Hurst Review LPN

The nurse is preparing to administer a hepatitis B vaccine 1 mL IM to a client. Which syringe should the nurse use to administer this vaccine?

A: 3

The primary healthcare provider has prescribed 1000 mL of DW5 to infuse over a 12 hour period. The drop factor is 20 gtt/mL. How many gtt/min should the nurse administer? Round answer to the nearest whole number.

A: 28

The primary healthcare provider prescribes an intravenous infusion of D5W at 125 mL per hour. The drop factor is 20. How many drops per minute should the nurse administer? Round to the nearest whole number.

42

The nurse is caring for a client on the medical unit. The primary healthcare provider prescribed Lactulose 30 gram orally once a day. Available is Lactulose labeled 10 g per 15 mL. How many mL will the nurse administer? Round answer to the nearest whole number.

45 mL

The nurse is setting up the sterile field for the primary healthcare provider and another nurse to use. As the nurse and primary healthcare provider enter the room, they don sterile gowns and gloves. As the procedure begins, the nurse observes that the other nurse in the room has turned her back on the sterile field. What should the observing nurse do first? 1. Nothing, as everyone is individually accountable for their practice. 2. Provide the nurse with another gown and sterile gloves. 3. Inform the primary healthcare provider and the nurse that the sterile field ma have been compromised. 4. Remind the nurse not turn back on a sterile field.

A : 3 Rationales 1. Nurses serve as client advocates; therefore, action must be taken. 2. This is true; however, there is another action that should occur first. 3. Anytime a nurse observes that the sterile field is compromised or ma have been compromised, it is essential that it is reported to protect the client. 4. The nurse should not turn back on the sterile field; however, the observing nurse must take more definitive to protect the client.

The nurse should see the client with which problem first? 1. Recurring crushing chest pain 2. Needing an IVPB going to surgery in 5 minutes 3. Needing pain control post hysterectomy 4. Waiting to get back to bed after siting in a chair for 30 minutes

A: 1 Rationales 1. The client complaining of crushing chest pain is probably having a MI or should be seen first. This client takes priority over the other three clients. 2. This client is not the priority over the client with an oxygenation problem. This client will not die if not attended to first. 3. Pain never killed anyone but an MI will. 4. Will this client die if not put back to bed before taking care of the client having chest pain? No.

Which male client condition in the after-hours clinic should the nurse see 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

A: 1 Rationales 1. This client is likely to have testicular torsion, which requires immediate intervention. Infarction of the testes can occur if not treated promptly. 2. 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. 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 checked but is not the first priority. 4. This client does not have the most serious condition and would not take priority.

Which client should the nurse see first? 1. 53 year old client with chest pain scheduled for a stress test today. 2. 62 year old client with mild shortness of breath and chronic obstructive pulmonary disease. 3. 66 year old client with angina scheduled for a cardiac catheterization this AM. 4. 78 year old client who had a left hemispheric stroke 4 days ago.

A: 1 Rationales 1.the client may be experiencing a myocardial infarction and would require close observation. Therefore, this client would not be a priority over a client who may be experiencing a myocardial infarction (MI). 2. Dyspnea is one of the three (chronic cough, sputum production, and dyspnea) primary symptoms characteristic of chronic obstructive pulmonary disease. This client would be considered more stable than the liens who may be having a MI. 3. The client is scheduled for the procedure needed to further explore the angina. This client would be considered more stable than the client who may be having a MI. 4. After stroke has occurred, medical management is aimed at preventing a second stroke from occurring and rehabilitation. This client may have significant sequelae related to the stroke, but would not be considered acute nor a priority over the client possibly having a MI.

A client reports a diminished ability to visually focus on close objects and has noticed a need for a well lit environment to enhance vision. To what does the nurse attribute these changes? 1. Normal changes associated with aging. 2. Cataract formation. 3. A brain tumor. 4. Diabetic retinopathy

A: 1 Rationales 1. Aging results in stiffening of the lens, thus lessening the ability to focus. The retina is less sensitive to light making accurate vision low-light situations more difficult. Pupillary response diminishes, affecting the ability to adjust to changing light levels. 2. Cataracts present with blurred vision and a glare from lights. 3. Brain tumors increase intracranial pressure resulting in blurring of vision. 4. Diabetic retinopathy is caused by changes in retinal blood vessels and results in blurred vision and outright impairment in some fields.

Which referral would the nurse anticipate that the primary healthcare provider would make for a client who has difficulty eating using regular utensils? 1. Occupational therapist 2. Physical therapist 3. Rehabilitation nurse 4. Registered dietitian

A: 1 Rationales 1. An occupational therapist helps physically disabled liens adapt to physical limitations and is most qualified to help clients improve their ability to form activities of daily living. OT's help clients learn to approach tasks differently, use assistive devices or equipment, make adaptations to the home or work environments and find ways to assist the client in meeting personal goals. 2. The physical therapist is trained to deal with problems that limit their abilities to move, perform daily functions, or remain active and independent. However, physical therapists do not assist with special adaptations needed to perform activities of daily living such as eating. 3. A rehabilitation nurse can help a client eat, but isn't trained in modifying utensils. The rehabilitation nurse assists clients as they adapt to altered lifestyles and assists clients to attain and maintain the highest level of functioning. Some of the aspects included in the ole of the rehab nurse includes encouraging self care, preventing complications and further disability, setting goals for independent functioning, and assisting clients to access additional care needed. The rehabilitation nurse would work collaboratively with the occupational therapist (OT). The OT is the one who will best meet the needs of this client who is experiencing difficulty eating with regular utensils. 4. A registered dietitian manages and plans for the nutritional needs of clients but isn't trained in modifying of fitting utensils with assistive devices. This would be the role of the OT.

Which movements should the nurse expect to observe when evaluating the developmental stage of a 2 year old? 1. Stand on tiptoes. 2. Hops on one foot up to five seconds. 3. Goes upstairs without support. 4. Kicks ball forward.

A: 1 Rationales 1. By the age of two, the child should be able to stand on his/her tiptoes. 2. These are movements that a five year old should be able to perform. 3. These are movements that a five year old should be able to perform. 4. These are movements that a five year old should be able to perform.

A client hospitalized in the mental health unit asks if she can receive mail from her mother and sister. Which statement by the nurse indicates adequate understanding of client rights? 1. "All clients can receive and send mail, but staff must check for hazards." 2. "Clients are not allowed to receive mail while hospitalized." 3. "Receiving mail from family is not encouraged on inpatient units." 4. "I will check with the nursing supervisor about this."

A: 1 Rationales 1. Clients are allowed to send and receive mail. Mail must be checked for hazards to protect the client and the safety of others on the unit. 2. This statement indicates lack of understanding of client's rights. 3. This statement indicates lack of understanding of client's rights on the mental health unit. 4. The nurse would not need to check with the supervision. The client has a right to send and receive mail.

The wife of a client in the hospital inquires if cardio pulmonary resuscitation (CPR) will be done if the client stops breathing. The client has suffered from a terminal illness, and it appears that death is imminent. The client has a living will which requests "do not resuscitate." What should the nurse say to the wife? 1. "No the living will requests that no resuscitation efforts be performed." 2. "We will respond slowly with resuscitation efforts." 3. "We will begin the CPR, but the house primary healthcare provider will stop within a few minutes." 4. "We will only perform CPR, no defibrillation."

A: 1 Rationales 1. The wishes of the client will be honored. 2. These actions are not consistent with the client's wishes. 3. No resuscitation efforts are to be performed. 4. No resuscitation efforts are to be performed, including CPR.

Forty eight hours post coronary artery bypass surgery (CABG), the nurse notes the client's level of consciousness has decreased from alert to somnolent. BP 88/50, HR 130 and threads, resp 32, urinary output (OUP) has dropped from 100 mL one hour earlier to 20 mL this hour. What would be the nurse's first action? 1. Administer 100% oxygen per mask. 2. Lower the head of the bed. 3. Give furosemide STAT. 4. Re-check the BP in the other arm.

A: 1 Rationales 1. This client has developed signs of cardiogenic shock, one of the complications post CABG. Cardiac output is decreased, so the client needs more oxygen for the circulating blood volume. 2. Lowering the HOB will not help in cardiogenic shock but will actually make it harder for the heart to pump. 3. Poor kidney perfusion is the reason for the decreased UOP. The kidneys are trying to conserve what little volume the body has to maintain vital organ perfusion as long as possible. 4. Rechecking the BP will not help the problem. With the other symptoms, this BP is most likely accurate. This would only delay treatment and would not fix the problem.

While looking at a photo, a client outlines the portion that she can see. Based on what the client can see, the nurse anticipates that the client has what ophthalmic disorder? 1. Glaucoma 2. Cataracts 3. Macular degeneration 4. Retinal detachment

A: 1 Rationales 1. When the optic nerve deteriorates, blind spots develop in your visual field, starting with your peripheral (side) vision. If left untreated, glaucoma may lead to blindness in both eyes. 2. A cataract is a lens opacity or cloudiness. 3. Macular degeneration is progressive loss of central vision. 4. In retinal detachment a shadow begins laterally, slowly encroaching on central vision.

A nurse admits a client to the pre-op area of an ambulatory surgery unit. As the client is being prepared for surgery, a nurse notices that the client is exposed and pulls the curtain closed. How did the nurse exhibit client advocacy? 1. By ensuing client safety. 2. By promoting client privacy. 3. By obtaining informed consent. 4. By ensuring client confidentiality.

A: 2 Rationales 1. The nurse is not assuring client safety in this example. 2. The nurse is acting as a client advocate by promoting client privacy. 3. The nurse is not obtained informed consent in this example. 4. The nurse is not ensuring client confidentiality in this example.

A client is admitted with atrial fibrillation and heart failure secondary to chronic hypertension. Current medications include: Digoxin, Captopril, Carvedilol, Feurosemide, and Warfarin. Based on this profile, what lab work is essential for the nurse to monitor? 1. Digoxin level 2. Potassium level 3. PT/INR 4. aPTT 5. CPK-MB

A: 1, 2, 3 Rationales 1, 2, 3. Look at the hints: Atrial fib and heart failure, so automatically what do we know about his cardiac output? Decreased. Chronic hypertension, what does that mean for afterload? Increased. Look at the meds: antihypertensive, diuretics, anticoagulants, and dig. And we know that digoxin increases the force of the contraction and decreases the heart rate. So what lab work is essential to monitor? Dig level, potassium level because of the loop diuretic, PT/INR because of the anticoagulant. 4. aPTT is used to evaluate what? Heparin. 5. Well, this goes up with myocardial infarction.

The parents of a toddler tell the nurse that their child will not drink milk. What alternatives should the nurse recommend? 1. Frozen yogurt 2. Pudding 3. Hot cocoa in milk 4. Cheddar cheese 5. Watermelon

A: 1, 2, 3, 4 Rationales 1, 2, 3, 4. A 1/2-cup saving of fat-free frozen yogurt offers more than 100 milligrams of calcium. Pudding contains approximately 28% of the daily food allowance of calcium. An 8-oz. mug of homemade hot chocolate contains 285 mg of calcium. Cheddar cheese has 204 mg of calcium per serving. 5. 1 cup of watermelon supplies only 11 mg of calcium.

The nurse is caring for a client who has chronic renal failure, suspects that the client is experiencing anxiety. Which statements by the client would validate the nurse's suspicion? 1. "I do not think I can continue working." 2. "My husband has taken over the house cleaning and cooking." 3. "I fear I am dying." 4. "I have an "uneasy" feeling most of the time." 5. "Most of the time I feel very 'down and blue'."

A: 1, 2, 3, 4 Rationales 1, 2, 3, 4. The inability to maintain employment is of concern to most clients who have been used to working. With a chronic illness, the client is unlikely to be able to return to work. Anxiety related to role strain is common. The client may not be able to perform the duties that she once did, thus causing others to have to assume their roles. Death is a possible outcome if transplant does not occur. Fear may be a later diagnosis as the client's condition deteriorates. Clients with anxiety often report feeing uneasy or on edge. 5. These comments are more indicative of a depressed mood than anxiety. Depression may also occur in the client who has chronic renal failure.

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

A: 1, 2, 4, 5 Rationales 1, 2, 4, 5. Dexamethasone 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. 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. 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 pressure checked frequently.

Th nurse is caring a client who has terminal cancer, find that the client is extremely restless. In response to this data, what would be the appropriate nursing action? 1. Play soothing music. 2. Use chamomile aromatherapy. 3. Place soft restraints on arms. 4. Dim room lights. 5. Keep conversations quiet. 6. Massage forehead.

A: 1, 2, 4, 5, 6 Rationales 1, 2, 4, 5, 6. Muscle therapy may produce relaxation by quieting the mind and promoting a restful stat. Aromatherapy with chamomile may also help overcome anxiety, anger, tension, stress, and insomnia in dying clients. When the lights go down and the room darkens, this signals to the brain and it's time for rest. Keeping conversations quiet will help to decrease stimuli. Simple techniques such as repositioning pillows or bed clothes and gentle massage (if tolerated) can also provide relief from pain. 3. Restraints will only agitate the client more. Remember, use restraints as a last resort.

