Hurst Review

As part of the screening process to identify if a client is obese, the nurse calculates the client's body mass index (BMI). Weight - 180 pounds Height - 5' 5" Calculate the BMI to the whole number. Enter the answer for the question below.

Calculate BMI by dividing weight in lbs by height in inches squared and multiplying by a conversion factor of 703. [180-(65)^2] x 703= 29.95 or 30

The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. The nurse has just completed a 12 hour shift. What options would be appropriate for the nurse to take? Select all that apply 1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action. 5. Simply accept the assignment since overtime is mandatory.

Correct: 1,2, 3, 4 The nurse can accept the assignment, documenting personal concerns regarding working conditions in which managment decides the legitimacy of employee's personal concerns. This documentation should go to your manager. Refuse the assignment, being prepared for disciplinary action. If your reasons for refusal were client safety, nurse, safety, or an imperative personal committment, document htis carefully including the process you used to inform the facility (nurse manager) of your concerns. Keep a personal copy of this documentation, provide a personal copy to the immediate supervisor.

Which tasks could the nurse working on a cardiac unit delegate to an unlicensed assistive personnel (UAP)? 1. Bathe the client who is on telemetry. 2. Apply cardiac leads and connect a client to a cardiac monitor. 3. Help position a client for a portable chest x-ray. 4. Feed a client who is dysphagic. 5. Collect a stool specimen.

Correct: 1,2,3,5 The UAP can apply cardiac leads and connect the client to the monitor.

Which client in the L&D unit should the nurse see first? a. Primipara at 39 weeks gestation, who is dilated 3 cm and at -2 station who states, "I think my water just broke" b. Multigravida at term who is dilated to 6 cm and at -1 station with moderate contractions every 5-10 min c. primipara at 38 weeks gestation who is dilated to 5 cm and at 0 station with strong contractions q 4 min d. Multigravida at 36 wks gestation with pregestational diabetes in for a BPP for fetal wellbeing

Correct: A -2 station is high with the presenting part not engaged. This client is at risk for prolapsed cord, which would require relieving pressure on the cord and emergency c section. also, think about what is happening RIGHT NOW. What is the RIGHT NOW situation

A child is admitted to the hospital with a temp of 102.2F (39C), lethargic, and no UOP in 6 hours. Which prescription would be priority for the nurse to initiate for this child? a. Blood cultures x2 b. Ceftriaxone 250 mg IV q12 hr c. start IV and monitor site d. 1/2 NS at 40 ml/hr

Correct: A The IV can be started at any point, but should be done after the cultures SO THE SAMPLE CANNOT BE AFFECTED IN ANY WAY You chose C

A non english speaking client arrives in the ED with a 2 inch head lac. THe nurse attempts to complete the assessment but is unable to understand the info provided by the client or family. The facility interpreter lives several hours away; however a UAP is available and willing to help translate. The nurse should be most concerned about what situation? a. The UAP is not trained to interpret medical terminology for the client b. the facility translator is best qualified, but waiting causes delay of treatment c. obtaining consent through an unofficial interpretor is not considered legal d. the UAP is not providing direct care, which violates HIPAA

Correct: A The client can request the UAP to avoid waiting for the translator. If this happens, it is already considered consent. The main concern would be that the UAP does not know the medical terminology

A client who was hospitalized with a diagnosis of schizophrenia tells the nurse, "My veins have turned to stone and my heart is solid!" How would the nurse ID this statement? a. Depersonalization b. Echopraxia c. Neologism d. Concrete thinking

Correct: A depersonalization can lead to feelings of unreality (the feeling that ones parts have changed or sense of seeing oneself from a distance. Concrete thinking is the literal interpretation of the environment. It represents a regression to an earlier level of cognitive developement. You chose D

Following a thyroidectomy, a client reports SOB and neck pressure. Which nursing action is the best response? a. remove the dressing and elevate the HOB b. call a code, open the trach set, and position the client supine c. obtain VS d. immediately go to the nurses station and call the HCP

Correct: A the nurse should ID that the client is in respiratory distress. Get the dressing off the neck, elevate the HOB, and see if they can breathe better. Stay with the client. Getting VS is delaying treatment.

The nurse is caring for a client with chronic renal failure who recieves dialysis treatment. Which findings would indicate to the nurse that the client's AV shunt is patent? a. a bruit is heard with a stethescope b. a thrill is felt on palpation c. there is blood return on the venous side of the heart d. UOP is greater than 30 ml/hr e. there is a strong radial pulse in the arm with the AV shunt

Correct: A, B IV sticks should not be performed on the shunt or the extremity where the shunt is placed except for initiating dialysis. Also, radial pulses do not determine patency of AV shunt. Only the confirmation of a bruit and thrill ensure patency

A nurse from the maternity unit is pulled from the med surg unit for the first four hours of the shift. Which clients would be appropriate for the charge nurse to assign to the nurse from the maternity unit a. client with rheumatic fever b. client scheduled for an appy c. client one day post cardiac cath d. client diagnosed with MRSA e. client newly admitted with Guillan Barre

