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After reviewing the client assignments, the LPN/VN tells the RN the assignment is very unfair and requests that some of the clients be redistributed to the other staff. What should the RN do first? 1. Ask the LPN/VN how the client assignment should be adjusted. 2. Assign one of the LPN/VN's clients to another nurse. 3. Encourage the LPN/VN to use teamwork skills in caring for the clients. 4. Develop a strategic plan to assist with client assignments.

1. Correct: Explore her concerns; this is most therapeutic and helpful response. Finding out what are LPN/VN's concerns first will help the RN address the LPN/VN's request and build trust in the healthcare team relationship. 2. Incorrect: This statement does not help the RN understand the LPN/VN's concern about the assignment, an negates the confidence in the LPN/VN's abilities and skills. 3. Incorrect: This answer does not acknowledge the LPN/VN's concern. 4. Incorrect: This action will not help address the LPN/VN's immediate concern with the assignment and makes resolution of the issue much more complicated than it should be.

Which action by a nurse requires intervention by the charge nurse? You answered this question Correctly 1. The two-handed method is used to recap a needle. 2. A needleless system is used to give medication through an intravenous (IV). 3. A blunt cannula is used to withdraw medication from a vial. 4. An engineered sharp injury protective device is used to recap a used needle.

1. Correct: Needles should be recapped using a one hand scoop method to prevent accidental sticks. Two-handed method increases the risk that the nurse's non-dominant hand will be punctured with the needle. Think about it. You do not want the hand holding the cap to get close to the needle. What if you miss the needle and stick your hand. The best solution is to not recap at all. Place the needle in the sharps container at once. But if the sharps container is not close by then the one hand scoop method is appropriate. You are not exposing one hand to the needle. 2. Incorrect: This is a correct method to use. To prevent injury during injection administration or body fluid retrieval, use a one-handed scoop method, needleless system, blunt cannula for medication withdrawal from a vial, or an engineered sharp injury protective device whenever possible. 3. Incorrect: This is a correct method to use. To prevent injury during injection administration or body fluid retrieval, use a one-handed scoop method, needleless system, blunt cannula for medication withdrawal from a vial, or an engineered sharp injury protective device whenever possible. 4. Incorrect: This is a correct method to use. To prevent injury during injection administration or body fluid retrieval, use a one-handed scoop method, needleless system, blunt cannula for medication withdrawal from a vial, or an engineered sharp injury protective device whenever possible.

While making rounds, the nurse discovers a small fire in a client's room. What should the nurse do first? You answered this question Correctly 1. Remove the client from the room immediately. 2. Leave the client's room to obtain a fire extinguisher. 3. Instruct the unlicensed assistive personnel (UAP) to pull the fire alarm. 4. Evacuate all clients from the unit. Rationale

1. Correct: Rescue/Remove the client; first step in Rescue, Alarm, Contain, Extinguish (RACE). 2. Incorrect: Never leave the client in an unsafe environment. Remove the client from the area. 3. Incorrect: Not first action in RACE. Get the client out of the area first. The UAP may need to help you with this. Don't send the UAP away. 4. Incorrect: Not first action in RACE. Remove the client in immediate danger first. All clients may not have to be evacuated if the fire is contained and extinguished.

The charge nurse is observing a new LPN preparing to irrigate a client's indwelling urinary catheter. The nurse must intervene when the LPN initiates what action? 1. Gathers all sterile equipment for procedure. 2. Opens bottle of sterile distilled water to flush. 3. Allows return flow to be achieved by gravity. 4. Uses gentle pressure when flushing catheter.

2. CORRECT. The charge nurse is observing the LPN's ability to complete this invasive procedure, monitoring for any action that could harm the client. The charge nurse should intervene to prevent the LPN from using sterile distilled water. Only sterile normal saline (NS) can be used to flush out the catheter to prevent an alteration in the pH balance of the bladder. 1. INCORRECT. This process is appropriate since all equipment should be gathered prior to any procedure. A nurse must be organized and prepared before any client procedure. The question is asking for something the LPN has done incorrectly. 3. INCORRECT. After a urinary catheter has been gently flushed with NS, the LPN would allow the fluid and any urine to return into the sterile basin by gravity flow. This correct action would not require the charge nurse to intervene during the process. 4. INCORRECT. Flushing a catheter is a delicate procedure, requiring slight, gentle pressure to instill the normal saline. Forcing fluid into the bladder can cause trauma or damaged to the tissue. The LPN completed this action correctly, requiring no intervention by the charge nurse.

A nurse is planning to teach a group who works at a local mall about proper use of automated external defibrillators (AED). Which points should the nurse emphasize? You answered this question Incorrectly 1. The standard AED can be used on children over the age of 5. 2. All users of the AED must be trained in its operation. 3. CPR should be taught to users. 4. Primary healthcare provider oversight is needed to ensure proper maintenance. 5. The local EMS should be notified of the type and location of AEDs.

2., 3., 4. & 5. Correct: These are appropriate actions. 1. Incorrect: Standard AEDs can be used on children over the age of 8. For children ages 1-8, the AHA recommends the pediatric attenuated pads that are purchased separately.

What should a nurse include when teaching a client diagnosed with shigellosis regarding how to prevent the spread of the infection to others? 1. Wash hands three times a day with alcohol. 2. Do not return to work until authorized by local health department. 3. Do not prepare food for others while you are sick. 4. Avoid swimming until fully recovered. 5. No sex until several days after diarrhea has stopped.

2., 3., 4., & 5. Correct. These are correct actions to prevent the spread of infection. Shigella germs are present in the stools of infected persons while they have diarrhea and for up to a week or two after the diarrhea has gone away. Shigella is very contagious; exposure to even a tiny amount of contaminated fecal matter—too small to see-- can cause infection. Transmission of Shigella occurs when people put something in their mouths or swallow something that has come into contact with stool of a person infected with Shigella. 1. Incorrect. Wash your hands with soap carefully and frequently, especially after using the toilet.

A nurse receives a client in the post anesthesia care unit following application of a long leg cast to the left leg due to a fractured tibia and fibula. Which interventions should the nurse initiate? 1. Elevate foot of bed 30 degrees. 2. Palpate bilateral pedal pulses. 3. Apply ice packs to fracture site. 4. Mark break through bleeding. 5. Assess client's ability to move toes

2., 3., 4., & 5. Correct: The priority nursing assessment focuses on any intervention that maintains good circulation to the extremity and prevents complications that can impair mobility. This must include checking distal pulses in both legs to compare the strength of the pulse on both the affected and unaffected side. The nurse should also decrease swelling and risk of compartment syndrome by applying ice to fracture site, assess for bleeding, and check for tingling, coldness, numbness, and ability to move toes; in other words - neurovascular/sensation checks.1. Incorrect: The affected leg should be elevated, but not both. The nurse should place the affected leg on a pillow and not raise the foot of the bed since this would raise both extremities.

The client has been diagnosed with cutaneous anthrax in a cut on the right hand. What measure should be implemented by the nurse to prevent further spread of the disease? You answered this question Correctly 1. Wear mask only. 2. There are no precautions necessary. 3. Standard precautions. 4. Limit interactions with client.

3. Correct: Cutaneous anthrax is not spread person-to-person. However, it can be spread to others in rare events if the wound is draining. Standard precautions should protect the individual.1. Incorrect: Inhalation is not the mode of transmission for cutaneous anthrax; standard precautions should be used with every client.2. Incorrect: Standard precautions should be used in the care of every client.4. Incorrect: Clients need personal care and assistance throughout the treatment of the infection. Stay away from answers that ask you to limit interactions with the client.

A nurse is feeding a client diagnosed with a stroke who is exhibiting dysphagia. Which action by the nurse would be appropriate? 1. Elevate the head of the bed to 15 degrees. 2. Request the client to not hold food in their mouth. 3. Monitor for frequent throat clearing after eating. 4. Orient the client to the location of food on their plate.

3. Correct: When helping to feed a client with dysphagia, the nurse should monitor for signs of aspiration such as frequent throat clearing during and after meals. The client is trying to move the bolus of food down esophagus. Aspiration is a condition where food, liquids or saliva moves into the lungs instead of the esophagus during eating. 1. Incorrect: The client should be sitting upright or a high-fowlers position. This position allows for more flexibility of neck movement to promote swallowing. The nurse can keep the client's neck in the neutral position or their chin lowered to their chest. 2. Incorrect: Why is the client holding food in their mouth? Are they disoriented or with a cognitive impairment? Asking a client who is disoriented or with a cognitive impairment to not hold food in their mouth is not an effective intervention. 4. Incorrect: Does the location of the food on the plate affect how a client swallows the food. The location of the food will not affect the possibility of the client aspirating during swallowing food.

A client is admitted to the emergency department after sustaining burns to the chest and legs during a house fire. Which assessment should the nurse perform immediately? 1. Respiratory 2. Cardiac 3. Airway 4. Neurological

3. Correct: A fire in an enclosed area causes concern for carbon monoxide poisoning. In addition to the burns to the chest, there is the added potential for airway damage. 1. Incorrect: Important to assess respiratory status but not before airway. 2. Incorrect: Important to assess cardiac, but not #1. 4. Incorrect: This assessment would be done, but not #1.

A client has been admitted to the unit with recurrent nephrotic syndrome. Which signs and symptoms does the nurse expect to find when examining the client? 1. Anasarca 2. Foamy urine 3. Hypotension 4. Periorbital edema 5. Proteinuria

1., 2., 4., & 5. Correct: Ascites and anasarca develop with severe hypoalbuminemia. Foamy urine, which may be caused by excess protein in the urine, is seen with nephrotic syndrome. Swelling (edema), particularly around the eyes (periorbital) and in the ankles and feet, is a symptom. When the kidneys are damaged, protein can leak out of the glomerulus. 3. Incorrect: Hypertension will be seen with this client rather than hypotension.

Which action by an unlicensed nursing assistant would require the nurse to intervene? 1. Collecting I & O totals for unit clients at the end of shift. 2. Elevating the head of the bed 30°- 40° for the client post thoracotomy 3. Ambulating a client who is 2 days post vaginal hysterectomy 4. Turning off continuous tube feeding to reposition a client, then turning the feeding back on

4. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. The nurse should do this when repositioning is needed. Prior to turning feeding back on, tube placement needs to be verified. 1. Incorrect: Obtaining the urinary output of a client at the end of the shift is appropriate for the nursing assistant and should be documented and reported to the RN. 2. Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. 3. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. This is an appropriate and safe action for the unlicensed nursing assistant to do.

A client with a terminal illness, asks the nurse about palliative care. What would be the nurse's best response? 1. Palliative care is a holistic way of finding a cure for a serious illness. 2. Palliative care begins when the client has 3 months or less to live. 3. Palliative care will require you to change to a palliative care healthcare provider. 4. Palliative care prevents and treats symptoms and side effects of disease and treatments.

4. Correct: This is a correct statement. The goal of palliative care is to help the client living with a chronic, life threatening illness. It focuses on the client's symptoms and the relief of these symptoms. Palliative care helps the client obtain their best quality of life throughout the course of their illness. 1. Incorrect: Palliative care is not aimed at cure. It is provided to clients who have chronic, life threatening illnesses. 2. Incorrect: Palliative care can begin at diagnosis. Hospice care is usually offered when the person has 6-12 months or less to live. 3. Incorrect: The client does not need to give up his or her primary healthcare provider. This is not a requirement of palliative care.

Which client is at the greatest risk for developing pancreatic cancer? 1. 70 year old obese client who smokes one pack of cigarettes a day 2. 64 year old client who had gallbladder surgery less than 5 years ago 3. 58 year old client with Chron's Disease 4. 52 year old client whose mother died from pancreatic cancer

1. Correct: The incidence of pancreatic cancer increases with age. Cigarette smoking, exposure to industrial chemicals or toxins in the environment, and a diet high in fat, meat, or both are associated risk factors. 2. Incorrect: Diabetes and pancreatitis are associated with pancreatic cancer. 3. Incorrect: Diabetes and pancreatitis are associated with pancreatic cancer. 4. Incorrect: The inherited risk is small.

A community health nurse is reconciling medications of a client who was discharged from the hospital with a diagnosis of congestive heart failure, hypertension, and arthritis. After reviewing the client's medications, what action is most important for the nurse to take? Prescribed Furosemide 20 mg tablet by mouth every morning Carvedilol 6.25 mg one tablet by mouth twice daily Potassium Chloride 20 mEq one tablet by mouth every mornin current Saw palmetto one tablet by mouth every morning Adalimumab 40 mg subcutaneously every other week Captopril 25 mg one tablet by mouth every morning 1. Educate the client on the newly prescribed medications. 2. Inform the client to take the captopril at night. 3. Notify the primary healthcare provider that the client is receiving adalimumab. 4. Tell the client to stop taking saw palmetto.

3. Correct: This is the "most important" action for client safety. Medication reconciliation is "the process of comparing a client's medication prescriptions to all of the medications that the client has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner or level of care. [Adalimumab can cause serious side effects, including heart failure (new or worsening).] 1. Incorrect: Although the nurse will need to teach the client about the new medications, the most important thing for the nurse to do is inform the HCP about the client taking adalimumab. 2. Incorrect: The nurse cannot change the primary healthcare providers RX. Most HF clients go home on an ACE inhibitor, beta blockers, or both (as in this case). Ceptopril is an ACE inhibtor used for the treatment of hypertension and heart failure, and is often prescribed as two -three times daily. 4. Incorrect: Saw palmetto is used as a traditional or folk remedy for urinary symptoms associated with an enlarged prostate gland (also called benign prostatic hyperplasia, or BPH), as well as for chronic pelvic pain, bladder disorders, decreased sex drive, hair loss, hormone imbalances, and prostate cancer. Not saw palmetto contraindicated with prescribed medications.

A client is admitted to the hospital due to a deep vein thrombosis (DVT). Which intervention should the nurse initiate? 1. Ambulate client around room every 2 hours. 2. Assess Homans' sign every 8 hours. 3. Place sequential compression device on both legs. 4. Apply intermittent warm, moist soaks to affected area.

4. Correct. Warm, moist soaks help to decrease edema and ease the discomfort. 1. Incorrect. The client is placed on bedrest with a gradual increase in ambulation over several days to allow time for the clot to adhere to the vessel wall which will prevent embolization. 2. Incorrect. Manipulating the leg to determine Homans' sign can dislodge the clot. 3. Incorrect. Do not use sequential compression devices to treat a DVT. It could cause the clot to break loose or dislodge.