In caring for a client exposed to radiation, the nurse knows that the type of damage due to radiation exposure depends on which factors? 1. Dose rate 2. Organs exposed 3. Technician 4. Time of day 5. Type of radiation

A: 1, 2, 5 Rationales 1, 2, 5. The extent of damage due to radiation exposure depends on the quantity of radiation delivered to the body, the dose rate, the organs exposed, the type of radiation, the duration of exposure, and the energy transfer form the radioactive wave or particle to the exposed tissue. 3. The technician has no bearing on the type of damage due to radiation exposure. 4. The time of day has no bearing on the type of damage due to radiation exposure.

What developmental milestones does the nurse expect to see in a 4 year old child? 1. Can say first and last name. 2. Draws a person with 2 to 4 body parts. 3. Copies a triangle. 4. Can tell what is real and what is make believe. 5. Sings a song from memory. 6. Talks about likes and interests.

A: 1, 2, 5, 6 Rationales 1, 2, 5, 6. By the age of 4 years, the nurse would expect the child to know both their first and last name, be able to draw a person with 2-4 body parts, sing a song from memory such as the "Itsy Bitsy Spider" or the "Wheels on the Bus", and talk about what they like and are interested in. 3. When checking the developmental milestones of a 5 year old, the nurse should expect to see the child to be able to copy a triangle. 4. The 5 year old can distinguish between reality and make believe. The 4 year old often cannot tell the difference.

A pregnant female is attending a seminar for first time mothers and indicates difficulty understanding the topic of amniotic fluid. The LPN reiterates that amniotic fluid serves what functions? 1. Controls fetal body temperature. 2. Facilitates shedding of dead cells. 3. Protects the fetus from injury. 4. Assists musculoskeletal growth. 5. Helps with brain development.

A: 1, 3, 4 Rationales 1, 3, 4. Amniotic fluids plays a crucial role in the healthy growth and development of the fetus. The fluid helps to keep fetal body temperature at a consistent level while protecting against injury while in utero. Sufficient fluid allows the fetus to stretch and flex extremities, facilitating proper and symmetrical musculoskeletal growth. 2. Amniotic fluid does not cause the shredding of dead fetal cells; rather, the amniotic fluid contains old or dead cells which continually slough automatically from fetal skin over time. 5. Although amniotic fluid assists with the development of several fetal systems, including respiratory and gastrointestinal system it does not help with brain development.

A nurse is performing eye care for an unconscious client. Which actions should the nurse indicate? 1. Administer moist compresses to cover eyes every 2 hours. 2. Clean eyes with saline and cotton balls, wiping from the outer to inner canthus. 3. Use a new cotton ball for each cleansing wipe. 4. Instill artificial tears into the lower eye lids as prescribed. 5. Protect the eyes with a protective shield. 6. Monitor eyes for redness and exudate.

A: 1, 3, 4, 5, 6 Rationales 1, 3, 4, 5, 6. All of these interventions are appropriate for eye care of the comatose client. These actions prevent infection, keep eyes moist, and protect the eye from injury. 2. Clean the eyes with saline solution and cotton balls. Wipe from the inner to outer canthus. This prevents debris from being washed into the nasolacrimal duct.

The nurse is preparing to administer 1000 mL D5W IV over 12 hours. How many gtts/min will the nurse need to set the IV rate at? (DF 10 gtts/mL)

A: 14

A home health nurses caring for a Mexican-American client who has been discharged from the hospital post myocardial infarction. While the nurse is at the house, a curandero is also at the home at the request of family members. What is the best action of the nurse? 1. Leave, and return once the curandero has left. 2. Discuss the plan of care with the client, family, and curandero. 3. Ask the curandero to leave so that the client can be assessed. 4. Explain to the family that the curandero is not reliable healthcare option.

A: 2 Rationales 1. Leaving will not allow the nurse to discuss care of the client with all members of the healthcare team and family. This is a good time to learn about the curandero, health benefits, etc. 2. This is the best course of action for the nurse the health and healing of a client come from many components, including spirituality, religion, folk remedies, alternative therapies, and modern medicine. Unless something is harmful to the client, it is best incorporate all components into the care of the person. 3. The client and family have requested the curandero. Asking him to leave would be insulting. The nurse would not develop a good rapport with the client this way. 4. This does not take into account the client's beliefs in health, wellness, and illness. The nurse should work to incorporate folk medicine from the curandero as long as it will not harm the client.

The nurse notices that the primary healthcare provider walks away from the computer work station without logging out of the system, leaving a page of client medical information visible. What is the appropriate action by the nurse? 1. Log the primary healthcare provider off the facility's health information system. 2. Minimize or hide the screen so that the client information is no longer visible and inform the primary healthcare provider. 3. The nurse should do nothing because the primary healthcare provider is responsible for information accessed on the hospital's health information system. 4. The nurse should attempt to determine if the primary healthcare provider was finished.

A: 2 Rationales 1. Simple logging the other person off the computer system could be a correct option if that person cannot be found but if it is professional to discern if they will be returning. 2. It is appropriate and polite to initially minimize or hide the screen so that the information is no longer visible and then inquire whether the user will be returning to the computer work station. 3. Professionally remind them that they did not log out and left client information visible to unauthorized persons. 4. Better to ask primary healthcare provider if finished.

Which nursing action would be appropriate for the LPN to perform when working in an HIV/AIDS hospice setting? 1. Assessing for signs of secondary opportunistic infections. 2. Collecting data regarding response to pain medications. 3. Teaching the UAP about nutritional needs of HIV/AIDS clients. 4. Assisting clients with personal hygiene needs.

A: 2 Rationales 1. The nursing process, including assessment, requires a higher level skill set and should be carried out by the RN. 2. Data collection regarding response to pain medication is within the scope of practice of the LPN. 3. The development of a teaching plan and teaching are also aspects within the role of RN and should not be delegated or assigned to the LPN. The LPN, however, can reinforce teaching as needed. 4. Activities such as assisting clients with personal hygiene needs can be carried out by a lower level staff (UAP) and therefore, should not be delegated to the LPN.

A schizophrenic client tells the nurse, "The president of the just told me to leave the hospital immediately because a spy is on the way to tap into the secret information in my brain." What is the nurse's best response? 1. The voice you heard is because of your illness and will go away in time. 2. I know you think the President of the United States is talking to you, but I do not see the President. We are the only ones here. 3. I find it hard to believe that you have talked to the President of the United States. This is not the White House! 4. I think the primary healthcare provider needs to increase you medication dose, since you are still hearing voices.

A: 2 Rationales 1. This response gives reassurance. In fact, it is false reassurance because the voices may not completely go away. Remember that the client believes what they think is real. You are not going to help them by blaming it on their illness. 2. The correct answer is to present reality. When a client has a misperception of the environment, the nurse defines reality or indicates his or her perception of the situation to the client. This delusion is called "thought withdrawal". It is the belief that thoughts have been removed from one's mind by an outside agency. 3. This response is disagreeing. Never challenge the client or belittle the client with your response. 4. This response gives an opinion and does not bring reality into the conversation. You need to report the hearing of voices, to the primary healthcare provider, but this is not therapeutic for the client.

A client with schizophrenia tells the nurse, "The President of the United States just told me to leave the hospital immediately because a spy is on the way to tap into the secret information in my brain." What should the nurse tell the client? 1. "The voice you heard is because of your illness and will go away in time." 2. "I know you think the President of the United States is talking to you, but I do not see the President. We are the only ones here." 3. "I find it hard to believe that you have talked to the President of the United States. This is not the White House." 4. "I think the primary healthcare provider needs to increase your medication dose, since you are still hearing voices."

A: 2 Rationales 1. This statement gives false reassurance. 2. The correct answer is presenting reality. When a client has a misperception of the environment, the nurse defines reality or indicates his or her perception of the situation to the client. 3. This is disagreeing. 4. This gives an opinion.

Which electrolyte imbalance would be the nurse's priority concern in the burn client? 1. Hypernatremia 2. Hyperkalemia 3. Hypoalbuminemia 4. Hypermagnesemia

A: 2 Rationales 1. Well this one does occur when the client becomes so dehydrated, but it's not as dangerous as the potassium one. 2. Good job, when the cells lyse they release their potassium and then the serum potassium goes up! And if the kidneys stop...we are in real trouble! 3. Low albumin can sure cause some problems with keeping the fluids in the vascular space, but wait a minute. Is albumin an electrolyte? And just how dangerous is this low albumin for the burn client. No. 4. No, the magnesium doesn't go up unless the kidneys shut down-not a burn thing.

The nurse is conducting a health history with a client who is 10 weeks pregnant. During the interview, the client states, "I'm not so sure I'm really happy about this pregnancy". Which response by the nurs is most appropriate? 1. Many women feel ambivalent about being pregnant. 2. Tell me more about how you are feeling. 3. Why do you feel this way? 4. It seems there is never a good time to get pregnant.

A: 2 Rationales 1. While it is true that ambivalence about pregnancy is normal, the client should be afforded the opportunity to explore the interwoven feelings of wanting and not wanting to be pregnant. 2. Use of the open ended statement provides the client an opportunity for clarification of her feelings, ideas and perceptions. 3. Asking "why" questions can put the client in a defensive position and is not therapeutic. 4. This response reflects a personal opinion and may be irrelevant for this client.

A nurse is preparing to insert a nasogastric tube. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What is the client most likely experiencing? 1. Hyperventilation 2. Panic disorder 3. Somatization 4. Conversion disorder

A: 2 Rationales 1. A client experiencing hyperventilation would exhibit rapid respiratory rate, and tingling of lips and/or hands. Hyperventilation may occur with a panic attack but the best answer is option 2. 2. These are all signs of panic disorder. Additional s/s include: sweating, feeling of choking, chest discomfort, abdominal distress, dizziness, lightheadedness, faintness, feelings of unreality or being detached from self, fear of losing control, fear of dying, paresthesias, chills or hot flashes. 3. Somatization is the process by which psychological needs or stress are expressed in the form of physical symptoms. These reports of signs and symptoms are usually several years in duration. 4. Conversion disorder is a psychological disorder with symptoms or deficits affecting motor or sensory function that mimic a neurological or general medical disease.

A client, hospitalized for a respiratory infection, must leave the room for a test procedure. What intervention is appropriate for the nurse o perform so that spread of infection is less likely? 1. Ask the primary healthcare provider if the test can be performed in the room. 2. Ask the client to wear a mask when out of the room. 3. Make sure that all staff wear masks when providing care. 4. No special precautions are needed.

A: 2 Rationales 1. Not all tests may be performed in the room. There is a way to lessen spread of infection. 2. The client should wear a mask when out fo the room to prevent spread of droplets when coughing or sneezing. 3. Staff should weak masks while performing care; however, the client should wear the mask if out of the room. 4. Special precautions are needed to prevent spread of infection via droplets.

The nurse is caring for a client on the post surgical unit. What should the nurse know about short term treatment of post op pain? 1. There are no concerns about addiction from pain medications following surgery. 2. Pain control following surgery rarely results in addiction. 3. The opioid medications typically result in addiction. 4. The primary healthcare provider will not prescribe an addictive medication.

A: 2 Rationales 1. There are slight concerns about addiction with administration of opioids; however, it is usually not a concern for the majority of post op clients with short term use in the hospital. The nurse should use alternative methods for providing relief as well. Guided imagery, massage, gradual ambulation, are just a few examples. 2. When a person is in acute pain following surgery, the risk of addiction to pain medication is rare. The key is to provide the medication over a short period of time to get the client past the initial pain of surgery. Remember the client will be ambulation early ambulation and non pharmaceutical comfort measures should also be provided by the nurse to decrease the need for narcotics as client recovery continues. 3. Use of opioids may result in addiction; however, research shows that only a small percentage of the population is prone to addiction. The goal of postoperative pain management is to relieve pain while keeping side effects to a minimum. This is often best accomplished with a multimodal approach. 4. Opioids are potentially addictive; however, they serve a very useful purpose in the treatment of short-term post-op pain.

A client with a history of myasthenia gravis (MG) has been discharged from the hospital following a thymectomy. When reinforcing teaching with the client on how to prevent complications, the nurse emphasizes what daily actions are most important? 1. Include daily weight lifting exercises. 2. Practice stress reduction techniques. 3. Complete chores early in the day. 4. Take medications on time and prior to meals. 5. Eat three large meals daily.

A: 2, 3, 4 Rationales 1. Reinforcement of teaching for clients with myasthenia gravis would include gentle daily exercise combined with periods of rest throughout the day. Weight lifting would be too strenuous and would quickly tire this client, possibly leading to a myasthenia crisis. 2, 3, 4. Myasthenia gravis is a chronic autoimmune disorder characterized by progressive muscle weakening and chronic fatigue. Clients become weaker throughout the day, contributing to the potential for complications. Stress reduction techniques are important since stress can contribute to a myasthenic crisis, a severe respiratory emergency. Daily tasks, including ADL's, should be completed early in the day when the client has he most energy. Medications for MG, including neostigmine and pyridostigmine, must be taken on time and prior to meals. 5. Because of the difficulty in chewing or swallowing, multiple small meals throughout the day are safer and more beneficial to a client with myasthenia gravis. Medications are timed in relation to meals, so consistent but smaller meals would be more beneficial for the client.

