong's daughter

3. Obtain an oxygen saturation level (SpO2), administer oxygen PRN, perform a chest assessment and have the physician notified : The priority should be to complete a focused respiratory assessment (ABC's)

A 68 yr old in the medical unit following an MI has a history of type 2 diabetes mellitus and has orders for IV 0.9% NaCl at 30mL/h, oxygen PRN, oral hypoglycemic daily, nitroglycerin transdermal patch (Nitro-Dur) 0.4mg daily and nitroglycerin 0.3mg sublingual PRN for chest discomfort. When administering the oral hypoglycemic pill, he states " that doesn't look like the pill I take at home." What should the PN do? 1. Reassure the pt that this is the correct med order by the physician 2. Reassure the pt that this is the correct med although it may look different 3. Re-check the Dr's orders and the home medication history 4. RE-check the pharmacy label before giving the med

3. Re-check the Dr's orders and the home medication history

A 68 yr old in the medical unit following an MI has a history of type 2 diabetes mellitus and has orders for IV 0.9% NaCl at 30mL/h, oxygen PRN, oral hypoglycemic daily, nitroglycerin transdermal patch (Nitro-Dur) 0.4mg daily and nitroglycerin 0.3mg sublingual PRN for chest discomfort. While watching the pt's back during AM care the PN notices a reddened area on his sacrum. What is proper documentation of the PN's assessment finding? 1. Small reddened area noted over sacrum 2. Reddened area over sacrum the size of a grape 3. Reddened area over sacrum 3cm in diameter, skin intact 4. Skin over sacral area appears reddened

3. Reddened area over sacrum 3cm in diameter, skin intact

Joan is a 17 yr old, 155cm tall female, who normally weights 48kg. She lost 9kg in the past 3 months and has ammenorrhea. Joan describes an intense fear ofgaining weight and is preoccupied with food. She is admitted with a diagnosis of anorexia nervosa and is confined to the unit. Joan's lunch consists of a small bowl of soup, a dinner roll, a spinach salad and a pot of tea. What should the practical nurse do to meet the responsibility of recording food intake? 1. Be present to remove her dinner tray and note what was eaten. 2. Ask Joan to record her intake and provide her with an intake/output sheet 3. Remain with Joan while she eats and observe her intake 4. Continue with normal duties and periodically return to check

3. Remain with Joan while she eats and observe her intake : Provides most accurate data

MS. Findlay, 24 years old, is to receive 1 unit of whole blood. When taking the blood to Ms. Findlay's room the PN is asked by a staff member to also take a unit of packed cells to another client in the next room. What should the PN do to promote safety in the identification of both clients? 1. Clarify the name and room of the second client with the staff members 2. Take both units of blood and the requisitions to the two clients at the same time 3. Return for the packed cells after delivering Ms. Findlay's unit of whole blood 4. Request that the staff member ask the laboratory technician to return the packed cells

3. Return for the packed cells after delivering Ms. Findlay's unit of whole blood : only do one client at a time to reduce error

Mrs. Mayhew, 72 years old, has been admitted to hospital with chronic obstructive pulmonary disease (COPD). She is accompanied by her daughter, Adrianna, who indicates that her mother's condition has deteriorated. Mrs. Mayhew wears dentures. Which action is most important for the PN to take when cleaning Mrs. Mayhew's dentures? 1. Brush the dentures in a circular motion 2. Cleanse the dentures under hot running water 3. Rinse the dentures with warm water 4. Use a hard bristled toothbrush

3. Rinse the dentures with warm water : Warm water dilutes particles and rinses dentures more effectively without damaging the dentures Brush should be held horizontally and dentures should be brushed using a back and forth motion Hot water and hard-bristled toothbrushes could damage dentures

Mr. Manne, 45 years old, is admitted with weight loss not yet diagnosed. He reports a loss of appetite and a general feeling of fatigue. While receiving discharge teaching, Mr. Manne asks the PN what to expect in the descending colostomy pouch on a regular basis. What should the PN respond? 1. Liquid stool 2. Semi-formed stool 3. Solid stool 4. No stool

3. Solid stool - Descending colostomy because stool is formed out of sigmoid ostomy (ostomy on lower left side of abdomen) Liquid stool - Ascending colostomy Semi-formed stool - Transverse colostomy

24 yr old involved in cycling collision, he is admitted to the unit following open reduction of a fractured left femur. Which observation would indicate to the PN that he has thoroughly understood the teaching of the use of crutches? 1. Crutches are in contact with his axillae 2. When climbing the stairs he first places both crutches parallel on the first step 3. To sit the pt first holds both crutches on the side opposite his injured leg 4. The pt wears soft comfortable slippers