The charge nurse is evaluating a newly hired LPN/VN graduate. Before assigning a client to be prepped for a colonoscopy, the nurse asks the LPN/VN to verbalize the correct steps for completing an enema. In what order should the LPN/VN verbalize the steps for an enema? Explain procedure to the client. Assist client to a side lying position. Insert lubricated tip into rectum. Raise enema bag 18" to 20". Add warm water to the enema bag.

Explain procedure to the client. Assist client to a side lying position. Add warm water to the enema bag. Raise enema bag 18" to 20". Insert lubricated tip into rectum.

In which situations should the nurse notify the primary healthcare provider of a medication incident? You answered this question Correctly 1. Every occurrence. 2. Client is harmed or dies. 3. Medication incident is a near miss. 4. Nurse administers an incorrect dosage. 5. Client questions the medication color.

2. & 4. Correct: The primary healthcare provider should be notified if harm is brought to the client or death occurs as a result of the medication incident. The primary healthcare provider should be notified if the nurse administers an incorrect dosage to the client, and an incident report needs to be completed in this situation.1. Incorrect: The primary healthcare provider should be notified if harm is brought to the client but not for all events with medications. An incident report should be completed so the hospital can track incident patterns for quality improvement.3. Incorrect: Near misses do not need to be reported to the primary healthcare provider. Following the rights of medication administration every time ensures medication error prevention.5. Incorrect: The nurse should answer questions regarding medication color. Depending on the manufacturer, the shape and color of the medication can vary.

Which is an example of a sentinel event? 1. The terminally ill client is referred to hospice and dies 3 months later. 2. A client has a mammogram which reveals small cyst. 3. A client with a laceration to the knee falls when getting up unassisted after being instructed to remain in bed. 4. A client scheduled for knee replacement surgery has an above the knee amputation performed.

4. Correct: Yes! Unexpected occurrence causing death or serious injury.1. Incorrect: The terminally ill are expected to die.2. Incorrect: Sometimes cysts are found during mammogram- expected occurrence.3. Incorrect: Not enough injury for sentinel event.

What foods should the nurse inform the client to avoid for three days prior to a guaiac test? 1. Chicken 2. Carrots 3. Apple 4. Raw broccoli 5. Steak 6. Turnip greens

4., 5., & 6. Correct: Foods that affect this test include raw broccoli, red meats such as steak, turnip greens, cantaloupe, radish, and horseradish. All of these could cause a false positive reading for the guaiac test. 1. Incorrect: Red meats such as steak should be avoided, but chicken is okay. 2. Incorrect: Carrots are not prohibited and will not affect the results of the test. 3. Incorrect: The client can eat apples with no effect on the test results.

Which signs/symptoms does the nurse expect to note when caring for a client with a suspected cystitis? 1. Incontinence 2. Urgency 3. Frequency 4. Hematuria 5. Nocturia 6. Flank pain

1., 2., 3., 4. & 5. Correct: Signs and symptoms of cystitis include burning on urination, nocturia, incontinence, suprapubic or pelvic pain, hematuria, and back pain. 6. Incorrect: Flank pain is seen when the urinary tract infection progresses to the kidneys.

A charge nurse is caring for clients when a new admit arrives on the unit. What action by the charge nurse is most appropriate? 1. Instruct the unlicensed assistive personnel (UAP) to complete emptying the catheter bag, and assess the new admission. 2. Send the UAP to take VS on the new admit and begin the history until she can get there. 3. Assign a nurse on the floor to initiate the assessment process. 4. Ask the unit secretary to make the client and family comfortable until she can complete her present task.

3. Correct: The nurse is the only one who can assess.1. Incorrect: The UAP can empty the urinary catheter bag, but can not assess the client. 2. Incorrect: It is out of the scope of practice for a UAP to complete any portion of the admission assessment. 4. Incorrect: The unit secretary can welcome the client, but the admission assessment must be completed by an RN.

The nurse is monitoring the infection risk in a client that is to begin chemotherapy. Which activity should alert the nurse that the client is at a higher risk for infection? 1. Enjoys getting manicures and pedicures every two weeks. 2. Loves to go with the children to the local water park. 3. Relaxes in hot tubs when traveling. 4. Selects steamed vegetables as part of routine dietary intake. 5. Prefers to go barefooted when at home. 6. Keeps cats in the home and cleans the litter boxes once a week.

1., 2., 3., 5., & 6. Correct: Infection is one of the most common life-threatening complications associated with cancer and chemotherapy. You know that both the cancer and chemotherapy weakens the immune system. Therefore, clients on chemotherapy should be familiar with activities that should be avoided due to the risk of infection with the immunosuppressed state. There are several things that are known to increase the risk of infection in these clients. Did you pick up on these? Well, let's look at a few of these. Clients on chemo should not get manicures or pedicures at salons or spas and should avoid having false nails or nail tips applied. There is too great a risk of contamination at the public salons, so clients are encourage to use their own personal and well-cleaned tools for nail care at home. Another source of bacterial contamination is public water parks. Although these parks take measures to reduce the risk of infection to the general public, the risk is too great for a client on chemo. Swimming can result in accidental ingestion of water which increases the risk of cryptosporidium or other waterborne pathogens. Same thing applies to hot tubs. ​So why is going barefoot at home such a big deal? Well, this increases the risk of cuts, scrapes, or other injury that would increase the portal for infectious agents to enter. In addition, the exposure to potential infectious agents is greater. The oncologist may direct the client in the best way to deal with this client having cats in the home and cleaning the litter box due to the risk of exposure to bacteria and parasites. If allowed to clean the litter box, latex or rubber gloves, along with a mask over the nose and mouth is generally recommended to reduce the risk of infection. In addition, the client should be instructed to thoroughly wash the hands with soap and water after cleaning the litter box or after touching the cats. 4. Incorrect: Although the intake of fresh fruits and vegetables has been controversial, most agree that if washed properly, even fresh fruits and vegetables can be consumed. However, the oncologist should be the one to approve the dietary intake of these. Here, we have vegetables that have not only been washed, but steamed as well. These should be safe for consumption for clients on chemo.

A client is preparing to be discharged after a total colectomy with the creation of an ileoanal reservoir for ulcerative colitis. The nurse recognizes that education has been successful if the client makes which statement? 1. "Ulcerative colitis cannot be cured." 2. "I look forward to having the ileostomy closed." 3. "I am going to eat a hamburger and fries for dinner." 4. "Because of this surgery, I am at a higher risk of developing colon cancer."

2. Correct: Once the reservoir has healed, the ileostomy will be closed. 1. Incorrect: A total colectomy is removal of the entire colon. 3. Incorrect: It may take several days before solid food are tolerated. 4. Incorrect: The entire colon is removed so the client is not at risk for colon cancer.

What turning method should the nurse use to turn a client who has a spinal injury? 1. Lateral transfer 2. Slide sheet procedure 3. Logrolling 4. Mechanical lift transfer

3. Correct: Logrolling is used for the client who has a spinal injury. This technique keeps the client's body in straight alignment at all times. 1. Incorrect: Lateral transfer uses a spinal board to move the client from one bed to another. 2. Incorrect: Slide sheets enable clients to be slid up a surface or over to their side, that is, up the bed or rolled over in the bed. The difference is that all of the body may not be kept in perfect alignment as with logrolling. 4. Incorrect: A mechanical lift is used to move client from a bed to chair or chair to bed.

The community health nurse plans to educate a client diagnosed with tuberculosis (TB) how to avoid spreading the disease to others. What should the nurse include when educating this client? 1. Wear a N95 respirator when around family at home. 2. Have adult family members get the TB vaccine. 3. Complete TB medication regimen. 4. Live at a sanatorium until cured of TB.

3. Correct: The best way to prevent the spread of TB is by completing the medication regimen. TB bacteria die very slowly, and so the drugs have to be taken for quite a few months. Even when a client starts to feel better they can still have bacteria alive in their body. So the person needs to keep taking the TB treatment until all the bacteria are dead. All the drugs must be taken for the entire period of TB treatment. If the entire treatment is not taken then the bacteria may not all be killed. They may then become resistant to the TB drugs which then don't work. 1. Incorrect: This is not required. It is expensive and must be fitted to each family member. Cloth or disposable masks can be used. Also, the client should cover mouth when coughing or sneezing, as TB is spread through the air. 2. Incorrect: The vaccine, BCG, works against a severe type of TB that affects young children but it is not effective against the type of bacteria found in adults. That severe type of TB is called military TB, is rare in the US, so the vaccine isn't used on young children here. 4. Incorrect: This used to be common treatment protocol, but no longer.

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? pH - 7.49 PaO2 - 99% PaCO2 - 29 HCO3 - 23 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis

4. Correct: The blood gases confirm respiratory alkalosis. Why? The pH is 7.49 (normal 7.35-7.45). This pH indicates alkalosis since it is high. Which other chemical says alkalosis? The PaCO2 of 29 (normal 35-45) is low which indicates alkalosis. The HCO3 is normal. This means that the client is in respiratory alkalosis. 1. Incorrect: The blood gases confirm respiratory alkalosis. The Bicarb is normal, so the problem is not metabolic. 2. Incorrect: The blood gases confirm respiratory alkalosis. The PaCO2 of 29 (normal 35-45) is low which indicates alkalosis. For this client to bew in respiratory acidosis, the PaCO2 would be greater than 45. 3. Incorrect: The blood gases confirm respiratory alkalosis. The Bicarb is normal, so the problem is not metabolic.

What potential contributing factors for stress urinary incontinence should a nurse assess for in an elderly female client? 1. Lack of estrogen 2. Rising abdominal pressure 3. Multiparous vaginal births 4. Spinal cord injury 5. Dementia

1., 2., & 3. Correct: During pregnancy and childbirth, the sphincter and pelvic muscles stretch out and are weakened. Increased age, decreased estrogen, and a history of multiple vaginal births/pregnancies are contributing factors for stress incontinence. 4. Incorrect: Spinal cord injury results in urge incontinence because of damage to the nerves of the bladder. Urge incontinence means there is a sudden, involuntary contraction of the muscle wall. 5. Incorrect: With functional incontinence the person knows there is a need to urinate but cannot make it to the restroom. The dementia client cannot make the conscious decision or carry out the task of ambulating to the restroom.

A client diagnosed with new onset atrial fibrillation has been prescribed dabigatran. What should the nurse teach this client? 1. Place medication in a weekly pill organizer so that medication is not forgotten. 2. Do not take with clopidogrel. 3. Dabigatran decreases the risk of stroke associated with atrial fibrillation. 4. Take this medication with food. 5. aPTT and INR levels will be drawn monthly.

2., 3., & 4. Correct: Do not take dabigatran with any other anticoagulants, including clopidogrel due to increased bleeding risk. Dabigatran decreases the risk of stroke and systemic embolism in clients with atrial fibrillation that is not associated with a cardiac valve problem. Take this medication with food to decrease gastric side effects such as dyspepsia and gastritis. Proton pump inhibitors and histamine 2 recepter blockers may also decrease gastric side effects. 1. Incorrect: After container is opened, medication should be used within 30 days. It is sensitive to moisture and should not be stored in weekly pill organizers. To maintain efficacy, keep medication in manufacturer- supplied bottle. 5. Incorrect: This medication does not require monitoring of INR levels. However, the client should be informed about the risk of bleeding and to monitor for signs of bleeding.

The nursing supervisor is preparing a staff development program concerning the legal parameters of torts. Which example would the supervisor include as an intentional tort? 1. Administering a 0900 medication at 1030. 2. Administering a medication to an incorrect client. 3. Performing an invasive procedure without an informed consent. 4. Telling a client that their medication will be withheld if client does not behave. 5. Raising the side rails without a prescription when a client is at risk to fall.

3., & 4. Correct: An intentional tort occurs when a person intends to perform an action that causes harm to another. Performing an invasive procedure without consent is considered battery because the client has not given consent for the procedure. Threatening to withhold a medication is intentionally threatening to harm the client by not administering the medication. 1. Incorrect: This is an unintentional tort. The nurse did not intend to administer the medication 90 minutes after the ordered time. 2. Incorrect: The nurse unintentionally jeopardized the safety of the client. This is an unintentional tort. 5. Incorrect: This intervention by the nurse is appropriate. In an emergency the side rails maybe raised when the safety of the client is at risk.

The nurse is reviewing sequential lab results on a newly admitted client with multiple health issues. Critical changes in which body system require the nurse to immediately notify the primary healthcare provider? 1. Renal 2. Endocrine 3. Pulmonary 4. Cardiovascular

1. Correct: All lab values are fluctuating, but those most significantly outside of normal range are the BUN and Creatinine levels, reflecting possible renal failure. The nurse would need to immediately notify the primary healthcare provider of possible complications in the client's renal system. The sodium, potassium, and glucose are within normal limits. 2. Incorrect: Several lab readings could relate to the endocrine system, but most specifically are glucose and chloride. Both these electrolytes have fluctuating levels but remain well within normal limits. Therefore, the endocrine system is not the nurse's concern at this time. 3. Incorrect: The carbon dioxide levels listed reflect venous, NOT arterial, blood. Norms for venous carbon dioxide are 23 to 29 mEq/L (milliequivalent units per liter of blood), indicating these results are all within normal levels. Although chloride could also reflect the pulmonary system, there are no irregular results in chloride levels. 4. Incorrect: Many of these elements could affect the cardiovascular system, but most specifically sodium and potassium. At present, these levels are all within normal limits, although the potassium has risen to the upper most levels of normal. If those levels continue to climb, this could become a concern; however, this would not require a call to the primary healthcare provider at this time.

A client has been admitted with folic acid deficiency anemia. Which referral would most likely be appropriate for the nurse to make? 1. Alcoholic Anonymous 2. American Sickle Cell Anemia Association 3. Pernicious Anemia Society 4. Aplastic Anemia Support Group

1. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. This referral would be appropriate. 2. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. It is an inherited form of anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout the body. Normally, red blood cells are flexible and round, moving easily through blood vessels. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. These irregularly shaped cells can get stuck in small blood vessels, which can slow or block blood flow and oxygen to parts of the body. 3. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. The body needs vitamin B12 to make red blood cells. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. This protein is released by cells in the stomach. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. 4. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. Aplastic anemia is a rare but serious condition. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated.

An emergency room nurse is assessing a child with a suspicious spiral fracture to the right arm. The nurse is aware the best evidence to support possible child abuse is what? 1. Inconsistency between injury and explanation of the cause. 2. Child withdraws when the parent tries to hug or comfort. 3. Parents leave the room when questioned about the injury. 4. Lack of parental concern with injury or pending treatment.