Correct: A, B, C Rheumatic fever is not contagious at this point, so the maternity nurse could be assigned to this client

The client with a new diagnosis of HTN has been instructed to maintain a low sodium diet. Which foods does the nurse plan to teach the client to include on a low sodium diet? a. lemonade b. broccoli c. apple d. smoked sausage e. boiled shrimp f. tomato soup

Correct: A, B, C lemonade has about 5 mg of sodium

What assessment data would a nurse expect to find in a client diagnosed with acute IBD? a. bloody stools that contain mucus b. pallor c. anorectal excoriation d. UOP below 30 ml/hr Increased serum pre-albumin

Correct: A, B, C, D Stools will be bloody and contain mucus. The client will be malnourished, thus will be pale due to anemia. Anemia is related to folate deficiency

A QA manager plans to evaluate performance improvement regarding the implementation of fall precautions of at risk clients. What steps should the QA manager include? a. chart review for fall precautions implementation b. direct observation of the staff c. ask staff what fall precautions are taken for at risk clients d. identify at risk clients on the unit e. make unannounced visits to the unit for evaluating staff performance

Correct: A, B, D, E Asking the staff what precautions are taken on the unit sounds reasonable, but it doesnt mean that staff will actually follow through with it. It is important to identify at risk clients to see if the staff have identified them as well. Also, unannounced visits are good because they assure that staff do not just comply when it is time for an evaluation

Which task would be appropriate for the charge to assign to the LPN? a. collect data on a new client admit b. administer morphine IVP to a 2 day post op client c. bolus feeding a client who has a g tube d. reinserting an NG tube that a client accidentally pulled out e. Monitor PCA pain med being delivered to a client

Correct: A, B, D, E The LPN can collect data on a new admit and the RN would verify and co sign to complete the assessment. A LPN can MONITOR the PCA pain med but cannot INITIATE or ADMINISTER the med

An unresponsive client is admitted to the ED with suspected alcohol poisoning. What intervention should the nurse initiate? a. Insert NG tube b. pad side rails c. position supine with HOB elevated d. obtain blood sample for glucose level e. start an IV using a large bore catheter

Correct: A, B, D, E The client can experience hypokalemia, hypomagnesemia, and hypoglycemia

A client is being admitted with a diagnosis of cirrhosis of the liver. What assessment findings should the nurse anticipate in this client? a. firm, nodular liver b. ascites c. incr serum albumin levels d. incr ALT and AST e. lowered ammonia levels f. bleeding from the GI tract

Correct: A, B, D, F Incr pressure in the liver (portal HTN) causes a backward pressure throughout the GI tract. ESOPHAGEAL VARICES may form as a result of this pressure. IF variceal rupture occurs, GI bleeding will be noted. In addition, liver dx, such as cirrhosis, are the common causes of blood clotting problems bc the liver is unable to produce needed clotting factors

Which information should the nurse include when teaching the client who is scheduled for a sentinel lymph node biopsy (SLNB)? a. You may notice a blue-green discoloration in your urine or stool for the first 24 hours as the blue dye is excreted b. the risk of lymphedema in your hand and arm is increased after surgery c. you will have one or more drainage tubes inserted during the procedure d. a positive SLNB result means that cancer cells were found in the sentinel lymph node e. avoid using your arm on the side of the biopsy f. You will have a small incision under your arm

Correct: A, B, D, F THe sentinel lymph node is teh first node in the lymphatic system that receives drainage from the primary tumor in the breast and is identified by injecting a radioisotope or blue dye into the breast near the tumor the client undergoing a SLNB may not require drainage tubes as it is a less invasive procedure

Which intervention should the nurse initiate for a client post liver biopsy? a. apply direct pressure to the site immediately after needle is removed b. assess puncture site every 15 minutes for 1 hour c. position client on left side d. keep client NPO for 24 hours e. advise client that pain may occur in right shoulder as the anaesthetic wears off

Correct: A, B, E This shoulder pain is referred to as referred pain and is common.

A new nurse is documenting in a clients EMR. Which documentation would the charge evaluate as appropriate documentation? a. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services b. appears to be having abdominal discomfort c. permit signed for laparascopic cholecystectomy after discussing procedure with surgeon d. pre op diazepam 10.0 mg given po e. transferred to surgical suite per stretcher with side rails up, stable condition

Correct: A, C, E Appears is a subjective word. Pain should be assessed in an objective manner, such as a 0-10 scale, or a more objective description.

A client with cancer refuses tx and asks about options for hospice home care. The client's daughter asks the case manager to talk to the client into agreeing to cancer treatment. The nurse explains to the daughter that this violates which client right? a. to self determination b. to decline participation in research studies and experimental treatments c. to expect reasonable continuity of care d. to make decisions about the plan of care e. to advocacy

Correct: A, D The client has not been offterd research or experimental treatment. Also, the right to advocacy relates to the right to have another person present during interviews or exams.