3. To sit the pt first holds both crutches on the side opposite his injured leg

Mr. Rogers, 22 years old, weighs 90kg and is 165 cm tall. He is to receive IM iron dextran (Dexiron) daily. Which site would be most appropriate for administering this med? 1. Deltoid 2. Vastus Lateralis 3. Ventrogluteal 4. Dorsogluteal

3. Ventrogluteal (most popular site for IM injections)

What questions should the practical nurse ask a family member of a 75 yr old male new admission with Mid-stage Alzheimer's to obtain the most relevant info for updating a care plan? 1. Do you have any help at home 2. Are your children worried about their father 3. What help does Mr. Robichaud require each day 4. How frequently are you able to visit

3. What help does Mr. Robichaud require each day. (This information is critical in the development of a personalized care plan.)

The PN is assessing the elimination of a client with suspected cystitis. What question should the PN ask the client? 1. "Are you voiding large amounts of urine?" 2. "Is your urine dark brown in colour?" 3. "Does your urine have an odour similar to ammonia?" 4. "Do you feel that you are voiding more often?"

4. "Do you feel that you are voiding more often?" : client with cystitis goes to the washroom frequently; can indicate incomplete bladder emptying and retention of urine Small voids with cystitis Dehydration causes dark brown color Ammonia smell characteristic of urine

Mr. Goldwing, 68 years old, has Parkinson's disease. He has been admitted to an acute care unit, accompanied by his wife. Mr. Goldwing has been ordered an IV solution infusing at 125mL/hr. In a 24 hour period, how many mL would he receive? 1. 1500mL 2. 2000mL 3. 2400mL 4. 3000mL

4. 3000mL 125mL/1h = 3000mL/24h

When providing mouth care for a client who wears dentures, what should the PN do first? 1. Wear a mask to prevent spread of disease 2. Offer the client a denture toothbrush, toothpaste and mouthwash 3. Verify the Dr's orders 4. Apply gloves prior to removing dentures

4. Apply gloves prior to removing dentures : gloves worn whenever in contact with mucous membranes Masks not needed; Mouth would be washed with soft toothbrush first NOT denture brush

Practical nurse is helping orientate a new employee, an unregulated health worker. Practical nurse watches the UCP (unregulated care provider) helping a resident at mealtimes and notices she appears uncomfortable. What should the nurse do? 1. Suggest that the UCP share her concerns with other employees 2. Partner the UCP with a more experienced unregulated health worker 3. Invite the UCP to attend information sessions on Alzheimers disease 4. Ask the UCP how she feels about caring for clients with Alzheimer's disease

4. Ask the UCP how she feels about caring for clients with Alzheimer's disease

A pt, 68 years old, has chronic renal failure. She has been on peritoneal dialysis for the past 2 years. Her daughter brought her to the Emergency Department last night with a fever. Infection of her peritoneal dialysis catheter is suspected. As her hemoglobin is low, she is ordered ferrous sulfate. What side effects should the PN tell her to suspect? 1. Yellowing of the sclera 2. Rust colored urine 3. Discoloration of nail beds 4. Black colored stools

4. Black colored stools

Practical nurse witnesses resident fall to the floor. He does not appear visibly injured, but becomes aggressive when practical nurse tries to assess him. What should the practical nurse do? 1. Reassure the resident and request assistance with a mechanical lift 2. Stay with him and ask the nurse-in-charge to contact the primary care contact 3. Wait until the resident becomes calm and complete the assessment of his injuries 4. Call for assistance, reassure the resident and provide necessary care

4. Call for assistance, reassure the resident and provide necessary care

A PN has been given a client assignment that she believes is beyond her abilities. What should the PN do first? 1. Request a change in assignment 2. Provide care to the clients 3. Ask a colleague to assist with client care 4. Discuss feelings with her supervisor

4. Discuss feelings with her supervisor : first step in resolution of conflict between beliefs and abilities to give care Change in assignment isn't always possible Risk of work overload if care given regardless Asking a colleague to assist could be seen as abandoning the task

13 yr old female hospitalized with vomiting and generalized stomach pain. Her parents worry about recent changes in behavior and depressed mood. In accordance with the nursing care plan, the PN sits with the pt while she eats her meals and accompanies her to the bathroom. Today, the PN notices the females facecloths are missing from the bathroom. What action should the PN take? 1. Discuss the issue of lost facecloths, search the room when the pt is out of her room and document appropriately 2. Ask the pt where the facecloths are, ask her to return them and chart the missing facecloths 3. Ask the pt where the facecloths are and chart the suspicion that they are being used to hide uneaten food 4. Discuss the issue of lost facecloths with the pt and document appropriate information