A nurse is working with community officials to decrease the incidence of violence in the community. Which primary preventive measures might the nurse suggest? 1. Provide a safe haven for victims of violence. 2. Provide educational programs about types of violence. 3. Form a neighborhood watch program. 4. Develop a media campaign identifying risk factors of potential abuse. 5. Provide for the immediate removal of a victim of violence form the home.

A: 2, 3, 4 Rationales 1. This is a true statement but it not a preventive measure. This does not prevent violence from occurring; it is an intervention to decrease the change of future violence making it tertiary prevention. Tertiary prevention aims to soften the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often complex health problems and injuries (e.g. chronic diseases, permanent impairments) in order to improve as much as possible their ability to function, their quality of life and their life expectancy. Examples include: cardiac or stroke rehabilitation programs, chronic disease management programs (e.g. for diabetes, arthritis, depression, etc.); support groupies that allow members to share strategies for living well; vocational rehabilitation program to retrain workers for new jobs when they have recovered as much as possible. 2, 3, 4. There's are all appropriate interventions for the nurse to suggest to the community. The key is prevention. The nurse is teaching ways to prevent violence before it occurs. Primary prevention is true prevention. Primary prevention aims to prevent disease or injury before it even occurs. This is done by preventing exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury should closure occur. Examples include: legislation and enforcement to ban or control the use of hazardous products (e.g. asbestos) or to mandate safe and healthy practices (e.g. use of seatbelts and bike helmets); education about healthy and safe habits (e.g. eating well, exercising regularly, not smoking); immunization agains infectious diseases. 5. This is not a primary preventive measure but a secondary preventive measure. Removing the victim is not preventing primary violence but additional violence. Secondary prevention aims to reduce the pact of a disease or injury that has already occurred. This is done by detecting and treating disease or injury as soon as possible to halt or slow its progress, encouraging personal strategies to prevent re-injury or recurrence, and implementing programs to return people to their original health and function to prevent long-term problems. Examples include:regular exams and screening tests to detect disease in its earliest stages (e.g. mammograms to detect breast cancer); daily, low-dose aspirin and/or diet and exercise programs to prevent further heart attacks or strokes; suitably modified work so injured or ill workers can return safely to their jobs.

A nurse is calling the primary healthcare provider about a client who is experiencing a migraine. Which statements by the nurse are appropriate according to the communication tool SBAR (situation, background, assessment and recommendation)? 1. "Hello Dr, I am calling about one of your clients.' 2. "Jane Doe is reporting a migraine." 3. "Jane Doe was admitted two days ago. Pulse is 92, BP152/80, resp 22." 4. "From the data collection, she states she has a hx of migraines and is prescribed sumatriptan for relief." 5. "I recommend that she receive a dose of sumatripten. Do you agree?"

A: 2, 3, 4, 5 Rationales 1. The nurse should identify the primary healthcare provider by name and should then identify self, the agency the nurse is calling from and the client by name. For instance: "Dr. Smith, this is nurse Adams, RN. I am calling about your client, Jane Doe, at ABC hospital." 2, 3, 4, 5. First, the nurse should identify self, agency, and client calling about. Then deliver SBAR. The situation, background, assessment and recommendation (SBAR) technique has become the Joint Commission's stated industry best practice for standardized communication in healthcare, effortlessly structuring critical information primarily for spoken delivery. Each of these statements fulfills appropriate SBAR requirements.

A client with a T4 lesion suddenly reports a severe, pounding headache. Profuse diaphoresis is noted on the forehead. The blood pressure is 180/112 and the heart rate is 56. What intervention should the nurse initiate? 1. Place the client supine with legs elevated. 2. Assess bladder and bowel for distention. 3. Examine skin for pressure areas. 4. Eliminate drafts. 5. Remove triggering stimulus. 6. Administer Apresoline if BP does not return to normal.

A: 2, 3, 4, 5, 6 Rationales 1. The client should be placed immediately in a sitting position to lower blood pressure. 2, 3, 4, 5, 6. This phenomena is called autonomic dysreflexia. The cause of symptoms is a noxious stimulus and must be promptly treated.

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

A: 2, 4 Rationales 1. Precautions should be instituted and a stool sample sent for any client with persistent diarrhea. Isolation should be in placed with suspected c. Diff. 2, 4. Contact isolation will be needed to prevent the spread of infection. So 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. 3. 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. Medications to stop diarrhea will not be prescribed with c. Diff, because they cause even further irritation.

The nurse is caring for a client diagnosed with Addison's disease. Which finding would indicate to the nurse that a client has received excessive mineralocorticoid replacement? 1. Oily skin 2. Weight gain of 4 pounds in one week 3. Loss of muscle mass in extremities 4. Blood glucose of 58 mg/dL 5. Serum potassium of 3.2 mEq

A: 2, 5 Rationales 1. Oily skin would be seen with an increase in sex hormones such as testosterone such as testosterone and estrogen. Oily skin is not common with mineralocorticoids like aldosterone. 2, 5. Remember that aldosterone is a mineralocorticoid, which causes the client to retain sodium and water. Retaining sodium and water will cause the client's weight to increase. Also remember, any sudden gain in weight is due to water retention. Too much aldosterone makes you retain too much sodium and water and lose potassium. Normal potassium is 3.5-5.0 mEq/L, so a lowering of potassium could indicate high levels of aldosterone. 3. Too many glucocorticoids will cause the breakdown of protein and fat but muscular weakness and increased fatigue is seen with too little mineralocorticoids. 4. Too many glucocorticoids will inhibit insulin, causing the serum blood glucose level to go up. Normal blood glucose is 70-110.

Which tasks can the nurse assign to the unlicensed assistive personnel (UAP)? 1. Reporting lab results to the client 2. Measuring intake and output 3. Discontinuing an IV 4. Discussing client condition with the client's spouse 5. Performing oral hygiene for an older adult

A: 2, 5 Rationales 1. Reporting of lab results should be accomplished by the nurse who as the knowledge to interpret results. This is not appropriate for the UAP and must be done by a licensed nurse. 2, 5. Measurements of intake and output and oral hygiene for the older client are tasks that the UAP can perform, and these tasks may be assigned. 3. Removal of the IV requires assessment skills that the unlicensed assistive personnel does not have. 4. Discussion of client's condition should be done by the nurse with the client's permission.

A client who is one day postpartum has the following lab results. Which lab value should the nurse report to the charge nurse immediately? 1. Hemoglobin of 11 gm/dL 2. White blood cell count of 22,000 mm3 3. Hematocrit of 18 percent 4. Serum glucose of 80 gm/dL

A: 3 Rationales 1. A hemoglobin of 11 gm/dL is considered to be normal for pregnancy and postpartum. 2. It is not unusual for a postpartum woman to have a WBC up to 25,000 mm3 without infection because of the healing process of the reproductive system. 3. A hematocrit in postpartum women can drop as low as 20% and not require transfusion in the absence of symptoms of hypovolemia. A hematocrit of 18% and lower should be reported even in the absence of dizziness, lightheadedness, shortness of breath with exertion, and syncope. 4. Serum glucose of 80 gm/dL is within the normal range of glycemic control.

The nurse is caring for the post-operative client who underwent urinary diversion surgery. In the immediate post-operative period, which nursing intervention would be most appropriate? 1. Relieving anxiety related to altered toileting habits. 2. Implementing a low-residue diet which is low-fiber. 3. Administering analgesic medications. 4. Encouraging client participation in wound and stoma care.

A: 3 Rationales 1. Relieving anxiety is an appropriate intervention for a client having urinary diversion surgery but should be implemented following the initial post-operative period. 2. A low-residue diet is appropriate during the pre-operative period for client who will have urinary diversion surgery. 3. Analgesic medications are administered liberally during the initial post-operative period to relieve pain and promote comfort to allow client to turn, cough and deep breathe. 4. In the initial post-operative period where the client may be drowsy or in pain the client should not begin participating in would and stoma care.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Clean client's Hal fixation insertion sites with hydrogen peroxide. 2. Insert acetaminophen suppository in client's rectum. 3. Reapply pneumatic compression device to client's legs. 4. Check client's gag reflex prior to feeding. 5. Set up suction equipment in client room. 6. Reposition client every 2 hours.

A: 3, 5, 6 Rationales 1. The UAP can provide routine hygiene. The nurse would be responsible for wound care, including halo insertion pin site care. This requires skill beyond the UAP's knowledge. 2. The UAP cannot administer medications. 3, 5, 6. The UAP is trained on use of routine equipment such as pneumatic compression devices and can reapply the device to a client. Gathering needed equipment and supplies is within the scope of duties for the UAP. Repositioning a client every 2 hours is within the UAP's ability and can be assigned by the nurse. 4. The UAP cannot assess or evaluate a client. The RN must do this part of the nursing process.

The nurse is preparing to perform nasopharyngeal suctioning on a client who has been admitted to the hospital for a respiratory infection. The nurse applies a sterile glove on her dominant hand and a non-sterile glove on the non-dominant hand. What is the rationale for this intervention? 1. The procedure is not a sterile one. 2. The nurse should have used sterile gloves on both hands. 3. The non-sterile glove keeps the nurse's hands from contamination by the client secretions. 4. The sterile hand is used to apply the suction.

A: 3 Rationales 1. The catheter should be sterile upon beginning the suctioning. 2. Sterile gloves may be used; however, the nurse is this station is using a non-sterile glove to protect herself from contaminated secretions. 3. The non-sterile glove keeps the nurse from getting secretions on her hands. 4. The non-sterile gloved hand is used to apply the suction but this is not the rationale for why a non-sterile glove is used.

Which food item would the nurse include when planning diet instructions to promote bone growth for a client with a broken tibia? 1. Lettuce 2. Apples 3. Yogurt 4. Green beans

A: 3 Rationales 1. The serving size 50 g of lettuce has a calcium content of 19 mg. 2. The serving size of 182 g of apple has a calcium content of 11 mg. 3. The serving size of 150 g of yogurt has a calcium content of 240 mg. 4. The serving size of 90 g cooked green beans has a calcium content 50 mg.

The nurse is reinforcing instructions for a client diagnosed with salmonellosis about how to decrease the transmission to others. Which statement by the nurse would require follow up? 1. "I will wash my hands after feeding pets." 2. "I will use a meet thermometer to cook food to safe temperature." 3. "I will clean my hands with water before handling food." 4. "I will use disposable dishes until infection free."

A: 3 Rationales 1. This statement indicates the patient understands teaching. The client should wash hands after contact with animals, their food or treats, and their living environment. 2. A meat thermometer should be used to ensure foods are poked properly. Undercooked meat and unpasteurized milk is a source for the organism. 3. Salmonellosis is caused by the bacteria salmonella. Hands should be washed with soap and warm water. Only washing with water is not correct and requires the nurse to do further teaching with the client. 4. Disposable dishes help prevent the spread of infection. It prevents the organism from being transferred on dirty dishes.

The nurse is discussing information on adolescent obesity with parents of high-school students. What statement by the nurse is most comprehensive regarding obesity among teens? 1. Obesity among teen is often accompanied by psychologic issues like poor self-esteem. 2. Weight issues among teens are often due to excess eating out of boredom or stress. 3. Adolescent obesity is usually an inability to recognize signals of hunger or satiety. 4. Undiagnosed problems of the thyroid or pituitary contribute to teen obesity.

A: 3 Rationales 1. Through self-esteem or concern about physical appearance is common with adolescents, it is not necessarily a cause for obesity. 2. Weight issues are often related to an imbalance between caloric intake and energy expenditure. While adolescent frequently snack on high-calorie junk foods in response to stress or boredom, there are more significant contributing factors for teen obesity. 3. While all the options could be true in some cases, the most accurate and comprehensive basis for obesity is an individual's failure to recognize, or acknowledge, signals of hunger or satiety. Neural circuitry, along with specific body hormones, drives sensations of hunger and feeling satisfied. Adolescents experience fluctuating hormones, physical changes and emotional adjustments which can disrupt body functions, including recognition of brain signals. 4. It is possible that undiagnosed issues of the thyroid or pituitary could contribute to adolescent obesity. However, these disorders are not common and might also lead to extreme weight loss.

The nurse is reinforcing client education about timolol maleate. What should the client know about the newly prescribed timolol maleate eyedrops for glaucoma? 1. The medication works by causing the pupils to constrict. 2. The medication will dilate the canals of Schlemm. 3. This medication decreased the production of aqueous humor. 4. The medication improves ciliary muscle contraction.

A: 3 Rationales 1. Timolol does not constrict pupils. 2. Timolol does not dilate the canals of Schlemm. 3. Timolol does decrease aqueous humor formation; therefore decreasing intraocular pressure (IOP). 4. Timolol does not cause ciliary muscle contraction.

A nurse is caring for an elderly client being started on aa tricyclic antidepressant. The nurse is aware that the medication requires monitoring of which body system? 1. Endocrine 2. Nervous 3. Circulatory 4. Digestive

A: 3 Rationales 1. Blood glucose levels may become elevated while using this category of antidepressants, but hyperglycemia can be treated and controlled if the client responds well to the medication. This is not of greatest concern to the nurse. 2. Tricyclics increase body levels of norepinephrine and serotonin, and the client may experience drowsiness or ever blurred vision. The nurse will teach the client about safety precautions prior to discharge, but this is not the chief concern. 3. Tricyclic antidepressants can cause arrhythmias, changes in heart rate, and blood pressure fluctuations including orthostatic hypotension. A client's cardiovascular status should always be evaluated prior to starting this category of medication to determine the presence of pre-existing cardiac conditions. 4. Although tricyclic antidepressant medication may increase appetite, abuse constipation and weight gain, these are expected side effects and not of major concern.