An LPN is on the L&D unit and is helping a nurse with multiple admissions. What tasks could the LPN complete until the nurse is available? a. take initial VS b. measure cervical dilation c. check fundal height and FHR d. obtain urine for protein and glucose e. collect vaginal swab test for chlamydia

Correct: A, D, E The LPN can take initial VS

A client is admitted to the ED with possible status epilepticus, and the client is placed in a semi fowler position. what would the nurse frequently monitor for in the client? a. LOC b. following commands c. ability to get OOB d. blood sugar level e. maintain airway f. VS

Correct: A, E, F following commands corresponds to LOC. BS level has nothing to do with status epilepticus (according to hurst)

The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. What should the nurse do first? 1. Feed the client after warming the food. 2. Speak to the UAP to determine what happened with the feeding. 3. Pick up the tray and tell the UAP that they didn't do a good job. 4. Provide a between meal supplement to the client.

Correct: B Communication is important in delegation, as is followup. There may be a reason why the tray was not served. The key word in the stem is first. The other options may be correct but this was not the best first option

A client is taking an NSAID for the relief of joint pain. A GI bleed is suspected. Which lab value alerts the nurse to the possibility that the client is chronically losing small amounts of blood? a. Prolonged bleeding time b. elevated reticulocyte count c. Decreased platelet count d. Elevated bands

Correct: B Elevated reticulocyte count increases production of RBCs. IF a client is chronically losing blood, the body's response is increased RBC production. A decreased platelet count will cause bleeding but will not tell the nurse if there is a chronic bleed You chose C

A hispanic mother and her child visit the PHCP office due to a fever. Upon entering the room, the nurse immediately asks what is happening and begins to check the temp. Which response is likely from the mother? a. accepts the tx of the nurse and thinks it appropriate b. takes offense to the abrupt nature of the tx c. thinks the nurse is busy and needs to rush d. thinks the nurse is efficient

Correct: B Hispanic culture in present time oriented and desires attention and genuine interaction. You chose C

Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to receive a new admit? a. client admitted with possible TB awaiting skin test results b. client diagnosed with seizure dx c. client with new pacemaker scheduled to be dx this morning d. client with a hx of mild HF prescribed one unit of PRBC for anemia

Correct: B OB nurses would have the appropriate knowledge to care for clients w seizure dx bc of preeclampsia. Option D is incorrect bc the client has a hx of HF, which can put them at risk for FVE when recieving blood YOu chose D

The new nurse is caring for a client receiving O2 by nasal cannula. Which action would require the charge to intervene? a. apply gauze padding beneath the tubing b. Use petroleum jelly on the nares and cheeks c. provide mouth and nose care q 4 hours prn d. place the O2 tubing above the ears

Correct: B Petroleum jelly is a combustible substance. It should not be used with O2 therapy You chose A

A client presents to the ED reporting fever, cough, and malaise. The nurse notes that the client has a rash appearing as vesicles, most prominent on the face, palms of the hands, and soles of the feet. In addition to triaging the client as emergent, what should the nurse do? a. send the client to the waiting room b. place the client in a negative pressure room c. put a surgical mask on the client d. initiate contact precautions

Correct: B The client may have smallpox. The first thing the nurse should do is place them in a negative pressure room, which will protect others from exposure. Airborne precautions are necessary. You chose D

A client is being tx in the ED for dehydration. Which CVP reading would the nurse identify as their desired response to tx? a. -1 mmHg b. 4 mmHg c. 10 mmHg d. 15 mmHg

Correct: B The desired CVP reading is 2-6 YOu chose C

Which suggestions should the nurse provide to a client reporting frequent episodes of constipation? a. take a stool softener b. increase intake of fruit in the diet c. monitor elimination habits for the next week d. rest after each meal

Correct: B The nurse can suggest increasing fiber. Option C does not suggest a way to fix the problem YOu chose C

The client who had spinal surgery 2 days ago shares with the nurse the inability to dorsiflex the right foot. What is the best comment the nurse can reply to the client? a. Can you point your toes and foot down? b. Does your doctor know about this? c. Its probably due to the spinal anaesthesia you had. d. Think that happens a lot and should go away soon

Correct: B The nurse needs to first know if the doctor is aware of the problem. Dorsiflexion is the backward bending and contracting of the hand or foot. Plantarflexion is the extension of your foot at the ankle joint and occurs at a hinge joint. The primary distinction between the two is the direction of flexion.

The nurse is teaching a group of clients about SSRIs. Which comment by a client in the group indicates adequate understanding of the effects/ SE of the med? a. my weight may decrease while taking this drug b. I may expect increased sweating while taking this drug c. I may actually feel more depressed while taking this med d. I should feel better after a couple of days after beginning the med

Correct: B These drugs cause temp dysregulation, which can increase sweating. It does not cause worsening of depressive symptoms You chose C

A client diagnosed with schizophrenia tells the nurse, "God is going to heal me. I do not need medication." Which response by the nurse would best promote compliance with the prescribed med regimen? a. Yes, I believe that God will heal you b. Many people of faith believe that one way God works to heal is through medication c. We are talking about your medications right now d. What if God does not heal you and you should have taken the medication?