1. Correct: The best evidence to support suspicion of child abuse is an inconsistent story between how the injury occurred and the injuries noted in the child. There may be additional signs noted by the nurse, but specific details about what led to the injury, compared to the physical assessment, provides clear evidence for possible abuse. 2. Incorrect: While most children become clingy when an illness or injury occurs, withdrawing from a parent is not clear evidence of abuse. It could be an indication of dysfunctional parenting or incomplete bonding, but not necessarily child abuse. 3. Incorrect: Though most parents seem very concerned and are overly attentive, others may be overcome with grief that the incident happened. When questioned about the cause of the injury, a parent may exit the room, overcome by a sense of guilt and responsibility for the occurrence. This action is not true evidence of child abuse. 4. Incorrect: Parental response to an injured child widely varies and can be inconsistent based on multiple factors, such as sex and age of child, personal perceptions, cultural practices and even the circumstances of the event. Parents can become so overwhelmed by the incident that even non-abusive parents may seem indifferent while trying to remain strong.

A 3 day post-operative client with a left knee replacement is reporting chills and nausea. Temperature: 100.8ºF/38.2ºC, pulse: 94, respiration: 28 and blood pressure is 146/90. What is the nurse's best action? 1. Call the surgeon immediately. 2. Administer extra strength acetaminophen per prescription. 3. Assess the surgical site. 4. Offer extra blankets and increase fluids.

1. Correct: The client's symptoms are indicative of infection, and the primary healthcare provider needs to be notified and may want diagnostic tests performed. The other actions are appropriate to treat the symptoms and provide comfort, but they are not the best action to fix the problem. 2. Incorrect: While this may be appropriate, it may also delay treatment of the problem, which is infection. Remember, you can only pick one answer to fix the problem and this action will only treat the symptoms. 3. Incorrect: The primary healthcare provider may want the site assessed, but this also delays treatment. Since you can only pick one option, this is not the best. 4. Incorrect: Comfort measures are always appropriate, but this is not the best action available.

A client returns to the clinic two days after receiving treatment for diarrhea caused by a Campylobacter jejuni infection. The client reports a tingling sensation that began in the toes yesterday and has spread to the feet and legs today. The nurse notes muscle weakness in the legs and that the client is having difficulty walking steadily. Based on this data, what does the nurse suspect is wrong with the client? 1. Guillain-Barré Syndrome 2. Multiple Sclerosis 3. Myasthenia Gravis 4. Systemic Lupus Erythematosus

1. Correct: The clues in this stem are diarrhea from Campylobacter jejuni, tingling sensation that began in the toes, spread to the feet and legs today, muscle weakness in the legs, and difficulty walking steadily. These s/s point to Guillain-Barré Syndrome. 2. Incorrect: Multiple Sclerosis damages nerves but not in an ascending progression from toes to head. 3. Incorrect: Myasthenia gravis is caused by a breakdown in the normal communication between nerves and muscles. Myasthenia gravis is characterized by weakness and rapid fatigue of any of the muscles under voluntary control. 4. Incorrect: Systemic lupus erythematosus, the most common form of lupus, is a chronic autoimmune disease that can cause severe fatigue and joint pain.

A Hispanic client is considering treatment options for cancer. The client says that she needs to discuss the options with her sons before she makes her final decision. What should the nurse say to the client? 1. You are wanting your sons to assist you in deciding about treatment options. 2. It is really your decision about which option you choose. 3. I will be happy to discuss this issue with you. 4. This shows that you are proud of your sons.

1. Correct: This is paraphrasing the client's statement and is a therapeutic response. Within this culture the family plays a very important role when making decisions about healthcare. 2. Incorrect: Although clients have the right to make autonomous decisions, it is important to remember cultural variations regarding the decision making process. 3. Incorrect: The nurse can discuss the issue; however, the males in the family have much influence on decisions. 4. Incorrect: This is giving an opinion on the relationship of the mother and sons. While this may be true, it does not focus on the cultural aspect of the question and is not the best response.

A client admitted to ICU has a prescription for an arterial line insertion to the right radial artery. What assessment findings by the nurse would be of concern? 1. Right sided mastectomy 2. Inability to abduct fingers of right hand 3. Negative Allen's test 4. Radial pulse 3+/4+ 5. Presence of A-V shunt to right forearm

1. Right sided mastectomy 3. Negative Allen's test 5. Presence of A-V shunt to right forearm Option 1: True. What do we know about care of the client post mastectomy? No blood pressures, no needle sticks on that extremity. Nothing. So, that means no arterial line on the right side. Option 2: False. The movement of the fingers of the right hand will not determine if there is adequate arterial blood getting to the hand and fingers. Option 3: True. The nurse wants to see a positive Allen's test, which means that the ulnar artery is patent and can supply arterial blood to the hand and fingers. Option 4: False. The strength of the pulse here is very good, which should not cause the nurse to be concerned. Option 5: True. What do we know about care of the client with an A-V shunt to the right forearm? No blood pressures, no needle sticks on that extremity. Nothing. So, that means no arterial line on the right side.

The homecare nurse is instructing the family of a client recently diagnosed with Parkinson's disease about potential neurologic changes. During the discussion, what signs should the nurse include? 1. Unsteady gait 2. Muscle rigidity 3. Hyperactive reflexes 4. Bradykinesia (slowed movements) 5. Expressive aphasia

1., 2 & 4. Correct: Parkinson's disease is a debilitating, progressive neurological disorder of unknown cause. The most classic symptoms include unsteady gait secondary to increasing muscle rigidity and bradykinesia, plus difficulty with purposeful movement. These symptoms worsen over time and are often accompanied by tremors in the extremities at rest. 3. Incorrect: Reflexes in clients with Parkinson's disease become progressively slowed, not hyperactive. Because this disorder affects the midbrain, and ultimately the connection of the basal ganglia, deep tendon reflexes decrease over the course of the disease. Hyperactive reflexes are associated with other neurologic disorders such as multiple sclerosis. 5. Incorrect: Expressive aphasia is associated with brain trauma or cerebral vascular accident (CVA) and prevents the client from verbalizing appropriate or desired terminology. In Parkinson's disease, the client's speech volume becomes too low and very monotone. Also, because of facial muscle rigidity, there is great difficulty articulating words enough to be clearly understood.

The nurse is caring for a client diagnosed with Guillain-Barre' Syndrome. What assessment finding would the nurse expect see in this client? 1. Areflexia 2. Dysphagia 3. Hemiplegia 4. Orthostatic hypotension 5. Hypertonia

1., 2., & 4. Correct: Guillain-Barre' Syndrome is an acute, rapidly progressing, and potentially fatal form of polyneuritis. It is characterized by ascending, symmetric paralysis affecting the cranial and peripheral nerves. Signs and symptoms include paresthesia, hypotonia, areflexia, muscle aches, cramps, orthostatic hypotension, hypertension, bradycardia, facial flushing, facial weakness, dysphagia, and respiratory distress. 3. Incorrect: Hemiplegia, paralysis on one side of the body, is not seen. There is a symmetric paralysis starting in the lower extremities and ascending through the body. In other words, weakness begins in the feet and progresses upward. The client gets better in reverse order. 5. Incorrect: Hypotonia rather than hypertonia is seen with this disease.

Which independent nursing actions should the nurse initiate for a client admitted with heart failure? 1. Monitor for distended neck veins 2. Measure abdominal girth 3. Evaluate urine output from diuretic therapy 4. Educate client regarding signs and symptoms of heart failure 5. Administer medications as prescribed

1., 2., 3., & 4. Correct: An independent nursing intervention is one that an RN can prescribe, perform, or delegate based on their skills/knowledge. A collaborative intervention is one that is carried out in collaboration with other health team members (physical therapist, healthcare provider). Dependent nursing intervention is one prescribed by a healthcare provider but carried out by the nurse. These actions do not require an order by a healthcare provider nor collaboration with another. They are independent nursing functions.5. Incorrect: Administering prescribed medications is a dependent nursing intervention and cannot be initiated without an order being in place. This is the only option that is dependent on the primary healthcare provider's actions first before the nurse can initiate it.

What should be included in the discharge teaching plan for a client who has lymphedema post right mastectomy? 1. Use a thimble when sewing. 2. Wear a heavy duty oven mitt for removing hot objects from the oven. 3. Long sleeves should be worn to prevent insect bites. 4. Shave underarms with an electric razor. 5. Avoid wearing jewelry.

1., 2., 3., & 4. Correct: Because lymphedema is a lifelong threat, teach the client hand and arm precautions to minimize the risk of injury, infection, and impaired circulation. All of these options are correct options to minimize these risks. Even a minor injury such as a pin prick or sunburn can cause painful swelling after lymph node removal. 5. Incorrect: The client may wear jewelry that does not inhibit lymph drainage. They should avoid jewelry that constricts the affected arm.

What signs and symptoms would a nurse assess for in a client who is receiving hospice care and is close to death? 1. Cool extremities 2. Mottling 3. Cheyne-Stokes respirations 4. Loss of appetite 5. Increased blood pressure

1., 2., 3., & 4. Correct: In the hours before death, blood will be shunted to the vital organs and not the periphery. This will make the extremities cool to the touch and mottled in appearance. Both cool extremities and mottling are due to reduced blood flow. Cheyne-Stokes respirations is a respiratory pattern that consists of loud deep inhalations followed by a pause of apnea. Loss of appetite will occur as energy needs decline. The use of moistened clothes around the mouth and lip balm may help with keeping lips moist and comfortable. 6. Incorrect: Blood pressure will not increase as death nears. The pumping action of the heart declines when death is occurring which leads to a decrease in cardiac output and blood pressure.

Which vaccines would a nurse participating at a health fair encourage a 65 year-old adult to receive? 1. Influenza 2. Herpes Zoster 3. Diphtheria 4. Pertussis 5. Pneumococcal vaccine 6. Measles, mumps, and rubella (MMR)

1., 2., 3., 4., & 5. Correct: Influenza is often quite serious for people 65 and older due to weaker immune defenses. CDC recommends a single dose of herpes zoster vaccine for people 60 years of age or older to prevent shingles.Tetanus, diptheria and pertussis (Tdap) vaccine is given to older adults to protect against whooping cough (pertussis), tetanus and diptheria. Adults should get one dose of the tetanus and diptheria (Td) vaccine every 10 years. For adults who did not get Tdap as a preteen or teen, they should get one dose of Tdap in place of a Td dose to boost protection against whooping cough. However, adults who need protection against whooping cough can get Tdap at anytime, regardless of when they last got Td. Pneumococcal vaccines protect against infections in the lungs and blood stream and are recommended for all adults over 65 years old and for adults younger than 65 who have certain chronic health conditions. 6. Incorrect. A booster for measles, mumps, and rubella is not indicated for this age group

A client diagnosed with rheumatoid arthritis has been prescribed dexamethasone orally as part of initial treatment therapy. What side effects should the nurse teach the client are expected? 1. Fatigue 2. Insomnia 3. Hypoglycemia 4. Truncal obesity 5. Increased appetite 6. Low blood pressure

1., 2., 4. & 5. Correct: Dexamethasone (Decadron) is a corticosteroid used short term to treat severe inflammation occurring in rheumatoid arthritis (RA). Expected side effects are associated with the body's response to excessive steroids in the system. Even short term use of corticosteroids will produce fatigue, secondary to insomnia, truncal obesity accompanied by thin extremities, and an increased appetite resulting in weight gain. Despite the short and intermittent use of corticosteroids for this auto-immune disease, some side effects remain permanently. 3. Incorrect: Excessive steroids in the body cause blood glucose levels to increase, resulting in hyperglycemia. Clients taking corticosteroids will need regular finger stick glucose monitoring while taking these medications for rheumatoid arthritis. 6. Incorrect: The body's response to increased corticosteroids in the system is an elevated blood pressure, often accompanied by headaches or nausea. Clients taking steroids will need to have blood pressure checked frequently.

The nurse is teaching a group of clients how to decrease the risk of developing osteoarthritis (OA). What should the nurse include? 1. Control blood sugar. 2. Use largest, strongest joints for lifting. 3. Do intense aerobic exercise, daily. 4. Maintain a healthy weight. 5. Wear joint padding with playing sports.

1., 2., 4., & 5. Correct: High glucose levels speed the formation of certain molecules that make cartilage stiffer and more sensitive to mechanical stress. The client should use the largest and strongest joints and muscles. Use both arms when lifting or carrying an object. By using the largest and strongest joints, less stress occurs on single joints or weaker areas of the body. Excess weight is one of the biggest risk factors for osteoarthritis. Although injuries aren't always avoidable, it pays to protect joints. If playing sports, wear protective gear, such as joint padding for soccer or hockey. And make sure any baseball field uses break-away bases. 3. Incorrect: Physical activity is one of the best ways to keep joints healthy. As little as 30 minutes of moderately intense exercise five times a week helps joints stay limber and strengthens the muscles that support and stabilize the hips and knees. However, it does not have to be daily or intense.

What assessment data would a nurse expect to find in a client diagnosed with a severe episode of acute inflammatory bowel disease? 1. Dark yellow urine 2. Fever 3. Frequent, hard stools 4. Lower abdominal cramping 5. Tachycardia

1., 2., 4., & 5. Correct: The client with a severe episode of actue inflammatory bowel disease will have frequent diarrhea that contains blood and mucus. This can lead to dehydration, so fluid volume deficit is a problem. What happens to urinary output then? It decreases and becomes concentrated. So urine will be a dark yellow color. This disorder is an inflammatory disorder, so fever is anticipated. Lower abdominal cramping or continuous pain is seen with acute episodes. What does the heart do when you are dehydrated? The heart increases the heart rate to get what little volume there is in the vascular space circulating. 3. Incorrect: Hard stools are not seen with this disease. Frequent diarrhea is expected.

When caring for a client on bedrest, which interventions should the nurse implement to decrease the risk of deep vein thrombosis? 1. Apply compression hose. 2. Place pillow under knees while supine. 3. Assist client to perform active foot and leg exercises. 4. Place client on intermittent pneumatic compression device. 5. Assess extremities for negative Homan's sign.