What vitamin is important in preventing peripheral neuritis in a client with alcohol abuse? 1. Vitamin D 2. Fat soluble vitamins 3. B vitamins 4. Potassium

A: 3 Rationales 1. Not vitamin D 2. While the liver is affected, so fat soluble vitamins are affected, the peripheral neuritis is related to the B vitamins. 3. Yes! Is the B vitamins 4. Potassium is an electrolyte.

What action should the nurs take when collecting data about a client's near vision? 1. Have client read a Snellen chart from 20 feet away. 2. Have client read Ishihara plates at 30 inches (75 cm). 3. Have client read a newspaper at 14 inches (36 cm). 4. Have client alternate gaze from a near object to a distant object.

A: 3 Rationales 1. The Snellen chart is used to test distant vision. To test distance vision, individuals stand 20 feet from the Snellen eye chart, cover one eye, read aloud the smallest line they can clearly see, and then repeat this process with the other eye. After performing an eye test, a person's visual acuity is written as a fraction. Normal vision is defined as 20/20 visual acuity, which means at 20 feet away from the eye chart, the person is able to read the line that most human beings with normal vision can read at 20 feet away. 2. Ishihara plates are used to assess color blindness, and are not used to test near vision. 3. The nurse can get a general idea of near visual acuity by asking the client to read from a newspaper. The newspaper should be held 14 inches form the eyes. This exam can also be done with the Jaeger chart containing a few short lines or paragraphs of printed text. The size of the print gradually gets smaller. The client is asked to hold the card about 14 in. (36 cm) from the face and re aloud the paragraph containing the smallest print he/she can comfortably read. Both eyes are tested together, with and without corrective lenses. This test is routinely done after age 40, because near vision tends to decline as one ages (presbyopia).

An LPN is taking vitals on an infant diagnosed with Tetralogy of Fallot. The mother asks why the baby seems so fatigued and turns blue when crying or feeding. What is the best explanation by the LPN? 1. "Your child has less blood flowing from the heart to the body." 2. "More protein and vitamins should be added to the daily diet." 3. "The heart is not pumping enough blood to oxygenate blood tissues." 4. "Increased daily activity can help increase strength and endurance."

A: 3 Rationales 1. The amount of blood flow is not diminished, but rather it's the quality of the blood that is the problem. The blood is unoxygenated and therefore the body does not receive enough oxygen to meet activity needs. 2. Episodes of cyanosis with exertion are common in children diagnosed with Tetralogy of Fallot. However, the amount of protein or vitamins in the child's diet will not correct this issue, since the cause is related to oxygenation and not diet. 3. This statement offers the mother a simple but accurate explanation without being overwhelmingly technical. It is also presented in the open-ended format, allowing the mother to ask additional questions, or express concerns. 4. Simple activities actually increase periods of cyanosis, which is related to the amount of oxygenated blood available during exertion. Increasing activity prior to surgical repair of the heart decrease endurance or tolerance.

An 8-year-old smiles when mom places the "B" paper on the refrigerator. Which Erikson development stag is this child displaying? 1. Autonomy vs. Shame and Doubt 2. Initiative vs. Guilt 3. Industry vs. Inferiority 4. Identity vs. Role Confusion

A: 3 Rationales 1. This should be accomplished in early childhood, 2-3 years. Children need to develop a sense of personal control over physical skills and a ease of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt. 2. This is Preschool 3-5 years. Children need to begin asserting control and power over the environment. Success in this stag leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt. 3. Children need to cope with new social and academic demands. Success leads to sense of competence, while failure results in feelings of inferiority. 4. This stage is for the adolescent, age 12-18. Teens need to develop a sense and personal identity. Success leads to an ability to sty true to yourself, while failure leads to role confusion and a weak sense of self.

The nurse is preparing to administer a dose of sacubitril/valsartan 24/26 mg by mouth. The nurse has not administered this medication before and is using a drug reference to review information about the medication. Which client and drug reference information supports the nurse's decision to withhold the sacubitril/valsartan? 1. Bilateral crackles noted to posterior lung fields. 2. Potassium - 4.8 mEq/L (4.8 mmol/L). 3. Currently taking trandolapril 2 mg by mouth daily. 4. Concomitant use or use within 36 hours of ACE inhibitors. 5. ACE inhibitors increase risk of angioedema. 6. Decreased hematocrit.

A: 3, 4, 5 Rationales 1. Bilateral crackles noted to posterior lung fields. 2. Potassium - 4.8 mEq/L (4.8 mmol/L). This is within normal limits and would not require withholding the sacubitrin/valsartan. 3, 4, 5. This client is currently taking trandolapril, which is an ACE inhibitor. The drug reference guide specifically said, "concomitant use (of sacubitril/valsartan) or use within 36 hours of ACE inhibitors" is contraindicated because giving with ACE inhibitors can increase the risk of angioedema. 6. This client's hematocrit is 43%, which is normal. Normal values: adult males: 42-52% (0.42-0.52). Adult women: 37-47% (0.37-0.47). Therefore, this would not influence the administration of the sacubitril/valsartan.

The nurse is reviewing morning laboratory results for multiple clients. Which client laboratory results should the nurse immediately report to the healthcare provider? 1. Client with chronic obstructive disease (COPD) and a PCO2 of 50 mmHg. 2. Diabetic client with fasting blood sugar of 145 mg/dL (8.0 mmol/L). 3. Cardiac client on furosemide with potassium of 3.1 mEq/L (3.1 mmol/L). 4. Client with sepsis and total white blood cell count of 16,000 mm3. 5. Client following a thyroidectomy with calcium level of 8.0 mg/dL (2 mmol/L).

A: 3, 5 Rationales 1. While this client's PCO2 of 50 is elevated (normal is 35-45 mmHg), this is neither unexpected or unusual for an individual with COPD. This client will frequently experience elevated levels of PCO2; therefore, the nurse should just continue monitoring for any changes in respiratory status. 2. This diabetic client has a fasting blood sugar fo 145, which is elevated above normal levels of 70-110. However, it is not uncommon for diabetics to occasionally have elevated glucose levels, even early in the morning. The nose can address this issue by referring to the sliding scale for insulin administration. This does not need to be reported immediately to the primary healthcare provider. 3, 5. Although all the laboratory results are outside of standard accepted levels, two particular clients are the most concerning. The cardiac client's potassium level of 3.1 is extremely concerning, since normal potassium levels should be between 3.5-5.0 mEq/L. Hypokalemia can cause muscle weakness and heart arrhythmias, such as PVC's. Secondly, after the client's thyroidectomy, their calcium level is 8.0 mg/dL (normal 9.0-10.5 mg/dL), indicating possible removal of parathyroid glands. Because hypocalcemia places the client at risk for seizures or laryngospasms as well as arrhythmias, the primary healthcare provider needs to be notified immediately so that corrective therapy can be initiated. 4. It is expected that clients diagnosed with sepsis will have extremely elevated white blood cell counts. Despite the fact that this lab resulting outside of normal values (4,500-10,000 mm3), this level is not concerning enough to immediately contact the primary healthcare provider.

The RN, LPN/VN, and unlicensed assistive personnel (UAP) are providing care for clients on the nursing unit. Which tasks could be completed only by the RN? 1. Administration of routine medications. 2. Dressing changes. 3. Assessment of newly admitted clients. 4. Calling primary healthcare provider about lab results. 5. Teaching the diabetic client foot care.

A: 3, 5 Rationales 1. Medication administration is within the LPN/VN scope of practice can be completed by the LPN/VN. 2. Dressing changes may be delegated to the LPN/VN as this is within the LPN/VN scope of practice. 3, 5. Admission assessments and teaching must be performed by the RN. The nursing process, along with teaching are outside the scope of practice of the LPN/VN. These are tasks that must be performed by the RN. The LPN/VN can reinforce teaching. 4. The LPN/VN may call lab results to the primary healthcare provider because this is within the scope of practice for the LPN/VN. If any additional prescriptions are required, the LPN/VN can't are these prescriptions over the phone.

A client with schizophrenia is admitted with a bowel obstruction, and a nasogastric (NG) tube is inserted. The client describes the pain as a 7/10. What would be the appropriate action by the nurse? 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

A: 4 Rationales 1. No they have real cause for pain, give them some pain medication. 2. Not necessary, it will sedate them, but not help the pain. 3. Not necessary. 4. Psychiatric clients have physiological problems too!

The nurse is reinforcing instructions for the spouse of a home care client recently diagnosed with Alzheimer's Disease. The nurse acknowledges that previous teaching was successful when the spouse makes what statement? 1. "Activities that provide stimulation will help to reorient my spouse." 2. "With medications and therapy, my spouse will begin to improve." 3. "Keeping the rooms dark and quiet will be calming for my spouse." 4. "As this disease progresses, I need to review safety issues at home."

A: 4 Rationales 1. Stimulating visual or auditory activities generally increase confusion and agitation in clients with Alzheimer's Disease because they cannot process the input fast enough. This statement by the spouse would indicate to the nurse that initial teaching was not successful. 2. Alzheimer's Disease is progressive until the ultimate outcome of death. Although medications have been developed that may have slow the progress of the disease, Alzheimer's is not reversible. This response by the spouse indicates that prior teaching was not effective, and further instruction is needed. 3. While a stimulating environment is not beneficial to the Alzheimer's client, a darkened environment can similarly create confusion and agitation. The effect, referred to as Sundowner's Syndrome, is characterized by an increase in hallucinations, confusion or agitation that occurs at night. Keeping rooms darkened would create the impression of nighttime, likely increasing client's anxiety or agitation. This statement by the spouse would alert the nurse that learning did not occur and that teaching needs reinforced. 4. Alzheimer's Disease is a progressive disorder characterized by declining mental abilities severe enough to interfere with activities of daily living. Clients demonstrate a deterioration in memory, language, judgement and behaviors. An LPNVN cannot initiate teaching but can re-evaluate that learning has been successful following the initial teaching by an RN. The client's spouse indicates understanding the importance of safety as the disease progresses, demonstrating to the nurse the previous teaching was successful.

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."

A: 4 Rationales 1. 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. Telling the family that things will be fine and to give themselves time are trite assurances and cliches that should be avoided by the nurse. Instead, you should use therapeutic responses that promote the expressions of grief by the family. 3. Again, by telling them to try not being upset in front of the dying family member, this is not demonstrating care and compassion to their family members who are grieving. This would be a barrier to assisting them to communicate and express their feelings of grief. 4. 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.

Upon admission to the hospital, a client declines to be listed in the facility directory. While charting at the nursing station, the LPN answers a phone call requesting information about this client. What is the most important appropriate response by the LPN? 1. "I will transfer your call to our admissions department." 2. "I cannot provide that information over the telephone." 3. "You will need to get permission from the person first." 4. "There is no record of that individual at our facility."

A: 4 Rationales 1. Transferring the call to admissions does not address the fact the client wishes to remain anonymous. This actually infers the client is in the facility, thus violating the client's privacy rights. 2. Although this response by the LPN is accurate, it also implies the client has been admitted to the facility. Such as comment violates the client's right to remain anonymous. 3. Again, this explanation by the LPN suggests the client is indeed in the facility and therefore violates privacy regulations and rights. 4. Hospitalized clients have the right to be excluded from a facility's directory and remain anonymous for the duration of stay. This statement by the LPN may seem untruthful but in fact the LPN is stating a true fact: that the individual is not listed in the hospital client directory.

A client arrives at the crisis center and reports stopping daily lithium because of pregnancy. What response by the nurse is most accurate? 1. "Are you positive that you are actually pregnant?" 2. "Lithium is perfectly safe throughout pregnancy." 3. "The psychiatrist can change you to another medication that is safe." 4. "It may be worse to suddenly stop the medication than to take the medication."

A: 4 Rationales 1. While this is a valid question by the nurse, there is a greater concern at this point. The client's pregnancy status can be verified at any time. 2. This statement by the nurse is not correct. Specific birth defects have been attributed to the use of lithium during pregnancy. 3. The psychiatrist would need to be notified that client has stopped the medication. However, there are very few medications for bipolar disorder that would also be completely safe during pregnancy. 4. Lithium is most often used to treat manic-depression. Suddenly stopping the medication could cause the client to relapse, experiencing worse symptoms than previously. It may also be more difficult to get those symptoms under control again if the client has stopped this drug suddenly. The client and primary healthcare provider would need the weight the benefits of the medication vs the possible birth defects attributed to the use of lithium during pregnancy.

The nurse is repositioning a client who is in the supine position to the right lateral position. Which nursing intervention would be implemented to position the client in the right lateral position? 1. The right leg is positioned on a pillow in front of the left leg. 2. Both need are kept in the extension position. 3. Both feet are placed in the inversion position. 4. The left shoulder be positioned forward.