Correct: B This allows the client to keep the belief that God will heal but will do it through meds. This promotes med compliance. Option 3 may make the client angry and may close communication with the client. It also does not promote med compliance

Which client will the charge of the Med surg unit assign to the LPN? a. 40 year old with GI pain, lipase level of 200 units/L, and bruising of the abdo b. 33 year old with fatigue, T4 level of 4 mg/dL, and periorbital edema c. 68 year old with enlarged prostate, PSA level of 4.5, and hip pain d. 75 year old with CHF, BNP of 600, and acute dyspnea

Correct: B This patient is exhibiting EXPECTED FINDINGS of hypothyroid, therefore the client is not complicated and can be assigned to the LPN. Option C indicates metastasis and therefore a complication

A charge is teaching a new nurse on the L&D unit the proper positioning of a client following an epidural. THe charge nurse knows the teaching was successful when the new nurse places the client in which position? a. lithotomy b. left lateral c. semi fowlers d. right lateral

Correct: B This position allows the placenta to stay well perfused and the client is less likely to experience side effects from the anaesthesia, such as hypotension

A client with hemophilia has been scheduled for extraction of wisdom teeth. The nurse anticipates that the client will recieve what priority intervention before this procedure? a. prophylactic AB b., a unit of cryoprecipitate c. PRBC d. FFP

Correct: B cryoprecipitate replaces deficient factors and prevents hemorrhage. FFP is generally used in situations such as massive hemorrage, severe anemia, cardiac bypass, or DIC.

An occupational health nurse is reviewing the current meds of a client who has recently been prescribed propranolol for HTN. Which current med taken with propranolol by the client should be of concern to the nurse? a. cyanocobalamin b. melatonin c. cetirizine d. esomeprazole

Correct: B melatonin can raise blood pressure in people who are taking beta blockers to control BP. Avoid using it in conjunction with propranolol or any other beta blockers

A client, with a T5 injury, has not had a bowel movement in three days. Today, the client reports a headache rated 10/10. The nurse takes the client's vital signs: BP 180/110, HR 52, RR 20. What action by the nurse takes priority? a. administer Hydralazine 20 mg IV b. elevate HOB 45 degrees c. Remove impaction with topical anaesthetic d. close air vents in the room

Correct: B These signs/symptoms should lead the nurse to realize that the client is experiencing autonomic dysreflexia. The priority is to lower the blood pressure by raising the head of the bed to a semi-fowler's position. 1. Incorrect. You may have to give antihypertensive medications, but first elevate the head of the bed. 3. Incorrect. You have to remove the stimuli, but first get that BP down, so the client does not have a hypertensive stroke. 4. Incorrect. Again, drafts can cause autonomic dysreflexia, but the priority is to decrease that BP. You chose C

A nurse is working with community officials to decrease the incidence of violence in the community. Which primary preventive measures might the nurse suggest? a. provide a safe haven for victims of violence b. provide educational programs about types of violence c. form a neighborhood watch program d. develop a media campaign to ID risk factors of potential abuse e. provide for the immediate removal of a victim of violence from the home

Correct: B, C, D

The nurse sees that a new medication noted in a recent prescription is on the client's list of allergies. In the role of client advocate, what actions should the nurse take to ensure client safety? a. document the med with times and doses given, then administer as ordered b. Notify the HCP immediately that the med prescribed is on the client's allergy list c. Stop the med on the clients MAR d. check the client's allergy band against the list of client allergies documented in the MAR e. call the pharmacy to see if the med needs to be changed

Correct: B, C, D the HCP, not the pharmacy, should be notified for the change. The HCP is responsible for changing the prescription

The client has suicidal ideations with a vague plan for suicide. The nurse who is teaching the family to care for the client at home should emphasize which points? SATA a. family members are responsible for preventing future suicide attempts b. when the client stops talking about suicide, the risk has increased c. warning signs, even if indirect, are generally present prior to an attemp d. one suicide attempt increases the change of future attempts e. report sudden behavioral changes

Correct: B, C, D, E

What electrolyte imbalance should the nurse monitor for when caring for a client diagnosed with chronic alcoholism? a. hypochloremia b. hypokalemia c. hypophosphatemia d. hypomag e. hypocalc

Correct: B, C, D, E The number 1 way of getting rid of K is through the kidneys. What does alcohol make you do? Diurese. Acute hypophosphatemia is seen in up to 50% of patients over the first 2-3 days after they are hospitalized for alcohol overuse. IT is manifested as rhabdo and weakness of skeletal muscle. Mag deficiency occurs due to diuresis as well. It is often accompanied by hypocalc, which may be aggrivated by a deficiency of Vit D

The nurse reassesses the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non-pharmacologic interventions may help the client's backache? SATA 1. Educating the client regarding pain and pain control. 2. Assisting the client into a side lying position. 3. Providing a back massage. 4. Providing heat therapy. 5. Using distraction techniques.