1., 3., & 4. Correct. The client will need compression or compression hose and/or intermittent pneumatic compression device. The client should perform leg and foot exercises to decrease stagnation of blood. Compression hose, foot and leg exercises as well as pneumatic compression devices increase venous return and prevents stasis of blood. Other interventions to decrease deep vein thrombosis (DVT) include early ambulation, passive and active range of motion, isometric exercises and anticoagulant drugs such as heparin. 2. Incorrect: Do not compromise blood flow by placing pillows under the knees, crossing legs, or sitting for long periods of time. Pillows under the knees help with pressure on the lower back. However, if pillows are left under the knees for an extended time, venous return could be compromised. A pillow under the knees is not a recommended intervention for DVT prevention. 5. Incorrect: Do not assess Homan's sign, as it may dislodge a clot. Homan's sign is not a preventative intervention. Assessing a Homan's sign is considered to be controversial, and this test may contribute to the release or dislodgement of a clot.

An unconscious client is admitted to the ICU with a closed head injury suffered in a fall. Despite aggressive efforts, the client expired within 24 hours. The nurse must complete postmortem care while awaiting the coroner. The nurse knows what action is not appropriate in this situation? 1. Remove indwelling catheter 2. Disconnect the ET tube from ventilator 3. Remove hospital ID band 4. Cap all intravenous lines 5. Wash body head to toe

1., 3., & 5.CORRECT. The client expired of injuries within 24 hours of being admitted to the hospital, which requires investigation by a coroner. It must be determined if death resulted from fall injuries, or whether any action, or lack thereof, by medical personnel contributed to the client's demise. When completing postmortem care on a "coroner's case", the nurse must leave all invasive lines and tubes in place for investigative purposes. Therefore, it would not be appropriate for the nurse to remove the foley catheter, although the urine can be emptied from the bag. It is also incorrect to remove any hospital identification bands. Washing the body should never be done since evidence could be disturbed or even removed. 2. INCORRECT. This action is acceptable since the client would not be transported while still attached to a ventilator. However, the endotracheal tube itself must remain taped in place when the client is transported to the coroner's facility. 4. INCORRECT. It is not necessary to leave the IV bags attached to intravenous catheters. The tubing and bags may be removed as long as the intravenous catheter itself remains intact on the client. Any variation of this standard procedure would be determined by the facility or coroner in advance.

A client has been admitted to the medical unit after sustaining a stroke. The admitting nurse initiates a nursing diagnosis of unilateral neglect related to a decrease in visual field and hemianopia from cerebrovascular problems as evidenced by consistent inattention to stimuli on the affected side. What nursing interventions should the nurse initiate for this client? 1. Instruct client to scan from left to right to visualize the entire environment. 2. Encourage client to practice exercises independently. 3. Position bed in room so that individuals approach the client on the unaffected side. 4. Apply splints to achieve stability of affected joints. 5. Touch unaffected shoulder when initiating conversation with client. 6. Position personal items within view on the unaffected side.

1., 3., 5., & 6. Correct: Instructing the client to scan from left to right will help the client to visualize the entire environment. The client has to be reminded to do this since only one side of the client's visual field is working. By positioning the bed so that individuals approach the client from the unaffected side and by touching the client on the unaffected shoulder, the client is not surprised or frightened when realizing someone is in the room. Placing personal items where the client can see them will allow the client to use the material. Then gradually move personal items and activity to the affected side as the client demonstrates an ability to compensate for neglect. 2. Incorrect: Practicing exercises independently focuses on impaired physical mobility rather than unilateral neglect. 4. Incorrect: Applying splints to affected joints focuses on impaired physical mobility rather than unilateral neglect.

A hospitalized client reports needing scented candles to aid sleep. The nurse informs client lit candles are not permitted in the facility. What appropriate alternatives could the nurse suggest to the client to assist with the sleep process? 1. Use an electric potpourri burner. 2. Place dry potpourri in nightstand. 3. Bring in live flowers to keep in room. 4. Spray scented air freshener frequently. 5. Dab scented oil on corner of the sheets.

2 and 5. CORRECT: The nurse must provide the client with alternatives methods to aid sleep that do not present a safety hazard. Potpourri is fragrant dried flowers or plant stems which emit a smell based on the assortment. Sprinkling a small amount inside the nightstand drawer would allow the scent to gently permeate the area next to the client's bed without presenting a safety hazard and the aroma would be consistent over long periods of time. Also, a tiny drop of an essential oil dabbed on the corner of the pillow case or sheet would also provide the client with desired needed sleep enhancement without impacting health or safety issues. 1. INCORRECT: Hospitals have specific regulations about outside electronics, requiring most to be checked by maintenance staff prior to use in the facility. An electric potpourri burner melts scented wax in a small open ceramic dish, providing odor as it dissipates. An open container of hot wax plus the need to keep the burner plugged in all night are extreme safety hazards to client and staff. 3. INCORRECT: This inefficient and costly method to aid client sleep is impractical on several levels. The fragrance of flowers rapidly fades, based on ambient temperature and room size. Additionally, the inconsistency of smell would not provide the same restful level of sleep during the night. 4. INCORRECT: Spraying non-hospital approved air freshener could prove problematic for other clients, since that odor would not be confined to just the client's room. Secondly, the quick dissipation of the spray would not provide an entire night of restful sleep.

While preparing to administer intravenous of chemotherapy the nurse accidently pulls the tubing apart, spilling the solution onto the floor. After clamping the tubing, what is the nurse's immediate action? You answered this question Correctly 1. Use disposable towels to clean up the liquid. 2. Obtain spill kit specific to this type of solution. 3. Complete an incident report for supervisor. 4. Call housekeeping to help clean up the floor.

2. CORRECT: Chemotherapy spill kits are pre-packaged supplies specific to the type of cytotoxic drugs used and are kept in close proximity to the location the chemo is administered. These kits vary slightly but all follow the basic guidelines. Individuals cleaning up the spill must be completely covered head to toe to prevent any contact with the drug. This includes inhalation. This option contains the word solution, which also appears in the question. 1. INCORRECT: Disposable towels are not acceptable to clean up a chemotherapy spill. Although these towels are absorbent for kitchens and bathrooms, only special absorbent pads can be used to clean up cytotoxic drugs. 3. INCORRECT: While it is true that the nurse will need to complete an incident report regarding the chemotherapy spill, it is certainly not the nurse's immediate action. Focus on staff and client safety first. 4. INCORRECT: The responsibility for cleaning up cytotoxic drugs is for the nursing staff involved at the time. Special training and knowledge is required to handle this issue.

A client scheduled for electroshock therapy becomes anxious prior to the initial treatment and refuses the procedure. What is the nurse's priority at this time 1. Administer pre-op sedation to help the client relax. 2. Notify the primary healthcare provider of the client's refusal. 3. Remind the client that the consent is already signed. 4. Ask the family to help convince the client to re-consider.

2. Correct. The client has withdrawn consent for the procedure; therefore, the primary healthcare provider should be informed immediately to cancel the treatment. The primary healthcare provider may wish to speak with the client, but the client can legally refuse any procedure at any time. 1. Incorrect. Pre-op sedation is considered part of the procedure for which the client has withdrawn consent. Giving this medication would violate the client's right to refuse treatment and could be considered assault by the nurse. 3. Incorrect. Signing a consent form indicates that the primary healthcare provider has informed the client of all potential risks of the procedure. The client's signature represents an acknowledgement and understanding of that explanation. It is not an iron-clad contract agreeing to have the procedure. 4. Incorrect. Involving family members to try to convince the client to have this procedure would be unethical and could be considered coercion. Depression does not make the client incompetent to make decisions about healthcare options.

The parents of a child admitted with rheumatic fever (RF) ask why the child has been placed on bedrest. The nurse explains that bedrest serves what primary purpose for the client? 1. Prevents permanent joint damage. 2. Decreases workload on the heart. 3. Helps regulate body temperature. 4. Reduces joint pain and body aches.

2. Correct: Rheumatic fever is a secondary, infectious process that occurs several weeks after an unresolved streptococcal infection, such as strep throat. The Group A beta-hemolytic strep can cause inflammation in the myocardium or epicardium, ultimately affecting the valves of the heart, particularly the mitral valve. The resulting thickening and fibrosis leads to cardiac stenosis which could lead to heart failure. During this illness, decreasing the workload on the heart is vital to help prevent cardiac complications. 1. Incorrect: Rheumatic fever causes increased body temperature, muscle aches and swollen painful joints, particularly knees, ankles and wrists. Although clients may need ibuprophen for pain and swelling, there is no permanent damage to the joints. Bedrest serves another purpose for this client. 3. Incorrect: It is true that these clients can run a high fever at times and even develop a red rash over the torso. However, the purpose of bedrest is not related to controlling body temperature. 4. Incorrect: It may seem logical that bedrest would decrease joint pain and body aches, but this is not the primary purpose for bedrest.

The nurse is working on health promotion plans for a small group of school-aged children who are at risk for obesity. Which baseline data would support the risk for obesity? 1. Spends one hour playing sports or swimming daily. 2. Spends at least two hours watching TV after dinner each day. 3. Assists mom in preparing low carb snacks for the family. 4. Participates in the marching band at school.

2. Correct: Sedentary activities, such as watching television, playing video games and using a computer to surf the internet or engage with friends can also contribute to obesity and cardiovascular health problems in later life. 1. Incorrect: The more active the child is, the less likely he is to be overweight. Activity for at least one or more hours per day should be encouraged.3. Incorrect: Children who are exposed to healthy snacks are less likely to be overweight and are more likely to choose healthy snacks.4. Incorrect: The marching band is an excellent source of exercise for the child. This information does not support the risk for obesity.

A client is admitted with a hip fracture after falling. Based on these lab values, what is the nurse's priority nursing intervention? Na+ 147 mEq/L (147 mmol/L) Specific gravity 1.030 Hct 55% 1. Provide foods high in iron 2. Increase fluid intake 3. Obtain a urine for culture 4. Measure intake and output

2. Correct: We already know that the question is about what life threatening complication? A pulmonary embolism. And these lab values say that the client is what? Dehydrated! So the only thing that is going to fix that is....... Increasing fluids. 1. Incorrect: This will not prevent pulmonary embolism. The problem is dehydration. Do something to fix the problem. Foods high in iron will not fix the problem. 3. Incorrect: This will not prevent pulmonary embolism. How will obtaining a urine sample for culture fix dehydration? It won't. This client needs to increase fluid intake. 4. Incorrect: We do want to monitor intake and output to see how the client is doing, however, this will not fix the problem. Hydrating the client will help the problem.

The nurse is caring for a client with multiple episodes of diarrhea and suspected Clostridium Difficile (C. diff). Which interventions should be included in the plan of care? 1. Institute contact precautions only after confirmation of stool culture. 2. Instituting contact precautions for all who enter the client's room 3. Using alcohol based foam for hand hygiene. 4. Dedicating equipment for use only in the client's room. 5. Requesting antidiarrheal medication for the client.

2., & 4. Correct: Contact isolation will be needed to prevent the spread of infection. Also the electronic equipment for vital signs must not be used in the room. The client will need a disposable stethoscope, BP cuff and thermometer dedicated for use in that patient room.1. Incorrect: Precautions should be instituted and a stool sample sent for any client with persistent diarrhea. Isolation should be in place with suspected c. diff.3. Incorrect: Soap and water must be used to clean the hands. Alcohol based foams do not have enough alcohol in them to destroy the c diff spores. 5. Incorrect: Medications to stop diarrhea will not be prescribed with c. diff. because they cause even further irritation.

A nurse has been educating a client newly diagnosed with diabetes, about proper foot care. The nurse knows teaching will need to be reinforced again when the client makes what statement? 1. "I should cut my toenails with nail clippers." 2. "Drying both feet thoroughly is important." 3. "I should never use nail polish on my toes." 4. "Weekly foot inspection must include the soles of the feet." 5. "I need larger shoes that don't pinch my toes."

3, 4 and 5 CORRECT: The nurse is evaluating the client for an understanding of proper diabetic foot care; therefore, an incorrect statement would require further instruction. There is no reason a client with diabetes could not use nail polish on toenails. Inspection of both feet, including the soles of the feet, must be done daily and not weekly. Most importantly, properly fitted shoes are crucial to prevent complications that might result in a blister or eventually an amputation. 1. INCORRECT: Diabetic clients are advised to use small clippers rather than scissors which could result in an injury from cutting too deep. It is easier to cut toenails straight across, as prescribed, with clippers. This comment indicates the client understood the teaching. 2. INCORRECT: It is crucial to thoroughly dry feet following a shower or if feet get wet, since moist skin can breakdown easily. Although diabetics have very dry skin, no lotion should be applied between toes. Absorbent, white cotton socks are best for diabetic clients, and may need to be changed more than once daily. This response indicates the client understands the information from the nurse.

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

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

The nurse is caring for a client admitted with heart failure associated with an acute MI. At which time point did the nurse begin to intervene incorrectly? 1110: IV D5W started with 20-gauge catheter to left hand at 20 ml/hr via infusion pump. Client reports chest pain at 8/10. BP - 180/102, HR - 108, RR - 30. 1115: Nitroglycerin 25 mg added to glass bottle of D5W 250 mL and connected to lowest left hand IV site with primary tubing and attached to infusion pump at 3 mL/hr. Client reports chest pain at 9/10. BP - 182/100, HR - 110, RR - 28. 1120: Client reports chest pain at 8/10. BP - 168/90, HR - 108, RR - 26. Nitroglycerin infusion increased to 6 mL/hr via infusion pump. 1125: Client reports chest pain at 7/10. BP - 154/94, HR - 100, RR - 24. Nitroglycerin infusion increased to 12 mL/hr via infusion pump. 1130: Client reports chest pain at 2/10. BP - 130/80, HR - 86, RR - 24. Nitroglycerin infusion increased to 15 mL/hr via infusion pump. 1. 1115 2. 1120 3. 1125 4. 1130

3. Correct: At 1125, the nurse failed to follow protocol for nitroglycerin infusion. The nurse increased the IV rate by 6 mL/hr (going from 10-20 mcg/min). 1. Incorrect: The nurse mixed the nitroglycerin appropriately and connected the tubing at the correct IV site. The infusion rate was started at 3 mL/hr which delivered the appropriate starting dose at 5 mcg/min. 2. Incorrect: At 1120 the client is still hurting and the BP is above 120 systolic, so the nitroglycerin infusion can be increased by 5 mcg/min which would increase the rate to 6 mL/hr. 4. Incorrect: At 1130 the client is still hurting and the BP is above 120 systolic, so the nitroglycerin infusion can be increased by 5 mcg/min which would increase the rate to 15 mL/hr.