A: 4 Rationales 1. The right leg is positioned forward in the left lateral position. For the right lateral position, the left leg is positioned on a pillow in front of the right leg. 2. Both legs should not be extended for the right lateral position. The left leg should be positioned forward with the knee flexed to decrease the internal rotation of the femur. 3. Inversion of the feet is described as positioning the ankles toward the midline of the body. The feet should be positioned in the neutral position to maintain proper ankle alignment. 4. The left shoulder should be addicted. The position of adducting the shoulder forward promotes improved chest expansion and decreases strain on the shoulder.

A nurse is to administer a time release capsule to a client who has difficulty swallowing. Which intervention would be the best course of action for the nurse to take? 1. Open the capsule and sprinkle it on applesauce. 2. Melt the capsule in juice or water. 3. Notify the charge nurse. 4. Break the capsule in half using a pill splitter.

A:3 Rationales 1. Sprinkling the medication over applesauce or pudding may be the only option the nurse has if there is no other form, but since this medication is time-released, the best answer and priority would be to get a liquid form, if available, for the drug. 2. Never melt a time release capsule or tablet as this would release the medication all at once. 3. If the client has difficulty swallowing a capsule or tablet, the charge nurse ask the primary healthcare provider to substitute a liquid medication if possible. 4. Breaking or splitting would also release the medication in blouses and could cause harm to the client.

The family of an elderly woman is concerned that their mother is not getting restful sleep. As a result, the family members' sleep is disturbed. Which questions would be important for the nurse to ask? 1. Has there been any change in your mother's state of health? 2. Can family members take naps during the day? 3. Does she take routine diuretics? 4. Has there been an increase in noise level? 5. Can the family take turns in managing the mother's sleep problems?

ANS: 1, 3, 4 Rationales 1, 3, 4. There may be a physical reason for the difficulty sleeping, perhaps pain or presence of an infection. Diuretics should be scheduled early in the day so as not to interfere with sleep. Perhaps there has been a change in medication schedule. Changes in the sleep environment, such as an additional TV in the home or other noise, may impact sleep. 2. This may be necessary; however, the nurse is working toward helping the mother of the family to sleep better. 5. The family may Neto do this over time; however, the focus is to help the mother of the family to sleep better.

In what order should the nurse address these client events that occur at the same time? Place in order of highest to lowest priority. 1. Client who is on bed rest due to a deep vein thrombus attempting to get out of bed. 2. The water seal chamber is empty in a client's closed chest drainage unit. 3. UAP reports a heart rate of 40/min in a client. 4. Client reporting urinary frequency and dysuria. 5. Client's tracheostomy needs to be suctioned.

Correct order: 1. UAP reports a heart rate of 40/min in a client. 2. Client who is on bed rest due to a deep vein thrombus attempting to get out of bed. 3. The water seal chamber is empty in a client's closed chest drainage unit. 4. Client's tracheostomy needs to be suctioned. 5. Client reporting urinary frequency and dysuria. Rationales 1. The first client that should be seen is the client with a tracheostomy that needs to be suctioned. This client has an airway problem. Maintaining a patent airway is vital to life and is always the first priority. 2. The next client to be seen in the client whose water seal chamber is empty which prevents the CDU from being a closed system. This can creat a breathing problem. The purpose of the water seal chamber is to low air to escape from the pleural space and yet prevent air from re-entering the pleural space. It is a one-way system. The water should be at the prescribed level (2 cm) to maintain this one-way water seal. If air is allowed to re-enter the pleural space, the lung can collapse again (pneumothorax). Once the other client's airway is suctioned, this would be the next priority. 3. The third client to be seen is the client with a heart rate of 40/min which may be affecting cardiac output. This is a circulatory problem. Circulation follows airway and breathing in priority setting. 4. The fourth client to be seen is the client on bed rest for a DVT. If the client gets up and ambulated, the clot can break lose and form an embolus. Although this could potentially be dangerous, it does not take priority over airway or circulatory issues that exist. 5. The fifth client would be the one reporting frequency and dysuria. This client does not have a life-threatening problem. Therefore, this would be the lowest in priority from the events presented.

When caring for a client admitted with a diagnosis of pheochromocytoma, which finding would indicate the client has elevated levels epinephrine and norepinephrine? 1. Headache 2. Hypotension 3. Bradycardia 4. Polycythemia

A: 1 Rationales 1. This disease is characterized by a headache, hypertension, tachycardia, hypermetabolism and hyperglycemia due to the increased release of epinephrine and noreppinephrine. 2. Hypertension, rather than hypotension, would be seen in this client. 3. The heart rate will increase rather than decrease. 4. Polychthemia is elevated red blood cell count, which is not seen with this disease.

Which food selection would need to be removed from the diet tray of a client recovering from thyroidectomy? 1. Fresh apple 2. V8 juice 3. Mustard greens 4. Ice cream

A: 1 Rationales 1. Too hard and crunchy. Need soft diet because esophagus is right behind the thyroid and trachea. 2. Not everyone likes V8, it is high in sodium and potassium but it's soft and has calories and vitamins. 3. Soft and full of vitamins. 4. Yes, ice cream with neck surgery (cold and soft).

In what order will the nurse reinforce instructions to a client on using a cane? 1. With can on stronger side of body, support body weight with both legs. 2. Move can forward 6-10 inches (15-25 cm). 3. Advance weaker leg forward toward the cane. 4. Advance stronger leg forward toward cane.

A: 1. With cane on stronger side of body, support body weight with both legs. 2. Move can forward 6-10 (15-25 cm) 3. Advance weaker leg forward toward the cane 4. Advance stronger leg forward toward cane. Rationales 1. First, with cane on stronger side of body, support body weight with both legs. This will support the even distribution of weight away from the weaker side to promote a normal gait. 2. Second, move and forward 6-10 inches (15-25 cm). Moving the cane the approximate distance of a normal gait helps with stability. 3. Third, and cane weaker leg forward toward the cane. This allows the weight to be supported by the cane and the stronger leg. 4. Fourth, advance stronger leg forward toward the cane. This allows the weight to be supported by the cane and weaker leg.

A psychiatric nurse seems a client sitting alone, but talking and occasionally placing a hand to the ear as if listening to someone. Then the client laughs. What does the nurse suspect this client is experiencing? 1. Auditory hallucinations 2. Delusions 3. Catatonic excitement 4. Anergia

A: 1 Rationales 1. Auditory hallucinations are false sensory perceptions of sound not associated with renal external stimuli. 2. Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background. 3. Catatonic excitement is manifested by a state of extreme psychomotor agitation. 4. Anergia is a deficiency of energy to carry out activities of daily living.

A client suffering from major depression spends all day in bed. Which nursing action should the nurse take? 1. Frequently initiate contact with client. 2. Frequently round at regular intervals. 3. Patiently wait for the client to come out of the bed. 4. Ask client about, "Why are you still in bed?"

A: 1 Rationales 1. Be accepting and spend time with the client even though pessimism and negativism may seem objectionable. Focus on strengths and accomplishments and minimize failures. 2. The nurse should round at frequent irregular intervals so that the client does not know when to expect the nurse and can plan suicide attempt. 3. The nurse should seek out the client. The depressed client is not likely to come looking for someone. 4. Do not confront the client about why the client is not doing something. This will not promote trust and client may not know why.

The nurse is preparing to make an occupied bed. Which action by the nurse is important to preserve client's self-esteem during this procedure? 1. Remove the top sheet first and replace with a clean one. 2. Inform the client that she will be uncovered only for a short time. 3. Ask the client to relax as the top sheet is removed and the bottom sheet is changed. 4. Cover the client with a bath blanket before removing any of the sheets on the bed.

A: 4 Rationales 1. The client's self-esteem will not be preserved if uncovered during this procedure. Being exposed to the nurse is very troubling for most clients. 2. The client should be covered throughout the procedure. 3. The client's self-esteem will not be preserved by relaxing. Being exposed is anxiety provoking and exposure is unnecessary. 4. The client should not be exposed during the bed change. Cover with a bath blanket as the top sheet is removed.

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

A: 1 Rationales 1. 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. 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, the red blood cells become rigid and sticky and are shaped cells can get stuck in small blood vessels, which can slow or block blood flow and oxygen to parts of the body. E. 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 pods 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. 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.

A nonambulatory client has experienced a chemical exposure. Which action by the nurse takes priority? 1. Don appropriate personal protective equipment. 2. Remove only contaminated clothes. 3. Avoid decontaminating the eyes. 4. Use hot water during decontamination.

A: 1 Rationales 1. Personal protective equipment should be donned prior to contact with the client to prevent contamination of the health care worker. 2. All clothes, jewelry, and personal belongings should be removed and placed into appropriate containers. 3. Decontamination of the eyes is performed using a saline solution via nasal cannula or Morgan lens. 4. Hot water is unnecessary unless the client is hypothermic during decontamination procedures.

Which task by the nurse should be performed first? 1. Suctioning the tracheostomy of an anxious client 2. Changing a colostomy bag that is leaking 3. Collecting admission data on a client that has been on the floor for 45 minutes 4. Administering pain medication for a client that is 8 hours post op

A: 1 Rationales 1. Suctioning the tracheostomy should take priority. This client is anxious which is a sign hypoxia and they need immediate action. 2. Not priority over airway. 3. Important, but not first priority over airway. 4. Important, but not first priority over airway.

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-Barre Syndrome 2. Multiple Sclerosis 3. Myasthenia Gravis 4. Systemic Lupus Erythematosus

A: 1 Rationales 1. The clues in this stem are diarrhea rom 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. Multiple Sclerosis damages nerves but not in an ascending progression from toes to head. 3. 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. Systemic lupus erythematosus, the most common form of lupus, is a chronic autoimmune disease that can cause severe fatigue and joint pain.

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.

A: 1 Rationales 1. The signs and symptoms displayed by the client suggest a rupture spleen and shock. The greatest concern in this situation is internal bleeding and possibly emergency surgery. The liens will need blood; therefore, the nurse should immediately obtain blood for type and cross match. 2. 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. Fluids are crucial for clients in shock and increasing in Lactated Ringers to 150 mL/hour. It is important to help maintain blood pressure. However, this is not the nurse's priority action. 4. 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 nurse is assisting with discharging the client after removing sutures from an abdominal wound. Which information should the nurse give the client at the time of discharge to reduce the risk of complications? 1. Inspect the wound daily for any changes 2. Resume normal activities when you go home 3. Keep the incision covered at all times 4. Follow up with primary healthcare provider when scheduled

A: 1 Rationales 1. The wound should be inspected daily for any signs of infection once the client goes home. Healing has only just begun by discharge. Signs of wound infection include: increased pain, swelling, redness, or warmth around the affect area; red streaks extending from the affected area; drainage of pus from the area; fever. 2. The client may be restricted in some activities, such as lifting, that would place undue strain on the suture line. 3. It is likely that the incision can be uncovered, but the primary healthcare provider prescription would apply here. Look for words like "all" which generally make the option wrong. Things are not that define. 4. This is true; however, the signs and symptoms of infection should be given to the client. If signs/symptoms develop, the primary healthcare provider should be notified prior to the next appointment.

A client receiving torsemide 20 mg every day reports an onset of cramping in the lower extremities. Based on this report, what current lab finding would the nurse expect? 1. Potassium level of 3.1 mEq/L (3.1 mmol/L) 2. Calcium level of 11 mg/dL (2.75 mmol/L) 3. Sodium level of 140 mEq/L (140 mmol/L) 4. PH level of 7.40

A: 1 Rationales 1. Toresmide is a loop diuretic, which causes the excretion of K+. Hypokalemia can result from use of this diuretic. Normal range for potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore the level of 3.1 mEq/L (3.1 mmol/L) is hypokalemia, and a common sign and symptom includes muscle cramps. 2. Normal calcium levels in the serum are 9.0-10.5 mg/dL (2.25-2.62 mmol/L). The level of 11 mg/dL (2.75 mmol/L) is hypercalcemia. Calcium acts like a sedative, so you would expect the client's muscle tone to be weak and flaccid rather than experiencing muscle cramping. 3. The normal sodium level is 135 to 145 mEq/L (135-145 mmol/L). Therefore, a level of 140 mEq/L (140 mmol/L) is WNL and would not be a factor in the client's report of muscle cramping. 4. The pH level of 7.40 is also WNL is not a lab finding that would be consistent with muscle cramping.

A female client with a history of frequent exacerbation of asthma asks the nurse to explain why she is at greater risk for fractures than other women her age. The nurse should explain to the client that she is at greater risk for osteoporosis for which reason? 1. "Because you have been taking steroids long term, calcium leaves the bone and goes to the blood, which places you at risk for osteoporosis." 2. "Because you take steroids, you have developed adrenocorticotrophic insufficiency, which causes serum calcium to drop. This places you at risk for fractures." 3. "Clients who have asthma are not able to exercise enough to prevent fractures from occurring." 4. "You should get a second opinion because asthma should not pu you at increased risk for fractures."

A: 1 Rationales 1. Use of steroids long term decrease serum calcium, so the body takes calcium from the bone and puts it in the blood in order to bring serum calcium back to normal. Every tie a steroid is given, calcium is removed from the bone, thus leading to greater risk for osteoporosis and at risk for fractures. 2. Not a cause of increased risk of osteoporosis. 3. Not a cause of increased risk of osteoporosis. 4. Drug therapy for asthma not asthma may put client at risk for osteoporosis.