Correct: B, C, D, E, F

A client with leukemia receiving high dose chemo is being evaluated for the development of tumor lysis syndrome. Which lab value should the nurse recognize as being a hallmark sign of tumor lysis syndrome? a. Thrombocytopenia b. hyperkalemia c. Hypocalcemia d. hyperuricemia e. hypomagnesemia f. hypoerphosphatemia

Correct: B, C, D, F When the cells are destroyed or lyse from the chemo, there is a release of K and phosphate from the cells. Therefore, hyperkalemia and hyperphosphatemia are direct results of cellular destruction. Purines are also released during cellular destruction. The purines are metabolized and converted into uric acid, which leads to hyperuricemia. In terms of hypocalcemia, remember the seesaw effect!

The nurse is cleaning and dressing a foot ulcer of a diabetic client. Which actions are appropriate? a. uses a clean basin and washcloth to clean the ulcer b. wears sterile gloves to clean the ulcer c. cleans ulcer with NS d. warms saline bottle in microwave for 1 minute e. cleans ulcer in full circle, beginning in the center and working towards the outside

Correct: B, C, E Normal saline is the preferred cleansing agent. As an isotonic cleaning solution, it does not interfere with the normal healing process

The staff nurse is caring for a 3 month old client recieving K IV therapy. Which actions indicate to the charge nurse that the staff nurse understands IV management? a. uses a 15 gtt factor drip chamber when changing the IV tubing b. Applies elbow restraints to prevent dislodgement of the IV catheter c. checks IV site hourly for blood return d. instructs UAP to count drip rate hourly e. attached a volume controlled IV administration set to IV bag prior to beginning iV therapy

Correct: B, C, E Young children and infants usually must be restrained to some degree to prevent accidental dislodgement of the needle. IV K is an irritant. When the fluid being infused is a known irritant or vesicant, the nurse should check the IV site hourly for blood return or possible infiltration. The volume controlled pump helps prevent FVE

The PHCP has prescribed a saline IM injection for a client who requests pain meds q 2-3 hours. What would be the nurse's best first action? a. administer the injection b. take VS c. question the prescription with the HCP d. notify the nursing supervisor

Correct: C The nurse should talk to the HCP before going to the nurse supervisor You chose D

The L&D charge is making staff assignments, including assignements to a new nurse. What client is most appropriate for the new nurse A. a gravida 3 para 2 in active phase of stage one, expecting twins B. a gravida 2 para 0 at 41 weeks gestation, awaiting induction c. a primigravida in active phase of stage one, waiting for epidural d. a 12 hour post c section needing assistance to ambulate

Correct: C The primigravida presents many opportuniteis for basic and diverse skills that would be educational for the new nurse. Induction of labor can lead to many problems which can be too complicated for the new nurse. The client requires close monitoring for this (IV titration, etc).

A nurse working in a psychiatric unit is caring for a client diagnosed with paranoia. The client becomes very agitated and shouts, "I am not going to my session today!" What action by the nurse would be most appropriate? a. sit with the client and say a prayer b. send the client to the session after explaining that shouting is not allowed c. escort the client to an easel and canvas in order for the client to paint. d. call for assistance and put the client in seclusion.

Correct: C Yes! Get tehm active. Redirect their activity. Setting limits is good, but here the client is disruptive and shouldnt go to group at this time. YOu chose C

The nurse just received an ABG that shows a borderline high PCo2 on a client who just had chest surgery. What should be the priority nursing intervention? a. tell the client to breathe faster b. medicate for pain and ambulate c. have the client use the IS d. prepare to administer bicarb to buffer

Correct: C Yes, the client just had chest surgery and the PCO2 is high. Yes, they are probably hurting due to the incision and don't want to take deep breaths. However, there is nothing in the stem of the question that states the client is in pain, so don't sedate the client to make the breathing problem even worse. In order to get rid of the excess CO2, the client needs to turn, cough, and deep breath.

A nurse is caring for a 65 yr old diagnosed with dehydration. The client has been receiving IV NS at 150 ml/hr for the past 4 hours. Which finding would the nurse need to notify the HCP? a. BP 136/84 b. report of nausea c. anxiety d. UOP at 50 ml/hr

Correct: C anxiety, restlessness, or any sort of apprehension is often the first s/s of acute pulmonary edema (OR AT LEAST HYPOXIA!!) You chose A

A client at 34 weeks gestation with PIH reports heartburn. Which action by the nurse has priority? a. administer antacid per standing orders b. check client's BP c. call the HCP immediately d. assure the client this is a normal discomfort of pregancy

Correct: C epigastric discomfort is commonly described as heartburn by pregant clients, but epigastric discomfort is a symtom of impending rupture of the liver capsule and seizure associated with worsening PIH and preeclampsia. As a new nurse we need to assume the worst. Call the HCP

What would the nurse include when teaching a client newly prescribed timolol maleate eyedrops for glaucoma? a. this med works by causing the pupils to constrict b. THis med will dilate the canals of Schlemm c. This med decreases the production of aqueous humor. d. This med improves ciliary muscle constriction