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

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

The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about nutrition and maintaining body weight. Which instruction is most important for this client? 1. Do postural drainage just before meals. 2. Consume fluids only at meal times. 3. Prepare meals high in carbohydrates. 4. Plan rest periods before and after meals.

4. Correct: Both ingestion and digestion require a great deal of energy expenditure for clients. Resting prior to eating helps decrease dyspnea, allowing the client to complete an entire meal. Relaxing afterwards compensates for the increased blood flow sent to the gastrointestinal system during digestion, again minimizing respiratory effort. Frequent rest periods throughout the daily are vital for COPD clients. 1. Incorrect: Postural drainage techniques help COPD clients loosen and expel excessive mucus that builds up from inflammation within the lung tissue. Because of specific therapy positions, including those in which the client faces head down, there is the chance of wheezing or vomiting. This can lead to aspiration or infection. The best time to complete chest therapies is at least an hour before or two hours after a meal. 2. Incorrect: Fluids help to thin excessive mucous secretions typical in chronic obstructive pulmonary disease. Also, if the client is using oxygen, the mucous membranes will quickly dry out. COPD clients are encouraged to drink at least 64 ounces of caffeine free liquids throughout the day, rather than just at mealtime. 3. Incorrect: Because dyspnea interferes with eating, weight loss and malnutrition are areas of concern for clients with COPD. Small frequent meals high in protein are important to maintain nutrition and improve the immune system.

A client with cervical cancer received an internal cervical radiation implant. What should be the initial nursing action if the radiation implant becomes dislodged and is found lying in the bed? You answered this question Correctly 1. Call the client's primary healthcare provider. 2. Pick up the implant immediately with gloved hands and place it in double biohazard bags. 3. Notify the radiology department. 4. Utilize long-handled forceps to pick up the implant and dispose of it in a lead container.

4. Correct: If a client is receiving a radiation implant, a lead container and long-handled forceps should be placed in the client's room and kept for the duration of the therapy. If the implant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it in the lead container. 1. Incorrect: The placement of the implant into the lead container should be done initially. The primary healthcare provider may be notified but this is not the initial nursing action needed. 2. The implant should be picked up with long forceps for distance and reduction of contact. In addition, a biohazard bag is not sufficient for proper disposal of the radiation implant. 3. The initial action is to use long-handled forceps and dispose of the implant in a lead container. Calling the radiology department is delaying care and exposing individuals to the implant.

How does the nurse identify the correct size of crutches for a client? 1. Turn the crutches upside down and measure from the heel to the shoulder. 2. Obtain a set of crutches and adjust the height until the client can stand comfortably while resting the axilla on the crutch pad. 3. Measure the client while standing upright from the axilla to the heel then adjust the crutches so that the elbow flexion is a 30-degree angle. 4. Measure the client from 2 inches below the axilla to 6 inches lateral to the client's heel.

4. Correct: Measuring the client from 2 inches below the axilla to 6 inches lateral to the client's heel correctly measures a client for crutches. This is the correct size while a client is standing. 1. Incorrect: This is not the correct way to choose the correct size crutches. Without the proper fit safety is a concern. 2. Incorrect: This is not how to choose the correct size of crutches. The client should not rest their weight on the crutch pad as this can cause damage to the brachial plexus nerve. 3. Incorrect: This is not how to choose the correct size of crutches. The shoulders should be relaxed, the hand piece should be adjusted to provide a 20°- 30° elbow flexion. The 2 inch drop below the axilla allows the weight to be pressed against the sides and the hands absorb the weight. The crutch should not be placed against the axilla or the brachial plexus nerve could be damaged.

The nurse is caring for a client and the family at a time of impending death for the client. What comment by the nurse would best assist the family to cope with their grief during this time? 1. "Don't cry. Your family member would not want it this way." 2. "Things will be fine. You just need to give yourself some time." 3. "Try not to be upset in front of your family member." 4. "I'm so sorry. This must be very difficult for you."

4. Correct: Nurses can best facilitate the family's expressions of grief by supporting and encouraging them to express themselves. This is the best option that best demonstrates that expressions of grief are acceptable and expected. Here, you are empathizing to provide emotional support during their grief and providing an open ended statement that would promote expression of the family members' grief. 1. Incorrect: Telling grieving family members not to cry is certainly not very therapeutic. They need to feel free to express their emotions of grief at the time of impending death of the loved one. This statement would be a barrier to demonstrating care and concern. 2. Incorrect: Telling the family that things will be fine and to give themselves time are trite assurances and clichés that should be avoided by the nurse. Instead, you should use therapeutic responses that promote the expressions of grief by the family. 3. Incorrect: Again, by telling them to try not being upset in front of the dying family member, this is not demonstrating care and compassion to the family members who are grieving. This would be a barrier to assisting them to communicate and express their feelings of grief.

The nurse is caring for a client diagnosed with schizophrenia who is admitted to the hospital for possible bowel obstruction. The client has a nasogastric tube (NG) and reports pain 8/10. What is the priority nursing action? 1. Decrease the stimuli and observe frequently. 2. Administer the prn sedative. 3. Call the primary healthcare provider immediately. 4. Administer the prn pain medication.

4. Correct: Small bowel obstruction has a clinical manifestation of crampy pain that is wave like and colicky due to persistent peristalsis above and below the blockage. Nursing care of the patient includes pain management. 1. Incorrect: Decreasing the stimuli and observing are not appropriate. The pain needs to be assessed and treated.2. Incorrect: Not necessary, it will sedate them, but not help the pain. Sedation is not a necessary intervention for pain. A medication to relieve pain is needed. 3. Incorrect: The nurse can administer pain medication as ordered. There is no need to contact the healthcare provider.

A young adult is brought into the ER after experiencing hallucinations at a beach party. The paramedics report a large quantity of beer cans and empty plastic baggies around the bonfire. During the nursing assessment, the client jumps up screaming, "Get those snakes away from me." What initial action by the nurse would most likely result in a positive outcome for client and staff? 1. Summon security to the ER to physically restrain the client. 2. Ask paramedics to restrain client to inject haloperidol. 3. Call nursing supervisor and request 4-point-leather restraints. 4. Close the door and quietly reorient client to current location.

4. Correct: The best initial reaction by the nurse with a hallucinating client is to decrease stimuli and try to re-orient the individual to location or surroundings. Arguing, shouting or attempting to restrain the individual could result in injury to client and staff. 1. Incorrect: Unless the client is holding a weapon and making terroristic threats, there is no need for security to restrain the client. The healthcare provider should be notified regarding client behavior for possible orders for sedation. 2. Incorrect: Restraining this client, even to inject haloperidol (Haldol) would escalate the situation to dangerous levels. Paramedic responsibilities do not include treating the client inside the emergency room. Client restraint inside the ER is not a medic protocol. 3. Incorrect: There is nothing wrong with notifying the supervisor about an out-of-control client in the emergency room. However, 4-point-leather restraints must be ordered by the healthcare provider and is done so only in dire cases in which the client is a danger to self or others.

The nurse is caring for a client in the 8th week of pregnancy. The client is spotting, has a rigid abdomen and is on bedrest. What is the most important assessment at this time? 1. Protein in the urine 2. Fetal heart tones 3. Cervical dilation 4. Hemoglobin and hematocrit levels

4. Correct: The client may be bleeding, and that is an emergency! Common causes of hemorrhage during the first half of pregnancy include abortion and ectopic pregnancy. Ectopic pregnancy is a significant cause of maternal death from hemorrhage and the classic signs of ectopic pregnancy include positive pregnancy test, abdominal pain and vaginal "spotting". Remember that in the ruptured ectopic pregnancy, bleeding may be concealed and severe pain could be the only symptom. 1. Incorrect: Protein in the urine indicates preeclampsia, which is a condition in which hypertension develops during the last half of pregnancy. 2. Incorrect: We can't hear them yet because the client is just 8 weeks pregnant. It may be possible to detect heart beat with a Doppler transducer at 10 weeks, but this client is only in the eighth week of pregnancy. 3. Incorrect: A vaginal exam may stimulate heavier bleeding and will not provide information about concealed bleeding. A transvaginal ultrasound will be performed to determine whether a fetus is present and if so, whether it is alive.

A client with nausea, vomiting, and diarrhea for the past three days has been prescribed one liter of normal saline with 40 mEq (40 mmol/L) of potassium chloride to infuse at 250 mL per hour. Which assessment would the nurse report to the primary healthcare provider prior to initiating the infusion? 1. Blood pressure of 106/54 2. Apical pulse of 112 per minute 3. Tenting of the skin over the sternum 4. Urinary output of 148 mL for the past 6 hours

4. Correct: The client's output is below normal. This could indicate a problem with renal perfusion. Potassium is excreted through the kidneys, so if the kidneys are not being perfused, the client would retain potassium. The healthcare provider would need to be aware of the client's low urine output. 1. Incorrect: A client in fluid volume deficit would have a low blood pressure. This is an expected assessment prior to fluid resuscitation. 2. Incorrect: A client in fluid volume deficit would have a fast pulse rate. This is an expected assessment prior to fluid resuscitation. 3. Incorrect: A client in fluid volume deficit would have tenting of skin. This is an expected assessment prior to fluid resuscitation.

The nurse notices the primary healthcare provider removes gloves after performing an invasive procedure on a client. The healthcare provider then enters another client's room without washing hands. What is the initial action by the nurse? 1. Ignore it since the primary healthcare provider knows best. 2. Contact the nursing supervisor. 3. Notify the chief of medical staff. 4. Remind the primary healthcare provider of the importance of standard precautions.

4. Correct: The nurse is the client's advocate and can remind the primary healthcare provider of the importance of washing hands before entering a client's room. Hand washing should be performed when going from one room to another. 1. Incorrect: Nurses are to be client advocates and resolve a problem that they see. The primary healthcare provider should wash their hands prior to entering another client's room. 2. Incorrect: The nursing supervisor is not the first step, the nurse is. This incident may be reported to the charge nurse at a later time but the client's safety is priority. 3. Incorrect: This is not the first step. The nurse should address the problem when it is witnessed. The nurse should follow the chain of command when reporting a problem but speaking to the chief of medical staff is not the best action at this time.

A client has been diagnosed with genital herpes. Which comment indicates understanding of the disease and prevention of the spread of the disease? 1. "I can be treated and then no one else is at risk." 2. "Using condoms will keep my sex partner from acquiring the disease." 3. "If I have no sores, I am not contagious to anyone." 4. "My sex partner should be tested because we have not always used condoms."

4. Correct: The sex partner may become infected even if using a condom. The condom does not always cover all lesions. Condoms do, however, reduce the likelihood of getting/transmitting the disease.1. Incorrect: Sex partners can acquire the disease even if no open sores are present. Treatment manages outbreaks but does not cure the disease.2. Incorrect: Condoms decrease the risk. Abstinence is the only guaranteed way to not expose your partner. 3. Incorrect: Sex partners may get the disease even if no open sores are present; therefore, they should be tested for the disease.

Which client with a heat-related illness should the emergency room nurse provide attention to first? 1. Elderly person with reports of dizziness and syncope following working in the yard in the sun for several hours. 2. Football player who was at summer practice and developed severe leg cramps, nausea, tachycardia, and diaphoresis. 3. Low income individual who reports that the power has been turned off and has not had air conditioning for several days and who is experiencing increased respiratory rate, fatigue, extreme diaphoresis, and hypotension. 4. Person who had been lying in a roadside ditch for an undetermined length of time and was found with altered mental status, poor muscle coordination, and hot, dry skin.

4. Correct: This client is demonstrating signs of a heat stroke. This client would be a priority due to the severity of dehydration as evidenced by the altered mental status, poor muscle coordination, and absence of sweating. 1. Incorrect: This elderly client is probably dehydrated and may have experienced some postural hypotension while working in the yard which could play a role in the syncope. This client will need a workup to rule out other underlying issues. However, this client would not be a priority over the client with altered mental status. 2. Incorrect: It is not uncommon for athletes to experience heat related dehydration with muscle cramps, nausea, tachycardia, and diaphoresis. This should be managed with fluid and electrolyte replacement. This client still has diaphoresis, which makes the client less a priority than the client who no longer is producing sweat. 3. Incorrect: This client is showing signs of heat exhaustion with dehydration. However, this client continues to have diaphoresis, which makes this client less of a priority to see than the client who no longer has diaphoresis and has altered mental status.

A RN and a LPN are caring for a client who is post-op total right hip replacement. Which action by the LPN would necessitate intervention by the RN? 1. Reinforcing teaching about the use of the overhead trapeze bar. 2. Reminding client of the need for using the incentive spirometer. 3. Reinforcing the hip dressing as needed due to breakthrough bleeding. 4. Providing socks for the client to put on to help warm the feet.

4. Correct: This is a safety issue and the RN must intervene to prevent possible dislocation of the hip. If the hip becomes dislocated, it could result in neuro-vascular damage as well as result in the client having to go back to surgery. If the LPN gives the client socks to put on, it would require the client to have flexion at the hip to apply the socks. Hip flexion is a leading cause of hip dislocation following hip surgery and should be avoided. 1. Incorrect: Although LPNs cannot develop a teaching plan, the LPN can reinforce teaching to this client regarding the use of the overhead trapeze bar. 2. Incorrect: The LPN is not developing a teaching plan here, but is reminding the client of teaching that has been performed for the need of incentive spirometry following surgery. This is an appropriate action by the LPN and would not require intervention by the RN. 3. Incorrect: LPNs can reinforce dressings and can perform dressing changes. The healthcare provider may prescribe initially for the dressing to be reinforced, and will prescribe when the dressing should be changed. Performing the dressing reinforcement by the LPN would not warrant intervention by the RN.