The schizophrenic client tells the nurse, "I am Jesus, and I am here to save the world!" The client is reading from the Bible and warning others of hell and damnation. The other clients on the unit are upset and several are beginning to cry. What nursing intervention is most appropriate? 1. Set verbal limits and have the client return to assigned room. 2. Explain to the client that not all people are Christians. 3. Remove the Bible from the client and explain that the client is not Jesus. 4. Ask the client to share with the group how the client is Jesus.

A: 1 Rationales 1. Yes, the nurse must set limits. This is disrupting others and so the client needs to be redirected to their room for a cool down and then another activity shortly thereafter this client is experiencing delusions of grandeur, which are not reality based, and require intervention that does not reinforce the behavior. 2. No, this will only reinforce the clients thought process or religion. 3. No, don't argue with the client. This is not therapeutic and does nothing to help resolve the disruption to the other clients. 4. This is ridiculing the client and also inflaming the situation. This is not desirable.

A young client comes to the mental health center reporting the need to sleep excessively, and states, "I cry at the drop of a hat." How should the nurse interpret this information? 1. Further screening for a mood problem is needed. 2. Anxiety assessment is warranted. 3. Symptoms of disordered thinking is being experienced. 4. Screening should be done for social isolation.

A: 1 Rationales 1. Depression alters sleep patterns and can lead to crying spells. 2. The client may be anxious, but the symptoms expressed fit most closely with depression, a mood disorder. 3. There is no indication from the client of disordered thinking. 4. If the client is depressed, isolation is likely, but the symptoms expressed indicated depressed mood.

Which victim would the nurse decontaminate first in a biological terrorist event? 1. Client who was exposed but is exhibiting no symptoms 2. Client who has an open leg fracture and head injury 3. Client who is not breathing and has no palpable pulse 4. Client with minor cuts and abrasions

A: 1 Rationales 1. Exposed victims with no symptoms are first priority. 2. Victims needing maximum medical care are third priority. 3. Deceased victims are the last priority. 4. Those with minor injuries are second priority.

The nurse is caring for a client that is undergoing a induction for fetal demise at 34 weeks. Immediately after delivery the mother asks to see the infant. What is the nurse's best response? 1. Bring the swaddled baby to the mother. 2. Explain that the cause of death must be determined before she can see the baby. 3. Ask her if she is sure she wants to see the baby. 4. Tell her it would be better to wait until she is in her room before she sees the baby.

A: 1 Rationales 1. Let the grieving mother see the infant to continue the grieving process. The mother has the right to make her own decision. 2. This is an untrue statement. In some cases, the cause may never be found. 3. This is non-therapeutic and implies that the nurse disagrees with the mother's decision to see the infant. 4. This is non-therapeutic and delays the mother's request. This response may also cause additional fear and anxiety.

A child in the manic phase of bipolar disorder is constantly interrupting a group session. What should the nurse do? 1. Engage the client to walk with the nurse to make another pot of coffee. 2. Ask the client to reflect on behavior to determine if it is appropriate. 3. Ask the group to tell the client how they feel when interrupted. 4. Instruct the client to perform jumping jacks and counting aloud to get rid of some energy.

A: 1 Rationales 1. Yes! Get them away and doing something purposeful. 2. That is embarrassing and humiliating to the client. 3. Sometimes this will be helpful during times of therapy, but the client is manic at this time, and probably will not believe them? 4. No. This, is getting the client active, but can the group continue with this attention seeking jumping, counting person? No. Get the client away from the activity.

The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (VTE). What actions should the nurse initiate? 1. Measure the calf and thigh daily. 2. Apply sequential compression device to legs. 3. Position paralyzed leg with each distal joint higher than the proximal joint. 4. Place a trochanter roll at the hip. 5. Perform passive range of motion exercises once daily. 6. Monitor for pain for checking Homan's sign.

A: 1, 2, 3 Rationales 1, 2, 3. Monitoring for VTEs is accomplished by measuring the calf and thigh daily, observing swelling, noting unusual warmth of the leg, and asking the client about pain in the calf. Prevention of VTEs include the use of sequential compression devices for bedridden clients. This device helps promote venous return. Positioning the paralyzed leg with each distal joint higher than the proximal joint will prevent dependent edema. 4. A trochanter roll does not prevent VTEs. They are used for the prevention of external hip rotation. 5. Passive range of motion exercises should be done several times a day to promote venous return and muscle tone. Once a day is not adequate. 6. Routinely checking the Homan's sign can actually cause a clot to dislodge. The nurse should not perform this procedure.

A client who has been taking phenytoin for several years arrives to the clinic for follow-up care. During the nurse's history and physical of the client, which findings indicate a possible side effect to the phenytoin? 1. Skin rash 2. Reports fatigue 3. Dyspnea on exertion 4. Pale conjunctiva 5. Heart rate 60/min

A: 1, 2, 3, 4 Rationales 1, 2, 3, 4. An adverse effect of phenytoin is aplastic anemia. Phenytoin is an anticonvulsant. Aplastic anemia is a blood disorder where not enough new blood cells are produced in the bone marrow. The blood cells include red blood cells, white blood cells and platelets. The most common symptom of decreased RBCs is fatigue and dyspnea upon exertion because RBCs are responsible for oxygen transport throughout the body. A common sign/symptom of aplastic anemia is also skin rashes. Collectively, these are signs/symptoms of aplastic anemia caused by this medication. 5. This a normal heart rate, and there is no concern for vital signs within normal limits.

Which interventions should be included in the plan of care for an adult client with constipation? 1. Allow adequate time for defecation. 2. Provide privacy for bowel elimination. 3. Suggest increasing fluid intake. 4. Encourage client to increase fiber in the diet through fruits and bran. 5. Encourage the client to delay the urge to defecate until after a meal.

A: 1, 2, 3, 4 Rationales 1, 2, 3, 4. Clients should have ample time for defecation. Rushing the client may lead to a client ignoring the urge. Privacy should be provided. The nurse way need to stay with weak or disabled clients. Increasing fluid intake will encourage softer stools. Fiber deficiencies may be present in many individuals, thus contributing to constipation. 5. Ignoring the urge to defecate may increase the risk of constipation. Trying to defecate after a meal may be helpful; however, if the urge occurs at other times, the client should go to the bathroom.

Which client statements would indicate to the nurse that teaching has been successful regarding prevention of hip prosthesis dislocation? 1. "I should not cross my affected leg over my other leg." 2. "I should not bend at the waist more than 90 degrees." 3. "While lying in bed, I should not turn on my affected side." 4. "It is necessary to keep my knees together at all times." 5. "When I sleep, I should keep a pillow between my legs."

A: 1, 2, 3, 5 Rationales 1, 2, 3, 5. Until the hip prosthesis stabilizes, it is necessary to follow these instructions for proper positioning to avoid dislocation. 4. The knees should be kept apart at all times.

A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. What information should the nurse include? 1. An Advance Directive includes a Living Will and a Medical Power of Attorney. 2. A person can be designed to make medical decision in the event the client cannot. 3. The spouse can rescind the Advance Directive if the client becomes unresponsive. 4. Anyone over age 18 can have an Advanced directive. 5. The client can indicate desire for Do Not Resuscitate (DNR).

A: 1, 2, 4, 5 Rationales 1, 2, 4, 5. Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. A Medical Power of Attorney is a type of Advance Directive that appoints a health care agent to make decisions on the client's behalf when the client is unable to do so. An adult (18 years or older) can create an advanced directive. A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. 2. An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document.

A nurse suspects that a child admitted to the emergency department is in diabetic ketoacidosis. What data would lead the nurse to this conclusion? 1. Dry mucous membranes 2. Fruity-smelling breath 3. Biot's respirations 4. Glycosuria 5. Clint report of abdominal pain

A: 1, 2, 4, 5 Rationales 1, 2, 4, 5. The client with diabetic ketoacidosis will have signs of dehydration due to polyuria and includes dry mucous membranes. Fruity breath odor is from the acetone that occurs with breakdown of fats and formation of ketones, which are acids. With DKA, the client would be spilling glucose into the urine. Vomiting and abdominal pain are frequently the presenting symptoms of DKA. E. The client will have Kussmaul respirations. Biot's respiration is a respiratory pattern characterized by periods of rapid respirations, then apnea periods. These are not the type of respirations that occur with diabetic ketoacidosis (metabolic acidosis).

What signs/symptoms would the nurse expect to find in a client diagnosed with late stage rheumatoid arthritis? 1. Effusion to knees. 2. Weight loss of 1 kg in 2 weeks. 3. Swan neck deformity. 4. Peripheral neuropathy. 5. Subcutaneous nodules on elbows.

A: 1, 3, 4, 5 Rationales 1, 3, 4, 5. As rheumatoid arthritis worsens, the joints becomes progressively inflamed and very painful. On palpation, these joints feel soft and look puffy because of synovitis and effusions, especially in the knees. Swan-neck deformity is a bending in (flexion) of the bas of the finger, a straightening out (extension) of the middle joint, and a bending in (flexion) of the outermost joint. Peripheral neuropathy occurs in later stages of the disease due to vasculitis. Subcutaneous nodules or rheumatoid nodules are firm bumps of tissue most commonly form around pressure points, such as the elbows. 2. A 1 kg weight loss over 2 weeks would more likely occur in the early stages of the disease. As the disease progresses, there is moderate to severe weight loss and accompanying anemia.

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? 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

A: 1, 2, 4, 5 Rationales 1, 2, 4, 5. 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 like 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 the clients with Ebola are vomiting or having 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 bd fluids and also provides a way to rapidly remove a soiled outer layer if contamination occurs on the apron. 3. Sterile gloves are not required, but two pairs, instead of one pair, of gloves should be worn so that a contaminated outer glover can be safely removed when providing client care or safely removed without self-contamination when removing the PPE. These gloves should be the very least have extended cuffs.

The nurse is collecting data from a parent who is seeking treatment for a child in a pediatric clinic suspected of having Fifth disease. What symptoms would the nurse expect associated with this illness? 1. Erythema on the cheeks 2. Joint pain 3. Temperature 102 degrees F (38.88 degrees C) 4. Swollen knees 5. Pruritic rash on soles of feet

A: 1, 2, 4, 5 Rationales 1, 2, 4, 5. These are common signs/symptoms of Fifth disease. 3. Low grade fever is seen with this disease.

A client is being admitted with a diagnosis of cirrhosis of the liver. What signs/symptoms would the nurse anticipate in this client? 1. Firm, nodular liver 2. Ascites 3. Hematuria 4. Abdominal pain 5. Bleeding from the GI tract

A: 1, 2, 4, 5 Rationales 1, 2, 4, 5. With cirrhosis, the liver can become very large in size and feel very firm and nodular upon palpation. Third spacing of fluids out of the vascular space (ascites) occurs due to lowered albumin levels. The client is often in a nutritional deficit which contributes to the lowered albumin level. Also, the liver is sick and unable to synthesize albumin. Abdominal pain occurs as the capsule around the liver stretches. This capsule has a lot of nerves, which produces the pain. Increased pressure in the liver (portal hypertension) 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 diseases, such as cirrhosis, are the common causes of blood clotting problems because the liver is unable to produce the needed clotting factor. 3. Hematuria is blood in the urine. This occurs with renal damage or urinary tract infections. Hematuria is not typically seen with cirrhosis.

The nurse is to administer a client's first dose of lithium. Prior to giving the medication, the nurse should verify that what tests have been completed? 1. Blood urea nitrogen (BUN) 2. Thyroid stimulating hormone (TSH) 3. Electroencephalogram (EEG) 4. Alanine aminotransferase (ALT) 5. Electrocardiogram (ECG)

A: 1, 2, 5 Rationales 1, 2, 5. Lithium is an anti-mania medication used to treat bipolar disorder or other manic issues. However, this drug may adversely affect other body systems, which is why it is vital to verify the client has no undiagnosed renal, thyroid or cardiac problems blood urea nitrogen (BUN) reveals the function of the kidneys while thyroid stimulating hormone (TSH) indicates how well the thyroid is working. An electrocardiogram (ECG) will show arrhythmias or rhythm problems with the heart. The nurse needs to verify these tests were completed and the results were given to the primary healthcare provider. 3. An electroencephalogram (EEG) is a study of brain wave activity achieved by placing dozen of external electrodes on the skull. While lithium may affect an individual's thought patterns and emotional stability, actual brain functions are not impacted. 4. Alanine aminotransferase (ALT) is an enzyme produced by the liver for the purpose of helping breakdown proteins for metabolism. This blood test would indicate the status of the liver, which is not a major concern while taking lithium.

A client who is obese and paraplegic needs to be repositioned in the bed. What actions should the nurse take? 1. Obtain assistance from a coworker. 2. Place the bed in the lowest position with the client close. 3. Adjust the bed to a workable position and move close to the client. 4. Use a draw sheet with the assistance of a coworker and pivoting the hips while pulling the draw sheet upward. 5. Use the client's arms and pull to head of bed to aid positioning.