Correct: C Timolol decreases aqueous humor formation, therefore decreasing IOP

A community health nurse is reconciling medications of a client who was discharged from the hospital with a diagnosis of CHF, HTN, and arthritis. After reviewing the client's meds, what action is most important for the nurse to take? a. educate the client on newly prescribed meds b. inform the client to take the captopril at night c. notify the HCP that the client is recieving adalimab d. tell the client to stop taking saw palmetto

Correct: C adalimumab can cause new or worsening HF

A client has returned to the unit following an upper GI series. What is the nurse's priority action? a. keep client NPO until the gag reflex returns b. perform an immediate cleansing enema c. administer 30 mls of milk of magnesia orally d. monitor VS q 10 minutes until stable

Correct: C an upper GI involves the ingestion of barium based contrast under fluoroscopy to view the esophagus, stomach, and small intestines. Following such a procedure, it is vital for the client to pass all the barium before a blockage occurs. The client is encouraged to drink large amounts of fluid and is administered an OTC laxative, such as milk of magnesia to remove the barium.

Which tasks should the nurse delegate to the UAP? a. demonstrate post op exercises b. reposition the TENS unit c. empty the indwelling catheter bag d. Assist a client with position changes every 2 hours e. apply anti embolism stockings

Correct: C, D, E

A client is discharged with halo traction. what should the nurse teach the client and family about home management with this traction? a. showering is permitted once a week with assistance b. apply baby lotion under the halo vest to prevent irritation c. sleep in whatever position is found to be most comfortable d. never pull on any part of the Halo traction e. clean around pins at least once daily with a new q tip for each pin site

Correct: C, D, E the client may sleep in whatever position is most comfortable. The placement of a rolled up towel, or pillow, either under the neck,m if on back, or under the cheek, if side lying, may be helpful.

What should the nurse include when teaching a client in renal failure about peritoneal dialysis? a. instill 250 ml of fluid into the peritoneal cavity over 30 minutes b. Use cool effluent when instilling into the peritoneal cavity c. Following the prescribed dwell time, lower the bag to allow fluid to drain out d. The fluid that is returned should be clear e. if all the fluid does not drain out, place the client in trendelenburg f. A sweet taste may be experienced when peritoneal dialysis is used

Correct: C, D, F Since the dialysate has a lot of glucose in it, the client frequently reports a constant sweet taste. The amount of fluid used in peritoneal dialysis is about 2000 to 2500 ml at a time. This filling of the peritoneal cavity is often completed in 10 minutes.

The charge nurse on the pediatric unit has several tasks that need to be completed. What tasks can be assigned to the UAP? a. obtain a urine sample from an infant b. empty an NG canister for a client with an ileus c. feed a child with bilateral burns of the hand d. change an ostomy appliance on child with a stoma e. ambulate an adolescent two days post appy

Correct: C, E Emptying containers are within the realm of duties for a UAP, but not an NG cannister. The nurse has to assess the color, consistency, and amount of drainage in the canister in addition to locating the position of the NG tube

The nurse manager is developing a new yearly evaluation form for the staff. What statements by the nurse manager would most likely improve staff outcome? a. How often do you need help to finish assignments? b. Are there any new skills you feel capable to learn? c. Describe how you organize your daily assignments d. Which tasks are most difficult for you to complete e. Explain any new goals you would like to achieve

Correct: C, E Positive outcomes are more likely when staff feels appreciated, receiving constructive and encouraging feedback on a regular basis. Evals can be very stressful when staff are uncertain of expectations or are percieved in a negative framework. Seeking clarification on how staff organize assignments indicates awareness and may help in developing protocols. Also, showing interest in individual goals will help devleop learning opportunities for all staff A: the tone is derogatory B: worded in negative manner D: negative approach may intimidate staff

A new nurse on a telemetry unit has been assigned a client admitted for tx of CHF. When completing a CO assessment, the nurse would evaluate which body function? a. skin turgur b. bowel sounds c. UOP d. pupillary reaction e. peripheral edema f. LOC

Correct: C, E, F Skin turgur relates to superficial body moisture, not fluids in the vascular system. Skin turgur reflects HYDRATION, not CIRCULATION

A nurse walks into the medication area of a long term care facility and sees a colleague taking a pill from a residents supply good of narcotics. The nurse says, "please dont say anything. I need my job and have a migraine." What actions should the nurse take? a. reassure the colleague that she won't tell this time b. insist that the colleague get some help c. report what was seen to the supervisor d. send the colleague home e. follow procedure to return the med to the resident's supply

Correct: C,E THe supervisor should be the one to help the colleague get help and send them home

A client is awake in the recovery room following a cardiac catheterization performed through the left radial artery. During the assessment, the nurse notes severe swelling of the left upper arm with a diminished left radial pulse, indicating an internal arterial hemorrhage. The cardiologist states the client will require immediate surgery to repair the leaking artery. The nurse understands what fact about the current consent form? 1. Can be assumed since it's an emergent situation. 2. Should be signed by client who is currently awake. 3. Is not needed since client consented to catheterization. 4. Must be approved by family or a spouse.