A client with a history of syncope and transient arrhythmias has been ordered a Holter monitor for 48 hours. The nurse knows that teaching has been effective when the client makes what statement? 1. No follow up care will be needed after the monitor is removed. 2. It is okay to shower or bath while wearing this equipment. 3. I have to take it easy and not exercise for the next two days. 4. It's important to write down all my activities during this tim

4. Correct:The purpose of the Holter monitor is to detect cardiac irregularities over an extended period of time, in this case 48 hours. Although the monitor will record heart rate and rhythm for two days, it is vital for the client to keep a log or diary during that time, indicating the precise time and type of every activity. Additionally, this log needs to indicate any chest pain or palpitations the client experiences during that time, to assist the primary healthcare provider in diagnosing cardiac dysfunctions. 1. Incorrect: A Holter monitor is a mobile diagnostic test utilized by the cardiologist to help determine a cause for this client's syncopal episodes or arrhythmias. Once the client has the monitor and electrodes removed, the primary healthcare provider will analyze the data before meeting with the client to discuss the findings. Regardless of any suggested treatment options, the cardiologist needs a follow up visit with the client. 2. Incorrect: Showering or tub bathing is not permitted while wearing the Holter monitor as this may interfere with the functioning of the equipment. Only a careful sponge bath is permitted. Clients are also instructed to avoid heavy machinery, electric razors, microwave ovens and even hair dryers since can also affect accuracy and performance of the monitor. 3. Incorrect: The purpose of wearing Holter monitor for 24-48 hours is to diagnose cardiac arrhythmias during ADL's or exercise. The client cannot remove the monitor at any time during that period since that would cause inaccurate readings, or even the loss of valuable data. The client is instructed to complete all routine daily activities during that time, including work or exercise, to help identify actions that contribute to the symptoms or cardiac irregularities.

The pathology report on a client diagnosed with urolithiasis reveals calcium oxalate stones. Which food selections by the client would indicate to the nurse that the client understands the prescribed low oxalate diet? 1. Spinach 2. Raspberries 3. Almonds 4. 100% bran cereal 5. Bananas 6. Raisins

5., & 6. Correct: Fruits provide valuable amounts of water, fiber, and antioxidants, all of which may help lower your risk for kidney stone symptoms. Many fruits are considered low-oxalate, meaning they contain less than 2 milligrams per serving. These include bananas, cherries, grapefruit, grapes, mangoes, melons, green and yellow plums and nectarines. Canned fruits, including peaches, pears, and dried fruits such as raisins, are also low in oxalate. 1. Incorrect: 1 cup of cooked spinach contains 1510 mg of oxalate. 2. Incorrect: Raspberries are the most significant fruit source of oxalate. One cup of raspberries contains 48 mg of oxalate. 3. Incorrect: 1 oz (28 g) of almonds contains 122 mg of oxalate. 4. Incorrect: One cup of 100% bran cereal contains 75 mg of oxalate.

What test should the nurse use to test a client's gross hearing acuity? 1. Weber's 2. Rinne 3. Audiometry 4. Whisper 5. Monofiliment testing

1., 2., 3., & 4. Correct: The Weber test uses a tuning fork to assess bone conduction by examining the lateralization of sounds. The Rinne test compares air to bone conduction. Audiometric testing determines the degree and type of hearing loss. The audiometer produces pure tones at varying intensities to which the client can respond. The ticking of a watch has a higher pitch than the normal voice. Have client occlude one ear. Out of the client's sight, place a ticking watch 1 inch (2-3 cm) from the unoccluded ear. Ask what the client can hear. Repeat with the other ear. With the whisper test, the examiner stands 12-24 inches (30-61 cm) to the side of the client and, after exhaling, speaks using a low whisper. The client is asked to repeat numbers or words or answer questions. Each ear is tested. 5. Incorrect: Monofiliment testing identifies sensory neuropathy, particularly of the feet.

An oncology client with a Hickman catheter is being discharged to receive chemotherapy via cassette pump at home. The nurse is aware that discharge instructions should include what information? You answered this question Correctly 1. Always use two pairs of gloves when preparing chemotherapy medications. 2. Discarded chemotherapy cassettes and tubings can be placed in regular trash. 3. Used needles or syringes must be placed into plastic chemotherapy receptacle. 4. Linens soiled with chemotherapy drugs can be washed with regular laundry. 5. Waste is placed into chemotherapy bags and picked up by medical supplier. 6. Regular home cleaning products are appropriate for spilled chemotherapy medications.

1, 3 and 5. CORRECT: Administering chemotherapy medications at home would require the same diligence and precautions that are used in the hospital setting. In order to prevent contamination, the individual preparing the chemotherapy should wear two pairs of gloves and should not prepare the drugs in an area where food is prepared. Used needles or syringes must be discarded in a hard, yellow plastic receptacle marked "chemotherapy". Any "soft" waste products, such as dressings or towels used to clean up spills, must be double-bagged and then placed into the designated "chemotherapy bag". These wastes are then picked up by the medical supplier for disposal. 2. INCORRECT: No equipment used to prepare or administer chemotherapy medications can ever be placed in regular trash. Specially designated chemotherapy disposal receptacles must be used for all types of chemotherapy waste. 4. INCORRECT: Several days after receiving chemotherapy, the human body eliminates unused or excess product through body waste such as stool, urine, or even emesis. Linens that become soiled with such waste products must be washed separately from normal linens for the first washing. A second washing is necessary, although the linens may be thrown in with other clothing for the second washing. 6. INCORRECT: It is never appropriate to use regular home cleaning products when cleaning up spilled chemotherapy drugs. The medical supplier who delivers the equipment will also deliver the specific "chemotherapy spill kit" needed for the medication in use. In the home setting, it is advised to clean up the area of the spill at least three times.

The nurse is caring for a client taking digoxin. Which electrolyte imbalance should be of most concern? 1. Hypokalemia 2. Hyponatremia 3. Hypomagnesemia 4. Hypocalcemia

1. Correct: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity could occur. 2. Incorrect: Hyponatremia, hypomagnesemia, and hypocalcemia do not interfere with digoxin. Any electrolyte imbalance can predispose the client to digoxin toxicity, but hypokalemia is the imbalance that can potentiate digoxin toxicity the most. 3. Incorrect:Hyponatremia, hypomagnesemia, and hypocalcemia do not interfere with digoxin. Any electrolyte imbalance can predispose the client to digoxin toxicity, but hypokalemia is the imbalance that can potentiate digoxin toxicity the most. 4. Incorrect: Hyponatremia, hypomagnesemia, and hypocalcemia do not interfere with digoxin. Any electrolyte imbalance can predispose the client to digoxin toxicity, but hypokalemia is the imbalance that can potentiate digoxin toxicity the most.

A charge nurse is observing a new nurse for proper use of standard precautions for infection control. Which actions indicate that standard precautions are being followed? You answered this question Correctly 1. Wearing clean gloves to convert an IV to a saline loc 2. Donning sterile gloves for a cesarean dressing change 3. Wearing a N95 respirator while caring for a child who has respiratory syncytial virus (RSV) 4. Putting on a gown to take care of a client who has toxoplasmosis 5. Performing hand hygiene after removing gloves

1., 2., & 5. Correct: Clean gloves are needed when there is a chance of coming into contact with blood or body fluids, which is likely to happen when converting an IV to a saline loc. Dressing changes in the hospital are a sterile procedure and require the use of sterile gloves. Hand hygiene should be performed before and after contact with a client immediately after touching blood, body fluid, non-intact skin, mucous membranes, or contaminated items. It should also be performed after removing gloves, before eating, and after using the restroom.3. Incorrect:The N95 respirator is used with airborne precautions and RSV requires droplet precautions. 4. Incorrect: Toxoplasmosis is transmitted through the feces of infected cats or through ingestion of raw or rare meats. A gown is not required in the care of this client because transmission occurs through ingestion of the parasites.

A client diagnosed with rheumatoid arthritis has been prescribed dexamethasone orally as part of initial treatment therapy. What side effects should the nurse teach the client are expected? 1. Fatigue 2. Insomnia 3. Hypoglycemia 4. Truncal obesity 5. Increased appetite 6. Low blood pressure

1., 2., 4. & 5. Correct: Dexamethasone (Decadron) is a corticosteroid used short term to treat severe inflammation occurring in rheumatoid arthritis (RA). Expected side effects are associated with the body's response to excessive steroids in the system. Even short term use of corticosteroids will produce fatigue, secondary to insomnia, truncal obesity accompanied by thin extremities, and an increased appetite resulting in weight gain. Despite the short and intermittent use of corticosteroids for this auto-immune disease, some side effects remain permanently. 3. Incorrect: Excessive steroids in the body cause blood glucose levels to increase, resulting in hyperglycemia. Clients taking corticosteroids will need regular finger stick glucose monitoring while taking these medications for rheumatoid arthritis. 6. Incorrect: The body's response to increased corticosteroids in the system is an elevated blood pressure, often accompanied by headaches or nausea. Clients taking steroids will need to have blood pressure checked frequently.

A nurse is caring for a client diagnosed with the ebola virus who is experiencing vomiting and diarrhea. What personal protective equipment should be worn by the nurse while providing care to this client? You answered this question Correctly 1. Single use impermeable gown 2. Powered Air Purifying Respirator (PAPR) or N95 respirator 3. One pair of sterile gloves 4. Single use boot covers 5. Single use apron

1., 2., 4., & 5. Correct: The nurse should wear a single use (disposable) impermeable gown OR a single use impermeable coverall. Either a PAPR or a disposable, NIOSH-certified N95 respirator should be worn to reduce the risk of contamination in the case of an emergency situation where a potentially aerosol-generating procedure would be performed. The PAPR reduces the risk of self-contamination while providing client care, but the N95 respirator is less bulky. If the N95 respirator is selected for use, nurses should be extremely careful to make sure that they do not accidentally touch their faces under the face shield during client care. Disposable boot covers should be worn and should extend to at least mid-calf. Some agencies may add the single use shoe covers over the boot covers to reduce the risk of contaminating the underlying shoes. If clients with Ebola are vomiting or have diarrhea, a single use (disposable) apron should be worn over the gown to cover the torso to mid-calf. This will provide additional protection to reduce the risk of contaminating the gown (or coveralls) by the infectious body fluids and also provides a way to rapidly remove a soiled outer layer if contamination occurs on the apron. 3. Incorrect: Sterile gloves are not required, but two pairs, instead of one pair, of gloves should be worn so that a contaminated outer glove can be safely removed when providing client care or safely removed without self-contamination when removing the PPE. These gloves should at the very least have extended cuffs.

A client diagnosed with a brain injury continues to attempt to get out of the bed without assistance. Which nursing interventions would the nurse implement? You answered this question Correctly 1. Ask a familiar person to stay with the client. 2. Apply position change sensor to the bed. 3. Move client closer to the nursing station. 4. Reinstruct the client to not get out of the bed. 5. Provide positive and negative reinforcement

1.,2. & 3: Correct: Having a person directly monitor the client will decrease the possibility of the client getting out of the bed. In addition, a familiar person in the room can have a calming effect on the client. Bed alerts will notify the healthcare team that the client is moving in the bed. This will result in a quicker response time to evaluate, if the client is trying to get out of bed. The intervention of moving the client closer to the nursing station will increase the observation of the client. This increased visualization can allow the healthcare team to intervene if the client tries to get out of the bed. 4. Incorrect: Due to the brain injury, the client's ability to process information, including instructions is limited. The client may become agitated and exhibit restless behaviors. Reinstructing the client will not be effective if the client is having difficulty processing the initial instructions. 5. Incorrect: Due to the brain injury, cognitive deficits occur resulting in the decreased ability for the client to interpret information. The client will not have the ability to recognize positive reinforcement messages. The client should not be subjected to any negative reinforcement actions.

Which observations should the home health nurse discuss with the parents of a two year old regarding potential safety threats in the home? You answered this question Incorrectly 1. Security gates at the stairs. 2. Cleaning supplies under sink cabinet. 3. No blinds on windows. 4. Use of space heaters. 5. Water heater temperature 140°F (60°C) 6. Use of tablecloths

2, 4, 5 & 6 Correct: Cleaning supplies should be placed high away from child's reach. Cabinets should have childproof locks. Space heaters need to be checked every year prior to use. Additionally, small children can be burned by space heaters if they get too close. A guard should be applied. Water heaters should be set at no higher than 120°F (48°C). Burns may occur with a 6 second exposure to 140°F water temperature. Children can pull on table cloths and spill hot food or break dishes which could lead to injury. 1. Incorrect: Placing security gates at the stairs will prevent falls. 3. Incorrect: This is not a concern for the child. If there are blinds, the string should be out of the child's reach.

An elderly client returns to a surgical room from the post anesthesia care unit (PACU) following an open reduction and fixation of a fractured ankle. Which nursing assessment of the client takes priority? 1. Level of consciousness 2. Complete vital signs 3. Surgical dressing 4. Pedal pulses

2. CORRECT. Orthopedic surgeries can lead to multiple complications, particularly in elderly clients. An early change in vital signs, especially the blood pressure, can indicate complications from the surgery. Though vitals were taken prior to leaving the PACU, problems can occur during transfer back to the unit. Vitals should be taken as soon as the client is placed into bed. 1. INCORRECT. The client may be semi-conscious upon return to the unit since anesthesia is not yet completely cleared from the body. While the client's level of consciousness must be assessed and documented, it is not the nurse's first priority. 3. INCORRECT. Observation of the surgical dressing can provide valuable data about any potential or occurring complications such as bleeding. While this is a necessary assessment, the nurse knows there is another important first step. 4. INCORRECT. A neurovascular check of the surgical site, comparing that to the non-surgical side, is important following invasive orthopedic surgery. Pedal pulses could indicate problems at the surgical site; however, this is not the most immediate priority.

The nursing staff have not been able to control the outbursts of a violent adult client. The primary healthcare provider prescribes physical restraints to be applied for the next 8 hours. What is the nurse's best action? You answered this question Correctly 1. Apply the restraints for the 8 hours, with a trial release every 2 hours. 2. Explain to the primary healthcare provider that the prescription will have to be reissued in 4 hours. 3. Refuse to place the client in restraints unless the primary healthcare provider gets a permit signed from the family. 4. Apply the restraints, and observe the client hourly.

2. Correct: Orders for restraints or seclusion must be reissued by a primary healthcare provider every 4 hours for adults age 18 and older, every 2 hours for children and adolescents ages 9-17, and every hour for children less than 9 years. 1. Incorrect: Orders for restraints or seclusion must be reissued by a primary healthcare provider every 4 hours for adults age 18 and older, every 2 hours for children and adolescents ages 9-17, and every hour for children less than 9 years. 3. Incorrect: A permit is not needed if the client is a risk to self or others. The primary healthcare provider must write a prescription for restraints. 4. Incorrect: Clients in restraints or seclusion must be observed and assessed every 10-15 minutes with regard to circulation, respiration, nutrition, hydration, and elimination.