4. Discuss the issue of lost facecloths with the pt and document appropriate information

What should the PN do when changing a simple sterile dressing? 1. Wear sterile gloves to remove the dressing 2. Obtain a specimen from the would for culture and sensitivity 3. Cleanse the surrounding skin area prior to cleansing the incision line 4. Dispose of the dressing in a bag/container

4. Dispose of the dressing in a bag/container : precaution needs to be taken to avoid contamination with any wound drainage Sterile gloves not needed; clean gloves suffice No indication of infection; specimen not needed Incision line should be cleansed first

Mr. Manne, 45 years old, is admitted with weight loss not yet diagnosed. He reports a loss of appetite and a general feeling of fatigue. Mr. Manne has surgery for colorectal cancer with the formation of a colostomy. While performing a dressing change, the PN notices that Mr. Manne's stoma is swollen and bluish in colour. What should the PN do first? 1. Continue with the dressing change 2. Request that the surgeon be notified 3. Leave a message with the physician's office 4. Document these findings and report at change of shift

4. Document these findings and report at change of shift : Change in Color (Ischemia/Necrosis): Caused by an inadequate blood supply to the stoma. Sometimes a stoma will "pink up" as swelling decreases. If the stoma continues to darken--turns dusky blue, dark brown or black, you should report this to your physician immediately. Normal: Red or pink, moist appearance. Slight bleeding is normal with cleansing. Swelling should decrease over a period of 6-8 weeks after surgery. Movement of the stoma is normal, and it may move in and out with changes in your position.

Mrs. Mayhew, 72 years old, has been admitted to hospital with chronic obstructive pulmonary disease (COPD). She is accompanied by her daughter, Adrianna, who indicates that her mother's condition has deteriorated. Which action should the practical nurse take to promote Mrs. Mayhew's comfort? 1. Position in semi-Fowler's position 2. Place both of her arms on pillows 3. Assist her to a recliner and elevate her feet 4. Encourage her to lean forward while sitting

4. Encourage her to lean forward while sitting : promotes increased lung expansion Would not promote lung expansion Placing both arms on pillows would not be as comfortable as allowing her to choose a position Reclining her and elevating feet can compromise breathing

The PN is employed in a private residence caring for Ms. Jones, a 60 year old woman with type 1 diabetes mellitus. One morning, Ms. Jones is found unconscious. What should the PN do initially? 1. Check blood glucose 2. Administer insulin 3. Assess vital signs 4. Ensure a patent airway

4. Ensure a patent airway : Remember ABC's The initial action is to ensure she is getting oxygen to her brain then assess vitals

Mrs. Hochban, 62 years old, restricts her fluid because of urinary incontinence. What should the PN do initially to assist Mrs. Hochban to regain control of her bladder? 1. Ask her to record her 24-hour urine output 2. Instruct her in pelvic floor exercises 3. Encourage her to drink cranberry juice 4. Ensure that she voids every 1-2 hours

4. Ensure that she voids every 1-2 hours : client should be encouraged to void every 1-2 hours in the early stages of bladder retaining Recording her urine output will not help to regain bladder control Pelvic floor exercises work but wouldn't be first step Cranberry juice won't help

Mr. Rao, 45 years old, has been admitted following an open cholecystectomy. He has a nasogastric (NG) tube in place connected to suction and an IV. In the past 2 hours, Mr. Rao's NG output totals 1500mL. After assessing his vital signs, what should the practical nurse do first? 1. Assess the client's pain 2. Ask a colleague to assess the NG output 3. Continue to monitor the NG output 4. Ensure that the physician is notified

4. Ensure that the physician is notified : Urinating at a rate of 750mL/h is suggestive of hypervolemia cholecystectomy - is a surgical procedure to remove your gallbladder 750 and 2500 ml of urine in a 24 hour period Average rate of approximately 25 to 30 ml/hr

24 yr old involved in cycling collision, he is admitted to the unit following open reduction of a fractured left femur. He is refusing to have his dressing changed. What should the PN do first? 1. Ask if he needs an analgesic 2. Ask what would be the best time to change his dressing 3. Inform him that his dressing needs to be changed now 4. Explore the reason he doesn't want the dressing to be changed now

4. Explore the reason he doesn't want the dressing to be changed now

Mrs. Proud, 32 years old, is pregnant for the third time. Her first pregnancy ended at 17 weeks gestation and her second child was delivered at 36 weeks gestation. Six hours later, Mrs. Proud's cervix is 100% effaces and 9cm dilated. She is restless and crying out in discomfort. In which stage of labour is Mrs. Proud? 1. First stage of labour in the latent phase 2. Early in the third stage of labour 3. Early in the second stage of labour 4. First stage of labour in the transition phase