A: 1, 3, 4 Rationales 1, 3, 4. The nurse should solicit a coworker for help, adjust the bed to a workable position, move close to the client, use a draw sheet with the assistance of a coworker, and pivot the hips while pulling the draw sheet upward. These steps will prevent injury to the nurse and client. 2. The bed needs to be adjusted to the nurse's working height not in the lowest position. 5. The client's arms should not be pulled on or used to position a client.

The client has the need for droplet precautions due to a respiratory illness. When providing care for this client, when is it appropriate for the nurse to wear a mask? 1. Performing tracheostomy care 2. Delivering mail to the client's room 3. Bathing the client 4. Feeding the client 5. Making routine room checks

A: 1, 3, 4 Rationales 1, 3, 4. The nurse will be in close contact with the client and may become contaminated by droplets from the client's respiratory tract. The client may cough while the nurse is feeding or bathing the client. 2. Delivering the mail without close contact with the client should not require the nurse to apply a mask. 5. Routine rounds do not necessarily involve close contact with the client.

Which comments made by the nurse indicate an understanding of confidentiality as it relates to mental illness? 1. "Client approval is needed prior to talking with family members." 2. "I cannot discuss possible client abuse with outside agencies." 3. "Client situation can be discussed in the care planning meeting." 4." Discussion about clients while in the elevate is prohibited." 5. "It is not appropriate to discuss the client's condition with other nurses while in the cafeteria."

A: 1, 3, 4 5. These comments indicate understanding of mental health care and confidentiality. 2. Nurses may discuss issues of abuse with appropriate agencies.

A client with a history of schizophrenia was admitted with abdominal pain and has been undergoing diagnostic tests. When the nurse enters the room, the client is alone and looking at the wall and states "Why should I hurt them?" What would be an appropriate intervention by the nurse? 1. Directly ask the client "Are you hearing voices?" 2. State "Tell the voice that you do not want to hurt anyone." 3. Focus on reality based topics of conversation. 4. Observe for signs of increasing anxiety in the client. 5. Tell the client "you know that you are not being told to hurt someone." 6. Inquire about what the client believes he or she is being told to do.

A: 1, 3, 4, 6 Rationales 1, 3, 4, 6. Did you pick up on the cues that this client is experiencing auditory hallucinations? The most obvious cues that this client is hallucinating are the verbal response when there is no one present and the client present and the client is looking at the wall when responding. When you think a client is hallucinating, you should directly ask the client about the hallucination by asking such questions as :"are you hearing voices?" In order to intervene with a client who is experiencing a hallucination, you should focus on reality-based diversions including reality-based topics of conversation. Also, hallucinations can be anxiety producing for clients, so you should observe for any signs of increasing anxiety, which can be a sign that the hallucinations are increasing. The nurse can explore the hallucination experience with this client by asking directly "What are the voices telling you to do?" Another way to specifically explore the hallucination with this client is to ask if they are being told to do something that would cause harm to someone. 2. You never want to react to the client's hallucinations as if they are real. In this case, you would not tell the client to talk back to the "voices" and argue with them to discuss things as if the voices are real. 5. You do not want to negate the client's hallucination experience, but you do offer your own perception that you do not hear the voices. Telling the client that they are not being told something would only escalate their anxiety and perhaps cause them to become irritable or upset. The voices are "real" to the client.

Which client assignment would be appropriate for the LPN to accept? 1. Client scheduled for an MRI of the kidneys. 2. Client requiring administration of antineoplastic medications. 3. Client one day post open cholecystectomy with moderate amount serous drainage on dressing. 4. Client post ileal conduit surgery this AM without drainage in the drainage bag. 5. Client diagnosed with osteoarthritis reporting frequent joint stiffness.

A: 1, 3, 5 Rationales 1, 3, 5. There is nothing in the option regarding the client going for an MRI of the kidneys that would indicate that this client is unstable. This client can be assigned to the LPN. The one day post op client with a moderate amount of serious drainage on the dressing is stable. Skills required to care for this client are within the LPN's scope of practice. This client diagnosed with osteoarthritis reporting frequent joint stiffness can be considered stable and can be cared for by the LPN. The knowledge and skills required to care for these three clients all within the scope of practice for the LPN. 2. Administration of antineoplastic medications require the skills and knowledge of a qualified registered nurse. 4. A ileal conduit is a procedure that diverts urine from the bladder and provides an alternate cutaneous pathway for urine to exit the body. Urinalysis output should always be at least 30 mL per hour. This client should be assessed and monitored by the RN to ensure that the stents placed in the ureters have no become dislodged or to ensure that edema of the ureters is not occurring.

The nurse enters the client's room and finds the client having a seizure on the floor. Which nursing interventions should the nurse implement? 1. Loosening tight shirt or jacket. 2. Move the client to the count. 3. Place a pillow under the head. 4. Position the head tiled forward. 5. Insert a wash cloth between the teeth.

A: 1, 4 Rationales 1, 4. Client safety should be the priority action. The tight clothing should be loosened to reduce the potential of the clothing obstructing the airway. During a seizure, the head is tiled forward to allow the tongue to advance forward. This will assist in the drainage of saliva and mucus. 2. If the nurse tries to move the client during a seizure to the couch, there is a possibility that both the nurse and client could be injured. The client is safer on the flor than trying to move the client. 3. During a seizure, the head should not be placed on a pillow. The pillow may cause the client's airway to become occluded, and an increase of saliva and mucus in the mouth may not drain properly. 5. The nurse should not open the mouth of the client during a seizure. This action may result in injury to the client's teeth and/or jaws. The muscles in the jaws may spasm which will seal the mouth tight.

The nurse is caring for a client that is drowsy and has en elevated PCO2 level. What are some common drugs that cause retained CO2? 1. Narcotics 2. Diuretics 3. Steroids 4. Antiemetics 5. Hypnotics

A: 1, 4, 5 Rationales 1, 4, 5. Narcotics sedate and decrease the respiratory rate. Some antiemetics like promethazine are very sedating. Sleeping pills can cause sedation to the point of hypoventilation. 2. Diuretics do not affect breathing patterns. 3. Steroids do not affect breathing patterns.

What is the priority nursing action to take when reinforcing teaching of a client about warfarin? 1. Advise the client to call the prescribing primary healthcare provider before taking any new medications or supplements. 2. Advise the client to notify a healthcare provider if experiencing dizziness of lightheadedness. 3. Advise the client of the need to have the International Normalized Ratio (INR) checked frequently. 4. Advise the Clint that warfarin in used to prevent thrombosis.

A: 2 Rationales 1. A client should always ask the prescribing primary healthcare provider before taking any new medications or supplements, but this is not highest priority. 2. Dizziness and lightheadedness could be a symptom of bleeding, which is a very common and very serious side effect of warfarin. 3. This option is too vague. The frequency of INR monitoring will be determined by the client's primary healthcare provider. This is not priority over bleeding. 4. This is definitely important information for a client to know, but not highest priority.

What preferred lab value would the nurse expect to see the primary healthcare provider prescribe fro a client admitted with generalized malnutrition? 1. Albumin 2. Prealbumin 3. Iron 4. Calcium

A: 2 Rationales 1. Albumin is a major serum protein that is below normal in clients who have inadequate nutrition. However, it can take weeks to drop. 2. The preferred lab value to screen for generalized malnutrition is prealbumin. This assessment is preferred because it decreases more quickly when nutrition is not adequate. 3. Low serum and anemia indicate an iron deficiency. Again, the prealbumin will decrease soon than other lab values that assess nutrition level. 4. Older women may have low calcium levels which place them at risk for bone demineralization. But, prealbumin provides more data on generalized nutrition.

Which observation of a six month old infant would concern the nurse? 1. Able to sit unsupported for a few seconds. 2. Posterior fontanel is closed. 3. Legs stay crossed at the knees when placed in that position. 4. Birth weight has doubted.

A: 3 Rationales 1. Should be able to sit up at 6 months. 2. Posterior fontanel closes at 2 months. 3. Legs stay crossed ... not normal ... not supposed to be that flexible ... fat legs won't stay crossed. 4. This is normal, birth weight doubles at 5-6 months.

The client complains of crushing substernal chest pain radiating down the left arm. Which measure should the nurse initiate first? 1. Monitor for abnormalities on a cardiac monitor 2. Administer oxygen at 2L/nasal cannula 3. Start an intravenous (IV) line of D5W to keep open 4. Draw blood for Troponin level

A: 2 Rationales 1. Looking and watching is what you are doing if you select this option. Will monitoring the client on the cardiac monitor first help the client? No. Give the client oxygen first. 2. So what should the nurse be worried about? That the client is having a MI? Yes. A crushing substenral chest pain radiating down the left arm is classic for an MI. So what option can help the client? Oxygen administration to get more oxygen to the heart muscle. 3. Getting an IV line is good so that cardiac medications can be given, but help the client first by starting the O2. If you wait to provide oxygen until after starting the IV, the client may be waiting while heart muscle is dying. 4. Yes, the lab will be there shortly, but get started with O2 while you wait.

Which prescription can the LPN/VN implement when assisting an RN with the care of a client diagnosed with an abdominal aortic aneurysm? 1. Obtain vital signs every 15 minutes. 2. Insert a urinary catheter for hourly urinary outputs. 3. Place a PICC line for fluid management. 4. Provide morphine 1 mg per PCA pump at a 10 minute lockout.

A: 2 Rationales 1. The UAP can do this task as well as the LPN. Delegate this to the UAP. 2. Inserting a urinary catheter is within the scope of practice for the LPN. 3. The RN with special training can insert a PICC line. The LPN cannot do this. 4. This is an RN task to set up PCA infused morphine.

The nurse is planning to administer oxycodone with acetaminophen for pain control as prescribed by the healthcare provider. As the nurse enters the room, he checks the client's arm band. The nurse notes that the client is allergic to acetaminophen. What should the nurse do? 1. Give the medication as prescribed. 2. Return to the nurse's station and notify healthcare provider of allergy. 3. Ask the client if she is allergic to acetylsalicylic acid. 4. Ask the client to rate her pain on a scale of 1 to 10.

A: 2 Rationales 1. The client is allergic to acetaminophen; therefore the medication should not be given. 2. Oxycodone and acetaminophen cannot be given if the client is allergic to acetaminophen. Call the primary healthcare provider for another medication. 3. The drug does not contain acetylsalicyclic acid. 4. Pain assessment is important; however, there is a more crucial action needed here.

Which activity should the nurse instruct the client to avoid following a total high replacement? 1. Using an abduction pillow while sleeping 2. Crossing the legs 3. Using a toilet extender 4. Showering rather than taking a bath

A: 2 Rationales 1. The client should use an abduction pillow to keep the hip in proper alignment and prevent his dislocation. 2. Crossing the legs can pop the hi out of place. 3. A toilet extender keeps his in proper alignment and prevents hip dislocation. 4. Showering rather than sitting in the tub to prevent flexion of the hip, which can cause dislocation.

A nurse admits a client to the pre-op are of an ambulatory surgery unit. As the client is being prepared for surgery, a nurse notices that the client is exposed and pulls the curtain closed. How did the nurse exhibit client advocacy? 1. By ensuring client safety. 2. By promoting client privacy. 3. By obtaining informed consent. 4. By ensuring client confidentiality.

A: 2 Rationales 1. The nurse is not assuring client safety in this example. 2. The nurse is acting as a client advocate by promoting client privacy. 3. The nurse is not obtaining informed consent in this example. 4. The nurse is not ensuring client confidentiality in this example.

The nurse has just inserted an in dwelling catheter into the hospitalized client. The nurse has cleared the items from the client's bed, has disposed of them, and has removed the gloves. What should the nurse do next? 1. Tidy the room. 2. Wash hands. 3. Perform care for the other client in the room. 4. Apply clean gloves and provide care to the other client in the room.

A: 2 Rationales 1. The nurse should not tidy the room until after washing hands. 2. Standard precautions include washing the hands after removing gloves, and before performing other tasks. 3. The nurse should perform hand hygiene before going to the next client. 4. Hand hygiene should be performed first, before putting on new gloves and performing care on another client.

A nurs wants to find out a better way to perform oral care on unresponsive clients. What is the best action for the nurse to take in order to achieve this goal? 1. Try different methods of oral care on unresponsive clients to see what works best. 2. Discuss the issue with the leader of the "best practices" committee. 3. Read all the current literature related to oral care on unresponsive clients. 4. Ask the primary healthcare provider to suggest the best oral care procedure.

A: 2 Rationales 1. This is doing research, which requires the research process be implemented, including appropriate approval. The best practice utilizes current research in their recommendations. 2. The best action for the nurse is to identify a problem, and follow up with the appropriate person. An experienced person who can research "best practice" regarding the issue is needed. The best practice committee works to improve clinical practice based on current research. 3. This will not take a lot of time and is best initiated from the "best practice" committee. The nurse could definitely be a part of the committee. But the evidence-based care leaders are trained to help nurses through the proper process of evidence based research. 4. This is a nursing responsibility and the best practice committee is the best place to begin. The primary healthcare may have suggestions but this is not the best action.