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

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

The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate to the nurse that the client should not be advanced to the next level? 1. Facial flushing 2. Reports shortness of breath 3. Heart rate increase of 10 beats/min. 4. Systolic blood pressure increase of 10 mm Hg

2. Correct: The onset of shortness of breath could be an indicator that the client should not advance to the next level. The client should be instructed to stop and rest if chest pain or shortness of breath occurs. While in a rehabilitation program, it is imperative to give the client very specific guidelines for physical activity so overexertion will not occur. 1. Incorrect: Facial flushing is not life-threatening. The client can advance to the next level. 3. Incorrect: An increase in heart rate of 10 beats a minute is an expected finding with physical activity. This would not prevent the client from advancing to the next level. 4. Incorrect: An increase in systolic BP is an expected finding with physical activity.

A new mother asks the clinic nurse why her baby should receive recommended vaccinations. What is the best response by the nurse concerning vaccinations? You answered this question Correctly 1. "Vaccinations give antibodies to your baby to protect them from disease." 2. "Vaccinations will help your baby produce antibodies against disease causing organisms." 3. "Federal law requires that your baby receive recommended vaccinations." 4. "There is no reason not to vaccinate your baby since only mild, uncomfortable reactions can occur."

2. Correct: Vaccines are suspensions of antigen preparations intended to produce a human immune response to protect the person from future encounters with the organism. 1. Incorrect: Vaccines will cause the body to produce antibodies. Vaccines give possible immunity to the baby. 3. Incorrect: Vaccines are required for admittance into public school. If a child is homeschooled, the parent may not have the child vaccinated. 4. Incorrect: It is true that the vaccination may cause a mild reaction, but this is not the best response. This answer does not address the mother's question.

What should the nurse tell a 68 year old client who states that they have started experiencing tremors? 1. "This is nothing to worry about and is common with aging." 2. "You should increase your intake of potassium." 3. "We need to let your primary health care provider know because it may indicate a problem." 4. "Have someone check your blood pressure the next time you experience tremors."

3. Correct: Fine tremors are the first symptom reported in 70% of client's diagnosed with Parkinson's Disease. 1. Incorrect: Tremors are not a normal age change. 2. Incorrect: Tremors may indicate a problem. 4. Incorrect: Tremors may indicate early onset Parkinson's Disease.

The nurse is caring for a client who is unresponsive during a postictal state. Which position is correct for this client? 1. Orthopneic 2. Dorsal recumbent 3. Sims' 4. Reverse trendelenburg

3. Correct: Sim's is a semi prone position where the client is halfway between lateral and prone positions. Often used for enemas or other examinations of the perianal area. Sim's is used for unconscious client's because it facilitates drainage from the mouth and prevents aspiration. 1. Incorrect: Orthopneic position places the client in a sitting position with arms resting on an overbed table. It allows maximum expansion of the chest. This would not be a safe position for an unresponsive client. 2. Incorrect: Dorsal recumbent is a back lying position where the shoulders are slightly elevated on pillows. it is used after surgeries and anesthetics. 4. Incorrect: Reverse trendelenburg is where the body the body is completely straight but the head is elevated and the feet are down. This position helps with gastroesophageal reflux disease, snoring, and with some surgeries.

A nurse is evaluating an unlicensed assistive personnel (UAP) for proper body mechanics while lifting a heavy object off of the floor. What action by the UAP would indicate a need for further instruction by the nurse? You answered this question Correctly 1. Testing the weight to determine if additional assistance is needed. 2. Keeping the feet shoulder width apart. 3. Bending from the waist to pick up the object. 4. Holding the object close to the body upon rising.

3. Correct: You should not bend at the waist. This will injure your back. Lower your knees, and stay close to the object to use thigh muscles. 1. Incorrect: This is correct. If it is too heavy do not attempt to lift alone. 2. Incorrect: This is correct and will help maintain balance as you lower yourself to the floor. 4. Incorrect: This is correct. Holding close to the center of gravity will help prevent injury to your back and arms. Body mechanics describes the ways we move as we go about our daily routine. Poor body mechanics are often the cause of back problems. When we don't move correctly and safely, the spine is subjected to abnormal stresses that over time can lead to degeneration of spinal structures. The process of lifting places perhaps the greatest loads on the low back and therefore, has the highest risk of injury. Use of proper lifting mechanics and posture is critical to prevent injury. How to lift safely: Place the load immediately in front of you. Bend the knees to a full squat or lunge position. Bring the load towards your chest. Assume a neutral position with your back. Tighten the lumbar and buttocks muscles to "lock" the back. Lift now from the legs to the standing position DO NOT Lift from a twisted / sideways position. DO NOT Lift from a forward stooped / imbalanced position.

Two cognitively impaired siblings are clients in the same hospital room. During rounds, the nurse notes they have removed identification bracelets. Because of similar appearance, the nurse is unable to identify the correct client for blood work. What would be the most reliable method for the nurse to use to properly identify these clients? You answered this question Correctly 1. Draw blood to type and crossmatch and compare with chart. 2. Call the primary healthcare provider to identify each client. 3. Ask nurses on the next shift to try to identify the clients. 4. Notify family to come in and identify clients in person.

4. CORRECT: The only way to definitely identify a client with no identification bracelet who is unable to identify self is to have immediate family verify the client in person. When the family member arrives and verifies the client, the hospital must apply a new ID bracelet in the presence of the family for added security. 1. INCORRECT: Even typing and cross-matching to determine the blood type does not guarantee a correct identification. Additionally, both clients may have the same type blood since they are siblings. 2. INCORRECT: A primary healthcare provider would not necessarily be able to identify a specific client. Having hundreds of clients would make it more difficult to remember individuals correctly. It is unlikely that the healthcare provider could correctly indicate which client needed blood work. 3. INCORRECT: This is the least effective approach to properly identify the clients. Certainly, nurses spend more time with clients than other healthcare individuals, but asking another nurse to make this type of identification is still extremely risky and unreliable.

What personal protective equipment should the nurse wear into the room of a client who has been placed on droplet precaution? You answered this question Correctly 1. Gloves 2. Gown 3. Goggles 4. Mask

4. Correct: For a client on droplet precautions, a facemask is worn for close contact with the client. 1. Incorrect: The only requirement for droplet precautions is that a mask needs to be worn. However, if there is a reasonable expectation of contact with secretions, such as through contact or spraying, additional standard precautions would be needed, such as gown, gloves, and goggles. There is not indication in this stem about additional precautions needed. 2. Incorrect: The only requirement for droplet precautions is that a mask needs to be worn. However, if there is a reasonable expectation of contact with secretions, such as through contact or spraying, additional standard precautions would be needed, such as gown, gloves, and goggles. There is not indication in this stem about additional precautions needed. 3. Incorrect: The only requirement for droplet precautions is that a mask needs to be worn. However, if there is a reasonable expectation of contact with secretions, such as through contact or spraying, additional standard precautions would be needed, such as gown, gloves, and goggles. There is not indication in this stem about additional precautions needed.

While preparing an information sheet for a client diagnosed with a vancomycin-resistant enterococcus (VRE) urinary tract infection (UTI), the home health nurse should include which instructions? You answered this question Correctly 1. Wash hands with hot water and soap when hands are soiled. 2. Gloves are not needed in the home since contamination with VRE has already occurred. 3. Wash hands before using the bathroom and after preparing food. 4. Clean the bathroom and kitchen with warm water and bleach.

4. Correct: The bathroom and kitchen should be cleaned with warm water and bleach to decrease contamination. The client should wash hands after using the bathroom and before preparing food.1. Incorrect: Instructing the client and family to wash with hot water can cause drying and cracking of the skin. Hands should be washed with all contacts. Washing hands is the single most important thing to do to prevent infection.2. Incorrect: Gloves are needed with VRE to prevent spread of infection. Gloves are especially needed if contact with blood or other infectious materials is anticipated.3. Incorrect: Hands should be washed after using the bathroom and prior to handling or preparing food.

A client with diabetes is hospitalized for debridement of a non-healing foot ulcer. Following the procedure, the nurse notes that the client has become confused and combative. The family expresses concern with the behavioral changes and requests that the client be restrained in bed. What is the nurse's priority action? You answered this question Correctly 1. Notify the primary healthcare provider. 2. Apply a vest restraint as requested by family. 3. Move client to a room near the nurse's desk. 4. Obtain a finger-stick blood glucose level.

4. Correct: The client's behavior has negatively changed following the ulcer debridement procedure. The nurse's priority is to determine the cause of the client's confusion. The nurse is correct to investigate other possible causes for the behavior changes, including an abnormal glucose level in this diabetic client. 1. Incorrect: The nurse will indeed have to contact the primary healthcare provider about the client's change in behavior. However, the first priority would be to assess the client and collect data prior to placing that phone call. 2. Incorrect: The nurse understands that restraints cannot be applied by family request. Additionally, applying a restraint can often increase negative behavior while ignoring the actual cause. 3. Incorrect: Although assigning confused clients to a room near the nurses' station is an accepted practice, this does not determine the cause for the changing behavior and is not a priority at this time. The nursing priority is to assess the client for possible factors causing the behavior changes.

A client on a surgical unit frequently quarrels with the staff. Which nursing intervention should the charge nurse implement? You answered this question Correctly 1. Involve the client in their plan of care. 2. Delegate 2 nurses to work with the client. 3. Accept the client's behavior as confrontational. 4. Encourage the client to be more cooperative. Rationale Strategies Let's Talk 1. Correct: The client has the right to be involved in the decision making of their care. The healthcare team should recognize the client as the center of the team. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. 2. Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. This action is a defensive intervention, and does not address the quarrelsome behavior. 3. Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. 4. Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns.

An unlicensed assistive personnel (UAP) is assisting a client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention by the nurse? You answered this question Incorrectly 1. Holds chest drainage unit (CDU) at the level of the chest. 2. Disconnects the chest tube from suction. 3. Allows the client to ambulate. 4. Helps client use a walker. Rationale Strategies Let's Talk 1. Correct: The drainage system should be held below the level of the chest to promote drainage and prevent backward flow of drainage back into the pleural space. 2. Incorrect: The chest tube system can function because of gravity and does not have to be attached to suction when the client ambulates. Leaving it connected to suction would be a safety hazard as the client could trip and fall over the tubing. 3. Incorrect: There is nothing in the stem to indicate that the client cannot ambulate. Having a chest tube does not mean the client must not ambulate. 4. Incorrect: There is nothing wrong about having the client use a walker while ambulating. This could potentially prevent a fall.

A client on routine dialysis asks the nurse about the process of a family member donating a kidney. In what order should the nurse explain the steps for kidney organ donation?

First, the donor and recipient will undergo tissue typing and antibody screening; compatibility of tissues and cells of the donor and recipient have to be determined. Second, the donor will undergo psychosocial examination and counseling. Once it has been confirmed that the donor and recipient are compatible, the donor will undergo a psychosocial examination to assess the organ donor's motive for giving the organ and to ensure donor is making an informed decision. Pre-donation counseling for a nephrectomy is required. Third, the recipient and donor will be assessed and treated for any infection. Both must be free of infection at the time of kidney transplantation so they will be assessed for any infections, including gingival gum disease and dental caries. Fourth, the recipient will undergo hemodialysis. If a dialysis routine is established, then hemodialysis is performed the day before transplantation to optimize recipient's physical status. Fifth, the recipient will receive immunosuppressive agents. Lifelong immunosuppressive agents are prescribed to prevent rejection of the organ.

The nurse manager is making rounds in a long-term care facility and discovers an unfamiliar client standing in the hallway in a puddle of liquid. What is the nurse manager's priority action? 1. Ask client to state name and room number. 2. Find dry clothes and clean client completely. 3. Wipe up puddle of liquid and call housekeeping. 4. Contact unit charge nurse to identify the client.

3. Correct: The issue in this scenario is safety. Whether the nurse manager knows this client is not important at the moment. Liquid on the floor poses a safety hazard for clients, visitors, and staff. The priority action is to remove this risk immediately before an injury occurs. 1. Incorrect: Even though the nurse does not recognize this particular client, the priority concern is not focused on identifying this individual. 2. Incorrect: While the client will certainly need clean, dry clothes, the most immediate concern is a safety issue. The nurse can summon a UAP to help the client after addressing the safety issue. 4. Incorrect: The identity of the client is not the initial priority at this time. Consider the whole picture when thinking about safety.

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

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

When preparing an intramuscular injection for a neonate, which needle should a nurse select? 1. 18 G, 7/8 inch 2. 21 G, 1 inch 3. 25 G, 5/8 inch 4. 25 G, 1.5 inch

3. Correct: The most appropriate needle to select for use in administering IM injection to a neonate would be a 25 gauge, 5/8 inches long. Intramuscular injections are given in the vastus lateralis muscle of the thigh. 1. Incorrect: This needle is too large a diameter for a newborn infant. An 18 gauge needle is appropriate for the intravenous (IV) medication or blood administration in adults. 2. Incorrect: This needle would be too large for a newborn infant. A 21 gauge needle is typically used to draw up medication from vials or ampules (filtered needle required). 4. Incorrect: This needle would be far too long for a newborn infant and also for most children. A 1.5 inch needle is often needed to administer intramuscular injections to obese adults.

The nurse evaluates an electrocardiogram (EKG) and notices a U-wave. The nurse suspects that this occurrence is caused by which electrolyte imbalance 1. Hypermagnesemia 2. Hypocalcemia 3. Hypokalemia 4. Hyponatremia

3. Correct: The most serious complications of hypokalemia are cardiac changes. Hypokalemia impairs myocardial conduction and prolongs ventricular repolarization. This can be seen by a prominent U-wave (a positive deflection following the T-wave on the EKG). The U-wave is not totally unique to hypokalemia, but its presence is a signal for the clinician to check the serum potassium level. 1.Incorrect: Remember hypermagnesemia results in the client having a sedated appearance, decreased deep tendon reflexes, decreased level of consciousness, decreased respiratory rate, and ultimately cardiac arrest. 2. Incorrect: In hypocalcemia, this client is not sedated and will have an increased nerve excitability, tetany, appearance of Trousseau's, and Chvostek's sign. Cardiac manifestations include Vtach. 4. Incorrect: Hyponatremia results in neurological symptoms: confusion, irritability, and ultimately coma.

What action is most important for the nurse to take when a client receiving a cephalosporin develops abdominal cramping and diarrhea? 1. Administer antidiarrheal medication. 2. Increase fluid intake. 3. Provide food with the medication. 4. Notify the healthcare provider.