4. First stage of labour in the transition phase 1st Stage: Latent - onset of uterine contractions (20-40sec), ends with cervical dilation/effacement (0-3cm) Active - rapid cervical dilation (4-7cm), longer contractions (40-60sec), increased show (vaginal secretions) and chance of spontaneous rupture of membranes ("water breaking" rupture of amniotic sac from contractions) Transition - contractions peak (every 2-3min for 60-90sec), max cervical dilation (8-10cm) full effacement 2nd Stage: from full dilation and full effacement to birth -pushing phase -crowning: as fetal head pushes against perineum the vagina opens in a slit, then an oval, and finally a circle; from a dime to a quarter and then half a dollar. 3rd Stage: placental stage from birth to delivery of placenta Placental Separation - after birth uterus palpable as firm, round mass inferior to umbilicus -contractions start again and uterus is a discoid shape -uterus presses down and placenta starts to separate, bleeding internally helps push placenta away from uterine lining Placental Expulsion - placenta delivered via bearing-down or by Dr or midwife gently pressing on CONTRACTED uterine fundus (pressure on non contracted uterus causes evert (turn inside out) and hemorrhage)

4. Fractured femur

Mrs. Proud, 32 years old, is pregnant for the third time. Her first pregnancy ended at 17 weeks gestation and her second child was delivered at 36 weeks gestation. Mrs. Proud is full term and in early labour. How should the PN record her obstetrical history? 1. Gravida 2, Para 3 2. Gravida 2, Para 2 3. Gravida 3, Para 2 4. Gravida 3, Para 1

4. Gravida 3, Para 1 Gravida indicates the number of times the woman has been pregnant, regardless of whether these pregnancies were carried to term. A current pregnancy, if any, is included in this count.[citation needed] Parity, or "para" indicates the number of >20-week births (including viable and non-viable; i.e., stillbirths). Pregnancies consisting of multiples, such as twins or triplets, count as one birth for the purpose of this notation.[citation needed] Abortus is the number of pregnancies that were lost for any reason, including induced abortions or miscarriages. The abortus term is sometimes dropped when no pregnancies have been lost. Stillbirths are not included

Mrs. Gore will be given mydriatic medication during her eye examination. What would the PN do for Mrs. Gore prior to her leaving the clinic? 1. Instruct Mrs. Gore to wear sunglasses while driving 2.Irrigate Mrs. Gore's eyes with sterile water 3. Have Mrs. Gore wait in a darkened room for 15 minutes 4. Inquire about Mrs. Gore's transportation from the clinic

4. Inquire about Mrs. Gore's transportation from the clinic : safety precautions Driving is hazardous Sterile water and a dark room for 15 minutes won't address her light sensitivity

A 68 yr old in the medical unit following an MI has a history of type 2 diabetes mellitus and has orders for IV 0.9% NaCl at 30mL/h, oxygen PRN, oral hypoglycemic daily, nitroglycerin transdermal patch (Nitro-Dur) 0.4mg daily and nitroglycerin 0.3mg sublingual PRN for chest discomfort. The 2nd day on the medical unit, the pt develop diarrhea and begins vomiting. The Dr orders the IV rate to increase to 150mL/h. 2 hrs later the PN notices that he is dyspneic and his RR is 32 breaths/min. The PN auscultates his chest and notes adventitious sounds throughout. What should the PN do? 1. Discontinue the IV infusion and notify the physician 2. Reassess the IV rate and encourage deep breathing and coughing exercises 3. Maintain the IV infusion at 150mL/h and notify the physician 4. Notify the physician and anticipate a decrease in the IV rate

4. Notify the physician and anticipate a decrease in the IV rate

24 yr old involved in cycling collision, he is admitted to the unit following open reduction of a fractured left femur. Approximately one hour after he returns from the operating room, the nurse notices his dressing has a large red stain. After assessing the vital signs were normal what should the PN do next? 1. Elevate the left leg on 2 pillows 2. Lower the head of the bed 3. Cover the site with a pressure dressing 4. Outline the stain and add the date and time

4. Outline the stain and add the date and time

During admission, Mrs. Luniza, 72 years old, is confused about person, place, and time. What should the PN do first? 1. Assess mental health status 2. Perform a Mini-Mental State Examination 3. Assess for medication side effects 4. Perform a neurological assessment