Correct: D An additional procedure requires a new consent form which describes specifically what the cardiologist plans to do. Even though the client is awake, residual sedation from teh cath makes it necessary for a family member of spouse to sign the consent form You chose B

A client with a rare disorder has been admitted to a teaching hospital. The primary healthcare provider includes this client in medical students' morning rounds without notifying the client. When the angry client reports this to the charge nurse, what response by the nurse would be most appropriate? 1. "Consent is implied because this is a teaching hospital." 2. "These students will provide excellent care for you." 3. "I will call your primary healthcare provider to report how upset you are." 4. "You can refuse to be part of the students' study."

Correct: D Client's rights (Aka patient's bill of rights). Clients have the right to refuse care from any professional setting, including medical and nursing students. You chose C

A paralyzed adolescent admitted for decubiti debridement has brought multiple personal electronics, including a laptop, cell phone, and video game unit. The nurse notes the family has used extension cords to provide enough electrical outlets. What action by the nurse is most appropriate? a. inform family some of electronics must be taken home b. explain that extension cords are not permitted in the hospital c. Notify maintenance to install more outlets in the client's room d. ask client to have staff switch equipment in outlets as needed

Correct: D Extension cords are considered a safety hazard in the hospital setting, especially when provided by the family. Choice B does not offer an alternative option for the family and is therefore wrong. In choice D, the nurse has provided an alternative in order for the client to use personal equipment. Staff will assist the client to switch equipment when requested.

Which instruction is MOST important to include when teaching a child how to self administer a combined dose of isophane suspension and regilar insulin SQ? a. alternate the injection sites from one body area to another with each dose b. draw up the isophane suspension insulin forst and then the regular insulin into the same syringe c. massage the injection site after the med is administered d. insulin syringes should be stored at room temp

Correct: D Insulin sites are rotated, but within a chosen site, eg the abdomen, before moving on to another site. Insulin syringes and needles should be stored at room temp You chose A

Which task by the RN should be performed first? A. changing a burn dressing on a client that is cheduled q 4 hrs B. administering a scheduled IV AB C. teaching a newly diagnosed diabetic client about diet and exercise D. assessing a newly admitted client

Correct: D It is important to initiate the assessment within 1 hr of being admitted. The scheduled IV AB can be administered within the appropriate time frame YOu chose B

What room assignment would be best for the nurse to make for a primigravida with gestational diabetes who was admitted for glycemic control? a. a private room near the nurses station b. a room with a client with placenta previa c. a room with a client in preterm labor d. A room with a client admitted for pregestational diabetes

Correct: D Placing clients with similar diagnoses together can result in information sharing and emotional support. It is ok to put these two clients together. A private room is not required since the client has no emotional or infection control issues. Also, it is not necessary to place them near the nurses station because they do not need monitoring on that close of a level

A UAP has been floated to the ED because of several staff call offs. Since the UAP has never worked in the ED, what is the most appropriate task the charge nurse could assign? a. clean and restock the exam rooms after the client discharge b. Follow another UAP who has worked there previously c. Sit at the reception desk and answer incoming calls d. Escort clients from the ED to other areas for tests

Correct: D Since the UAP has never worked in this area before, they would not know what the rooms would need. UAPs frequently escort stable clients to other departments as part of their normal daily routine, so this would be something that the UAP is familiar with.

An 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? a. reinforcing teaching about the use of an overhead trapeze bar b. reminding the client of the need for using the IS c. Reinforcing the hip dressing as needed due to breakthrough bleeding d. providing socks for the client to put on to help warm the feet

Correct: D THe client will have to flex the hip to put on socks, which could lead to dislocation. LPNs can reinforce teaching

A nine year old child with ADHD is being admitted to the pediatric unit. Who should the charge nurse assign this client to room with? a. 10 yr old with crohns b. 8 year old with seizure history c. 6 yr old with asthma d. 7 yr old with UTI

Correct: D These children are close in age and the childs condition does not require a quiet environment that could be interrupted by a hyperactive child

A client at 32 weeks gestation is admitted to the obstetric unit with a BP of 142/90 and 1+ protienuria. Since no private rooms are available, the chare must assign the client to a semi private room. WHich client should the charge assign this client to room with? a. postpartum woman who delivered at term b. woman in preterm labor at 35 weeks gestation c. woman with placenta previa at 37 weeks gestation d. pre term labor client with twins at 28 weeks gestation

Correct: D This client should also be kept in a quiet environment as both are presented with the possibility of preterm labor. The postpartum woman will require many assessments. The woman at 35 weeks is closer to delivery and may have to deliver emergently

A client was admitted to the medical unit after an acute stroke. Which nursing activity can the RN delegate to the LPN? a. screen client for contraindications for TPA therapy b. place seizure precaution equipment in the client's room c. perform passive ROM exercises d. administer enoxaparin 1 mg/kg SQ q 12 hrs

Correct: D This is an action the LPN but not UAP can perform

A client has been on the nursing unit for two hours following a retropubic prostatectomy for the treatment of prostate cancer. The client is recieving a CBI of NS infusing at 1000 ml?hr. The client's UOP for the past two hours is 410 ml. What is the nurse's first action? a. Inspect the catheter tubing for obstruction b. Irrigate the catheter with a large piston syringe c. Notify the HCP d. Stop the irrigation flow

Correct: D The catheter output should be at least the volume of irrigation input plus the client's actual urine. A severe decrease indicates obstruction, in which case the first action is to stop the flow to prevent further bladder distention.