4. Correct: Notify the healthcare provider if diarrhea occurs as it can promote the development of Clostridium difficile infection. Cephalosporin difficile is a toxin producing bacteria that causes antibiotics-associated colitis, and can occur with antibiotic therapy. Cephalosporin is one of the most common antibiotics that cause clostridium difficile. 1. Incorrect: Taking a probiotic, stopping the antibiotic or switching to another antibiotic are standard treatments for antibiotic induced diarrhea. Administering an anti-diarrheal is not recommended for antibiotic induced diarrhea. 2. Incorrect: Increasing fluid intake will help with the associated dehydration seen with diarrhea, but will not correct the problem or decrease the risk of clostridium difficile. 3. Incorrect: If the client has GI upset, then cephalosporin may be given with food, however, the most important thing to worry about is the development of Clostridium difficile infection. So notifying the healthcare provider is the most important action.

A client has been admitted with a diagnosis of pneumocystis carinii pneumonia (PCP). What initial assessment findings would the nurse expect? (Select All That Apply). 1. Fever 2. Night sweats 3. Hemoptysis 4. Dry cough 5. Dyspnea

1, 4 and 5. CORRECT: Pneumocystis carinii pneumonia, now known as pneumocystis jirovecii, is caused by a fungus and occurs in clients with weakened immune systems. Expected assessment findings include fever, dry non-productive cough and dyspnea. Any additional symptoms are related to other co-morbidities and not the pneumonia itself. 2. INCORRECT: Night sweats are an early symptom of active tuberculosis and are often the definitive symptom, along with a productive cough, that indicates the need for immediate testing and isolation. 3. INCORRECT: Hemoptysis is among the late signs of lung cancer, in addition to weight loss. Lung cancer is asymptomatic in its early stages

A renal transplant client has received discharge education. Which statement by the client indicates that further teaching is necessary? 1. "I will need to notify my primary healthcare provider if I develop a fever." 2. "I need to check my BP daily and report an increased B/P." 3. "I will tell my primary healthcare provider if I become easily fatigued." 4. "I will be on steroids for 3 months, then I will not have to take them."

4. Correct: This statement indicates a need for further teaching. Doses of immunosupressive agents are often adjusted, but the client will be required to take some form of immunosuppressive therapy for the entire time that the client has the transplanted kidney. 1. Incorrect: Yes, fever is a sign of post transplant rejection. Additional signs and symptoms include oliguria, edema, increasing blood pressure, weight gain and swelling or tenderness over the transplanted kidney, flu-like symptoms, shortness of breath and/or fatigue. 2. Incorrect: Yes, hypertension is a sign of post transplant rejection. Additional signs and symptoms include oliguria, edema, increasing blood pressure, weight gain and swelling or tenderness over the transplanted kidney, flu-like symptoms, shortness of breath and/or fatigue. 3. Incorrect: Yes, fatigue is a sign of post transplant rejection. Additional signs and symptoms include oliguria, edema, increasing blood pressure, weight gain and swelling or tenderness over the transplanted kidney, flu-like symptoms, shortness of breath.

A client with distended and tortuous veins along the inner aspects of both legs asks the nurse how to decrease the development of these veins. What should the nurse advise? 1. Exercise 2. Follow a low protein diet 3. Wear low heeled shoes 4. Elevate legs above heart several times per day 5. Do not cross legs

1., 3., 4., & 5. Correct: These are varicose veins. Get moving. Walking is a great way to encourage blood circulation to the legs. Low-heeled shoes work calf muscles more, which is better for veins. To improve circulation in legs, take several short breaks daily to elevate legs above the level of the heart. Do not cross legs as it decreases circulation distally. 2. Incorrect: Low sodium diet will prevent swelling caused from water retention. A diet low in protein will not decrease the development of these veins. The key is to keep swelling down so that pressure on the veins is reduced.

The nurse is irrigating an acid chemical burn on a client's arm. Which would indicate to the nurse that irrigation can be stopped? 1. Client's pain rating has decreased from 6 to 2 on a 0 to 10 pain scale. 2. The pH value of the runoff solution is 7.0. 3. Client reports a burning sensation in the affected arm. 4. Capillary refill is less than 2 seconds in the affected arm.

2. Correct: A pH of 7 is nonacidic, so the solution's pH indicates that the acid chemical has been removed 1. Incorrect: Pain could indicate acid is still present. 3. Incorrect: A burning sensation may indicate acid is still present. 4. Incorrect: Capillary refill is not an indication that all acid has been removed.

What electrolyte imbalance should the nurse monitor for when caring for a client diagnosed with chronic alcoholism? 1. Hypochloremia 2. Hypokalemia 3. Hypophosphatemia 4. Hypomagnesemia 5. Hypocalcemia

2., 3., 4., & 5. Correct: The number one way of getting rid of potassium is through the kidneys. What does alcohol make you do? Diuresis. Acute hypophosphatemia is seen in up to 50% of patients over the first 2-3 days after they are hospitalized for alcohol overuse. Hypophosphatemia is manifested as rhabdomyolysis (muscle breakdown) and weakness of the skeletal muscles. Magnesium deficiency occurs due to that increase in diuresis as well. Hypomagnesemia is often accompanied by hypocalcemia, or lowered calcium levels, which may be aggravated by a deficiency of vitamin D. 1. Incorrect: Hypochloremia is usually caused by excess use of loop diuretics, nasogastric suction, vomiting or diarrhea due to small bowel abnormalities, and loss of fluids through the skin occurring because of trauma such as burns.

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

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

When planning post procedure care for a client who is having a barium enema, what must the nurse include? 1. Cardiac monitoring for potential arrhythmias 2. Monitoring urinary output 3. Administration of a laxative or enema after the procedure 4. Reordering the client's diet

3. Correct: The client must expel the barium post procedure. If the barium is not eliminated, it can harden in the colon and cause an obstruction. 1. Incorrect: It is not standard practice to place clients on a cardiac monitor after a barium enema. 2. Incorrect: Monitoring urine output has nothing to do with this procedure and does not answer the specific question related to this diagnostic procedure. 4. Incorrect: Reordering the client's diet is important but is not as life-threatening as a bowel obstruction.

Following hip replacement surgery, an elderly client is being transferred to a long term care facility for therapy. What priority action by the nurse best promotes continuity of care for the client? 1. Explain future care requirements to the family. 2. Call facility's nurse manager to give oral report. 3. Discuss client's needs with healthcare provider. 4. Send written summary of client needs to facility.

4. Correct: Written documentation is the most complete legal record for continuity of client care. In this format, the same specific information is then available to all staff having direct care contact with the client. 1. Incorrect: While the family will definitely need to be informed of the client's current and future therapeutic needs, such a discussion would have taken place prior to being discharged to long term care. Another action takes priority. 2. Incorrect: An oral report is vital prior to the client's arrival at a new facility so that an appropriate room and needed equipment can be available for the client's arrival. Though such an action is important, there is a better method to promote continuity of care. 3. Incorrect: Talking with the primary healthcare provider must be done at the time orders for transfer have been written to clarify specifics, which would then be relayed to the long term care facility. This is not the nurse's current priority.

A client arrives by ambulance after being thrown from a horse. The client is pale, clammy and tachycardic with bruising over left upper abdominal quadrant. The nurse is aware what prescription by the primary healthcare provider takes priority? 1. Obtain blood for type and cross match. 2. Administer hydromorphone IV for pain. 3. Increase Lactated Ringers to 150 mL/hour. 4. Send client to radiology for stat CAT scan.

1. CORRECT: The signs and symptoms displayed by the client suggest a ruptured spleen and shock. The greatest concern in this situation is internal bleeding and possible emergency surgery. The client will need blood; therefore, the nurse should immediately obtain blood for type and cross match. 2. INCORRECT: There is no indication in the scenario the client has pain. Pain medication should never be administered while the client is still being assessed or is in shock. 3. INCORRECT: Fluids are crucial for clients in shock and increasing the Lactated Ringers to 150 mL/hr. is important to help maintain blood pressure. However, this is not the nurse's priority action. 4. INCORRECT: A CAT scan is often prescribed prior to surgery to verify the extent of splenic injury and the amount of blood in the abdominal cavity. Though the order is written as 'stat', this is not the nurse's priority. Transporting an unstable client to another department requires preparation.

The unlicensed assistive personnel (UAP) reports to the nurse that a client who received morphine sulfate 4 mg IVP 30 minutes ago has a respiratory rate of 10 breaths/ minute. What is the nurse's priority intervention? 1. Administer naloxone 0.4 mg IVP. 2. Notify the primary healthcare provider of respiratory status. 3. Deliver breaths at 20 breaths/ minute via a bag-valve mask. 4. Instruct the UAP to ambulate the client.

1. Correct: The problem is respiratory depression due to morphine sulfate IV. Giving naloxone will reverse the respiratory depression. 2. Incorrect: The primary healthcare provider needs to know what happened, however, fix the problem first if you can. And we can, by giving the naloxone. 3. Incorrect: Give naloxone first and the client may not even need ventilation with a bag-valve mask. 4. Incorrect: Ambulation will not reverse the effects of the narcotic. And this is a safety issue. The client could fall.

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

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

The nurse has observed that the client on the skilled nursing unit has been consuming fewer calories over the past three days. There has been no other change in the client's condition. Which intervention is most important for the nurse to initiate? 1. Suggest that the family seek an appointment with the primary healthcare provider. 2. Ask the dietician to visit the client and discuss food preferences. 3. Note any weight loss over the next month. 4. Continue to monitor intake over the next couple of weeks

2. Correct: The nurse is using the expertise of other team members by requesting that the dietician visit the client. This is the most important measures to address the client's nutritional needs. The problem may be that the client simply does not like the foods that have been served and the dietician is the best one to address these issues. 1. Incorrect: An appointment with the primary healthcare provider may not be necessary. It is the best to first utilize available team members such as the dietician. The nurse would then notify the primary healthcare provider of any pertinent findings. 3. Incorrect: To simply monitor weight loss for a month would not be an appropriate intervention. There could be significant weight loss within a month. This is much too long to wait before taking measures to ascertain the reason for the client consuming fewer calories. 4. Incorrect: The nurse should monitor intake and weight over the next couple of weeks; however, there is a more immediate action that is appropriate. The nurse takes action by asking the dietician to see the client.

A client has just had a bone marrow biopsy. What is the nurse's priority intervention post procedure? 1. Apply ice pack to needle site. 2. Hold pressure on needle site for at least 5 minutes. 3. Observe needle insertion site every 2 hours. 4. Advise client to avoid activities that may result in trauma to the site for 48 hours.

2. Correct: When you see the word priority, you need to think: "What is the MOST important thing I can do for my client?" If you can only pick one answer, pick the life threatening answer or the answer that will decrease the risk for harm to the client. Here, that answer is hold pressure on the site to prevent bleeding. 1. Incorrect: There is nothing wrong with applying ice to decrease swelling, however, it is not the priority. Bleeding takes priority over swelling. 3. Incorrect: Yes, you want to monitor the client's needle insertion site at least every 2 hours, but you better make sure the bleeding stops immediately after the procedure first. 4. Incorrect: Nurses must teach about potential complications and ways to avoid them, but that is not the priority here.

The nurse is assisting the client on the correct procedure for applying anti-embolism stockings. Which statement by the client indicates that the client understands the procedure? 1. "The stockings should be applied when my legs are swollen." 2. "I will apply the anti-embolism stockings before getting out of bed." 3. "I will apply cortisone-10 ointment to skin on both legs every day." 4. "Prior to applying the stockings, I will look for reddened areas on my skin." 5. "When pulling up the stockings, I will allow for an extra roll of the stocking at my calves."

2., & 4. Correct: To promote increased blood flow in the legs, anti-embolism stockings should be applied before getting out of bed. After keeping the legs elevated during sleeping, the legs should be less swollen. The compression of the deep venous system will be more effective if swelling is decreased prior to applying the stockings. Both legs should be assessed for any reddened skin areas prior to applying the stockings. If reddened areas are noted, the cause of the reddened areas should be evaluated and treatment initiated, if appropriate. Client's symptoms should be addressed prior to the application of the stockings. 1. Incorrect: The purpose of the anti-embolism stockings is to promote increased blood flow in the legs. To promote the increase blood flow in the legs, anti-embolitism stockings should not be applied when the legs are swollen. If the legs are swollen when applying the stockings, the compression to the deep venous system is reduced. 3. Incorrect: Unless prescribed, the stockings should not be applied over any ointment that has been applied to the legs. The legs and feet should be dry. The stockings are to be worn over an extended period. If there is a skin condition that warrants treatment, the stockings may reduce the effectiveness of the treatment. 5. Incorrect: The client's leg should be measured to ensure that the correct size of the anti-embolism stockings is applied. An extra roll of the stocking at the calves would decrease the appropriate deep venous pressure and could also cause a pressure area on the calves.

The nurse caring for a client who had a transurethral resection of the prostate (TURP) would increase the flow of the continuous bladder irrigation for which assessment data? 1. The drainage is continuous but slow. 2. The drainage is cloudy and dark yellow. 3. The drainage is bright red. 4. No drainage of urine or irrigation solution is noted.

3. Correct: Indicates blood and increasing the flow helps flush the catheter. 1. Incorrect: Continuous irrigation causes continuous drainage. 2. Incorrect: The color is noted and color from pink to amber is expected. 4. Incorrect: Indicates a possible obstruction.

A nurse is evaluating an unlicensed assistive personnel (UAP) for proper body mechanics while lifting a heavy object off of the floor. What action by the UAP would indicate a need for further instruction by the nurse? 1. Testing the weight to determine if additional assistance is needed. 2. Keeping the feet shoulder width apart. 3. Bending from the waist to pick up the object. 4. Holding the object close to the body upon rising.

3. Correct: You should not bend at the waist. This will injure your back. Lower your knees, and stay close to the object to use thigh muscles. 1. Incorrect: This is correct. If it is too heavy do not attempt to lift alone. 2. Incorrect: This is correct and will help maintain balance as you lower yourself to the floor. 4. Incorrect: This is correct. Holding close to the center of gravity will help prevent injury to your back and arms. Body mechanics describes the ways we move as we go about our daily routine. Poor body mechanics are often the cause of back problems. When we don't move correctly and safely, the spine is subjected to abnormal stresses that over time can lead to degeneration of spinal structures. The process of lifting places perhaps the greatest loads on the low back and therefore, has the highest risk of injury. Use of proper lifting mechanics and posture is critical to prevent injury. How to lift safely: Place the load immediately in front of you. Bend the knees to a full squat or lunge position. Bring the load towards your chest. Assume a neutral position with your back. Tighten the lumbar and buttocks muscles to "lock" the back. Lift now from the legs to the standing position DO NOT Lift from a twisted / sideways position. DO NOT Lift from a forward stooped / imbalanced position.