4. Perform a neurological assessment : part of neurological assessment is the Glasgow Coma scale which includes orientation to person, place, and time. Physical reasons for confusion should be ruled out. Before assessing for psychiatric issues physical issues should be ruled out Mini-Mental should be done after a complete neurological assessment Medication side effects are second to complete neuro assessment

The resident son, asks the practical nurse whether he can participate in his father's daily care when he is available. What should the nurse do? 1. Invite the son to come and play cards with his father 2. Encourage the son to spend his days off with his father 3. Reassure the son that the fathers daily care is being provided by the health care team 4. Question son about what part of his father's care he would like to be a part of

4. Question son about what part of his father's care he would like to be a part of

Mrs. Wong, 74 years old, has been admitted to a medical unit with a diagnosis of tuberculosis (TB). She has an order for oxygen 3L/min via nasal cannula prn Mrs. Wong is in an isolation room and has airborne precautions in place. Because Mrs. Wong does not speak English, her daughter visits frequently. Mrs. Wong requires routine blood work but becomes upset and resists attempts to obtain her blood. Mrs. Wong needs further explanation about the procedure. Which intervention by the PN would be the most appropriate? 1. Use non-verbal communication techniques such as hand gestures to explain the procedure. 2. Ask Mrs. Wong's daughter to facilitate communication with the practical nurse 3. Explain to the physician that the client is resistant and the procedure cannot be completed 4. Reschedule the blood work for when a hospital interpreter will be available

4. Reschedule the blood work for when a hospital interpreter will be available Using hand gestures and a family member is not enough to relay a message; can be misinterpreted

Mrs. Caron, 92 years old, is confused and disorientated. The inter-professional team decides that she may ambulate on the unit only if she is supervised. A few days later, Mrs. Caron is lucid and insists that she be allowed to ambulate alone. What should the PN do? 1. Continue to supervise Mrs. Caron until the inter-professional team is consulted 3. Ask Mrs. Caron if a family member would be available to walk with her 3. Encourage Mrs. Caron to continue complying with the safety measures 4. Respect Mrs. Caron's wishes and allow her to ambulate alone

4. Respect Mrs. Caron's wishes and allow her to ambulate alone : code of ethics indicates a pt's rights be respected and dignity preserved.

Ms. O'Connor, 67 years old, has been living alone in her family home. She has just been admitted by ambulance to an acute care facility. She has acute osteoarthritis and this has made self-care impossible. Upon admission, the physician has ordered Ms. O'Connor to be on complete bed rest for 48 hours. Ms. O'Connor's acute stage of arthritis has subsided. What should the PN do first to promote Ms. O'Connor's independence? 1. Instruct her to sit up in the chair for her meals 2. Allow her 20 minutes to complete morning care 3. Encourage her to practice using her walker outdoors 4. Talk with her about patterns of activity and rest

4. Talk with her about patterns of activity and rest: assessing the client's capabilities and including client input is first priority for active independence Sitting position promotes self-care but not initial priority PN should not limit time needed for morning care Encouraging outdoor walker use might not yet be safe

75 yr old pt with tuberculosis, and has been placed on isolation precautions since being admitted to the hospital. Which action best indicates that the practical nurse knows how to collect sputum specimen from the pt? 1. Keep the specimen at room temperature and send to the laboratory for analysis 2. Collect the specimen in a clean, light occlusive container 3.Instruct the pt to use mouthwash prior to specimen collection 4. Teach the pt to deep breath and cough prior to expectoration

4. Teach the pt to deep breath and cough prior to expectoration

Mr. Spencer, 52 yr old with schizophrenia,lives in an apartment building. The PN visits daily for med admin and a mental status assessment. Lately, there have been reports from other tenants that Mr. Spencer hammers on the walls and yells for the noises to go away.Mr. Spencer risks being evicted if he does not stop. During today`s visit, Mr. Spencer is pacing,stating that the noises in his head are loud, and he had his hands over his ears. He has not bathed lately and his apartment has garbage on the floor. While visiting Mr. Spencer, the PN wants to discuss concerns with the client regarding his mental status and current living situation. Which is the best approach to use with Mr. Spencer? 1. Explain to Mr. Spencer that his behavior is very inappropriate, it is going to get him evicted and he will end up homeless again 2. Inform him that the voices need to be addressed by the psychiatrist and explain that the other tenants are frightened by the banging. 3. Tell Mr. Spencer that he could end up on the streets if he does not get his life organized. 4. Validate that the noises are bothersome and a visit to the psychiatrist may help. Explain that other tenants are troubled by the banging.

4. Validate that the noises are bothersome and a visit to the psychiatrist may help. Explain that other tenants are troubled by the banging.

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