In which situation should the nurse consult the client's advanced directive? a. client scheduled for breast reconstruction after masectomy b. client with T-5 spinal cord injury beginning rehab c. client diagnosed with Guillain-Barre who is recieving vent support d. comatose client with end stage chronic obstructive pulmonary dx e. client diagnosed with inoperative brain tumor who is confused

Correct: D, E A client diagnosed with Guillain Barre is mentally competent and being on a vent DOES NOT indicate that the client has lost decision making capacity

The nurse is reviewing the plan of care for a client during the first day post-craniotomy. Which actions can the nurse delegate to an experienced LPN working in the ICU? a. determine GCS b. check ET tube cuff pressure every shift c. reposition client from side to side q 2 hrs d. Administer acetaminophen via NG tube for temp greater than 101 (38.3) e. monitor I&O every hour

Correct: D, E ET tube cuff assessment is accomplished by an experienced RN

A homecare nurse is visiting a client with advanced Alzheimers living in the home of a daughter. The household includes two adults and 3 adolescents with extremely busy schedules. The daughter admits to feeling overwhelmed but is fearful of placing the client into a permanent care facility. What interventions by the nurse would be most helpful for the family at this time? a. call adult protective services and ask for recommendations b. request the HCP to order placement c. provide the family with brochures for various nursing homes d. encourage the family to join a local alzheimers group e. talk with the daughter regarding fears or concerns about placement

Correct: D, E It would be too soon to begin giving brochures if she is already concerned about placement

The ED nurse is assessing a client reporting severe abdo pain for several hours prior to arrival at the hospital. Assessment findings include slight mottlingof the lower extremities and a pulsating mass near the umbilicus. Which actions should the nurse implement immediately? a. position client on left side b. apply warm blankets to legs c. administer IM pain med d. alert OR staff e. Notify HCP f. Palpate mass to determine size

Correct: D, E The client would not benefit from warm blankets as the mottling is caused by the comprised circulation

A client presents in the ED with acute onset of fever, HA, stiff neck, N/V, and mental status changes. What interventions should the nurse initiate? a. provide a quiet environment b. pad side rails c. place on droplet precautions d. maintain head in midline position e. place ice packs under axilla for fever greater than 101

Correct: a, b, c, d A tepid sponge bath with help lower the fever. Placing ice under the axilla can cause shivering. Shivering can result in a rebound effect that increases the temp instead of lowering it

A nurse observes a fire has started in the trash can of a client's room. What steps should the nurse take? Place steps in priority from first to last. (Correct:) remove the client from the room activate the fire alarm close the door to the clients room obtain the fire extinguisher extinguish the fire

RACE: rescue, activate, contain the fire, extinguish the fire

In what order should the nurse address these client events that occur at the same time? place in order of highest to lowest priority: (correct) Client's trach needs to be suctioned The water seal chamber is empty in a clients closed chest drainage unit UAP reports a HR of 40/min in a client Client who is on bed rest due to DVT is attemping to get out of bed client reports urinary frequency and dysuria

The HR may be affecting CO. Although the DVT is potentially dangerous, it does not take priority over airway or circulatory problems that exist

In what order should the nurse assess assigned clients following shift report? Correct: Client diagnosed with pneumonia who has a pulse ox reading of 89% Client diagnosed with pneumonia who has an arterial oxygenation of 85% Client diagnosed with active TB who has a sputum specimen that needs to go to the lab CLient who had a feeding tube inserted, due to recurrent aspiration pneumonia, which is now clogged

The first client the nurse needs to assess is the pneumonia client with a pulse ox of 89. Supplemental oxygen should be used for this client The patient with an arterial oxygen level of 85% is next. Normal arterial oxygen is 80-100, so this is normal but on the low side. The nurse should assess for potential respiratory complications The third client is the TB client. Sputum specimens need to go to the lab in a timely manner. The nurse could assign the UAP to this task The fourth client is the feeding tube client. CLogged feeding tubes occur with regularity. Delay in feeding will not result in permanent damage.

A client presenting to the clinic has a history of SLE. Which finding would indicate to the nurse that the client is having a flare up of the disease? a. abdominal discomfort b. alopecia c. butterfly rash on face d. fever e. weight gain

correct: A, C, D SLE does not cause alopecia, only hair thinning