A new nurse has a prescription to insert a feeding tube. The new nurse has never performed the procedure, but learned how to do it while in nursing school. What would be the best action by this nurse? 1. Ask to observe another nurse perform the procedure. 2. Look up how to perform the procedure in the policy and procedure manual. 3. Tell the charge nurse that someone else will have to place the feeding tube down the client. 4. Insert the feeding tube as learned in nursing school.

A: 2 Rationales 1. This is passive. The best action would be to look up how to do the procedure, discuss with another nose, and ask that nurse to observe the insertion of the feeding tube. 2. The best action for the nurse to take is to look up how the procedure is done in the agency by looking it up in the policy and procedure manual. The nurse could then discuss the procedure with another nurse and ask the nurse to observe the new nurse while inserting the feeding tube. 3. This is not the best option. The new nurse needs to learn how to insert a feeding tube. This will not help the new nurse learn. 4. The nurse should follow agency policy and procedure. It is then best to discuss the procedure with another nurse and ask the nurse to observe the feeding tube insertion.

A hospitalized client using a K-pad on an injured muscle reports the pad is not warming up. What should be the nurse's initial action? 1. Unplug unit and plug into another wall outlet. 2. Check temperature setting on the heating unit. 3. Call maintenance to repair unit immediately. 4. Increase temperature on unit pad heats up.

A: 2 Rationales 1. While it is possible the outlet itself may be defective, this is not likely in a large facility. Additionally, an electric appliance should never be re-connected to an outlet while still in contact with the client. 2. The nurse is utilizing the nursing process by first collecting data pertinent to the situation. The actual problem could be related to he temperature dial on the unit, or even a malfunction in the pad itself however, the nurse must assess the situation by checking the basics, such as whether the equipment is even turned on. 3. It is unlikely maintenance would be available to examine the device immediately and most repairs should not be attempted in the client's room because of safety considerations. 4. The exact problem with the heating unit has not yet been established. Simply turning up the temperature setting is not safe since the pad may quickly get hotter, injuring the client.

A client has been admitted with a diagnosis of septic shock and has been successfully incubated. Which information requires the most immediate action by the nurse? 1. Lung assessment finding. 2. Blood pressure reading. 3. Elevated temperature. 4. Urine description and output.

A: 2 Rationales 1. The oxygen sat is 94%, so the adventitious lung sounds do not need immediate interventions. The abnormal lung sounds are the result of the diffuse infiltrates that occur as a result of the inflammatory process and increased capillary permeability which allows fluid to escape into the lung tissues and alveoli. As this progresses, gas exchange can be severely compromised. However, at this point, this client is remaining above 90% with the O2 sat levels, so the problem of poor tissue perfusion from hypotension would be the priority. 2. Septic shock involves persistent hypotension. The low blood pressure indicates that systemic tissue perfusion will not be adequate. This decreased perfusion will result in dysfunction and sometimes failure of one or more organs, such as the kidneys, heart, brain, liver and lungs. The blood pressure needs to be improved rapidly. This will be accomplished using IV fluids and sometimes vasopressors. 3. The second priority is to treat the infection that is a likely cause of the temperature of the temperature elevation and hypotension. Parenteral antibiotics are administered as soon as wound or blood cultures have been obtained. When sepsis is suspected, antibiotic therapy is essential and should be instituted as soon as possible. The early initiation of antibiotics can be a lifesaving measure. 4. This may be the cause of the sepsis, but the priority is to improve the tissue perfusion and ultimately raise the BP. The second priority is to treat the infection. As the tissue perfusion improves, and the infection is treated, the urinary output and appearance of the urine should improve unless permanent kidney damage resulted.

While receiving discharge instructions from a nurse, a client reports a sense of heaviness in the chest. The nurse, interested in obtaining the client's signature on the discharge instructions, dismisses the client's report. Which measures did the nurse fail to implement when caring for this client? 1. Failure to pressure client privacy 2. Failure to act as a client advocate 3. Failure to take appropriate action 4. Failure to appropriately diagnose 5. Failure to protect client self-determination

A: 2, 3 Rationales 1. There is no indication that client privacy was not maintained. 2, 3. The nurse failed to act as a client advocate because the nurse did not stop to obtain more information from the client about the symptoms. The nurse also failed to take appropriate action because the nurse did not document the symptoms and did not notify the primary healthcare provider of the client's symptoms. 4. It is not responsibility of the nurse to diagnose a client. 5. Client self-determination was not breached.

Which factors should the nurse reinforce with a parent about risk factors for otitis media? 1. Breast-feeding 2. Contact with siblings 3. Day care attendance 4. Season of the year 5. Age over 5

A: 2, 3, 4 Rationales 1. Breast-feeding decreases the incidence of acute otitis media. 2, 3, 4. Contact with siblings, day care attendance and season of the year all increase a child's risk of developing otitis media. 5. Age under 5 is a risk factor.

Upon admission to a hospital, a client asks a nurse about the Health Insurance Portability and Accountability Act (HIPAA). When teaching the client about HIPAA regulations, which provisions should the nurse include? 1. HIPAA guarantees individual access to health insurance. 2. Clients have the right to request a copy of their personal health information. 3. Health care agencies must keep a client's personal health information confidential. 4. A client's personal health information may be released to obtain health insurance benefits for the client. 5. All staff members have legal access to a client's medical record while the client is receiving medical care in a facility.

A: 2, 3, 4 Rationales 1. HIPAA does not guarantee access to health insurance. 2, 3, 4. HIPAA is federal legislation enacted to protect a client's health information and privacy. Clients have the right to request a copy of their personal health information. Health care facilities must keep all client information confidential per federal law. A client's personal health information may be released to obtain insurance benefits for the client. 5. Only staff members who are providing care directly to the client have legal access to a client's personal health information.

Which client assessments should be made routinely by the nurse to minimize risk of infection from an in dwelling urinary catheter? 1. Check to see if drainage receptacle is at the level of the bladder 2. Observe the catheter for flow of urine, odor, color, and any abnormal sediment. 3. Check tubing to assure that there is no tension on the catheter tubing. 4 make sure that gravity drainage is maintained. 5. Cleanse around urinary meatus three times per day with antiseptic solution.

A: 2, 3, 4 Rationales 1. The drainage receptacle should be below the level of the bladder. 2, 3, 4. Observing urine flow is important as is notation of color, odor and any sediment or blood in the urine. Tubing should be free of kinks and without tension on the tubing. Gravity drainage should be maintained at all times with no loops in the tubing below the level of the drainage receptacle. 5. There is no need to perform any special care of the meatus. Routine soup and water is all that is necessary when soiled or at the time of routine bathing.

A child was diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) in the clinic one week go. Today the child's mother calls the clinic to tell the nurse, "Ever since my child has been on methylphenidate he has not been able to sleep." What is the best response for the nurse to make? 1. "I will tell the primary healthcare provider, so that she can order a different medication for him." 2. "The insomnia will get better over time. Just wait it out." 3. "To prevent insomnia, give him the last daily dose at least 6 hours before bedtime." 4. "He may have overdosed on the medication. Take him to the emergency department now."

A: 3 Rationales 1. This is premature. Try changing the time to help with sleep. 2. This does not help the problem. The child needs to sleep. 3. This is a correct statement. If the medication is sustained-released, administer the dose in the morning. 4. The client has not overdosed based on the information.

The nurse is talking with the mom of a preschooler at the well-child visit. The mom reports that her 3 year old has a lot of energy and sleeps 9 hours per night. What data collection questions should the nurse ask in response to this comment? 1. Nothing, as this is normal for preschoolers. 2. Does your child take naps during the day? 3. Does your child wake up spontaneously or do you wake her? 4. Does your child appear rested upon awakening? 5. Does your child have trouble settling down for sleep?

A: 2, 3, 4, 5 Rationales 1. Preschoolers typically require 11-13 hours of sleep per day. Nine hours is not enough. 2, 3, 4, 5. Preschoolers typically require 11-13 hours of sleep per day. The child may be supplementing nighttime sleep with long naps. It is important to determine if the child has to be awakened after nine hours or if the child awakens spontaneously. The child may have to be awakened due to mom's work schedule. The adequacy of rest should be determined, as the child is sleeping less than is typical. The nurse should determine if the child has difficulty falling asleep. If so, perhaps more restful nighttime rituals should be implemented.

Which nursing actions would indicate proper sterile technique? 1. Using clean gloves, the nurse removes sterile forceps from the back age and places on sterile field. 2. The nurse does not allow any sterile item to get within one inch fo the drape border. 3. The nurse's arms stay above the waist. 4. When adding sterile saline to a sterile bowel, the nurse places the inside of the bottle cap up. 5. The nurs discards a package that becomes wet.

A: 2, 3, 4, 5 Rationales 1. Sterile can touch sterile only. If the nurse touched sterile forceps with clean gloves, the forceps would become contaminated. Further teaching would be needed. 2, 3, 4, 5. This is a correct procedure. Because the EGD of a sterile towel, drape, tray touches an unsterile surface, such as a table, the edge of the drape is contaminated (1 inch). A sterile object or field out of the range of vision or an object held below the waist is contaminated. The inside of the bottle cap is considered sterile. Placing the cap up will keep the cap sterile. When a sterile surface comes into contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action.

Which findings will direct the nurse towards determination that a client is experiencing normal grief reactions rather than clinical depression? 1. Anhedonia is prevalent. 2. The client states, "I have good and bad days." 3. Smiles at the nurse while talking about grandchild." 4. A persistent state of dysphoria is noted. 5. The client states, "I have been crying less."

A: 2, 3, 5 Rationales 1. Anhedonia is the inability to experience pleasure, which is seen in clinical depression. 2, 3, 5. A client going through a normal grieving process will experience a mixture of good and bad days. The client is able to experience moments of pleasure and cries less. 4. Dysphoria is a mood of general dissatisfaction, restlessness, depression, and anxiety. This is often seen in clinical depression.

The nurse has determined that a client is at risk for experiencing dumping syndrome after having had a partial gastric to my. Which teachings about this condition should the nurse reinforce with this client? 1. "After eating you should assume a right side lying position for 30 minutes." 2. "Drink liquids an hour after consuming meals." 3. "Eat three meads rather than ix smaller meals." 4. "Carbohydrates should be decreased in the diet." 5. "The primary healthcare provider may prescribe a multivitamin with iron."

A: 2, 4, 5 Rationales 1. The best position to delay stomach emptying is low Fowler's during mealtime and for at least 20-30 minutes after the meal. 3. The client should eat smaller, but more frequent meals. 2, 4, 5. Fluid intake with meals is discouraged: instead, fluids may be consumed up to one hour before or more hour after mealtime. Carbohydrates increase gastric motility which this client does not need. Therefore the diet should be low in carbs. Supplementary vitamins and iron may be recommended when the client has dumping syndrome.

An elderly widower has been admitted to a psychiatric crisis unit with a diagnosis of major depression with agitation. What behaviors would the nurse expect to observe during an initial assessment? 1. Memory loss 2. Difficulty focusing 3. Excessive sleepiness 4. Short-tempered 5. Hand-wringing

A: 2, 4, 5 Rationales 1. Despite the client's agitation, racing thoughts and difficulty focusing, there is no actual memory loss at any point during this activity. 3. While excessive sleepiness may be typical of depression, the agitation which accompanies this disorder makes it very difficult to relax or sleep at all. 2, 4, 5. This type of depression is characterized by the added component of agitation. The client experiences difficulty focusing because of racing thoughts and restlessness. Other symptoms include incessant talking along with short-tempered outbursts of anger towards everyone. The inability to sit still is commonly accompanied by fidgeting or hand-wringing, which would be apparent to the nurse during an initial assessment.

The nurse identifies that additional teaching about skin care is needed when an 80 year old client makes what statement? 1. "I shower 3-4 times per week." 2. "I apply moisturizers at least daily." 3. "I bathe in the tub at least 6 times a week." 4. "I drink 64 ounces (1.89 L) of liquid per day."

A: 3 Rationale 1. This is a true statement that the older adult should bathe or shower 3-4 times a week. Du to normal aging changes the client should decrease the number of times per week that the client either bathes or showers. 2. This statement does not require further teaching. The composition of the skin changes as a person ages. The epidermis will thin and the sebaceous gland produces less oil. Applying a moisturizer at least daily will protect the epidermis and compensate for less oil being produced. 3. This client will require additional teaching about skin care. The client should not bath 6 times a week. Due the elderly client's diminished secretion of natural oils and perspiration, the client should decrease the number of times per week that the client other bathes or showers. 4. Older people may experience dry skin patches. Drinking liquids will increase the skin's sweat production which will decrease dry skin patches. Drinking 64 ounces (1.89 L) per day should be enough to keep the elderly person hydrated.

The nurse is talking to the parents of a 4 year old who is suspected to have iron deficiency anemia. What statement by the parents would suggest the cause of this anemia to the nurse? 1. "Breakfast consists of iron fortified cereal most days." 2. "A typical lunch would be a chicken sandwich with orange slices." 3. "Our child drinks 30 ounces (887 mL) of milk a day." 4. "It is difficult to get our child to eat broccoli."

A: 3 Rationales 1. 3/4 cup of 100% fortified prepared cereal provides 18 mg of iron. 2. The body's absorption of iron increases when draining citrus juice or eating other foods rich in vitamin C (oranges) while high-iron foods (chicken) are eaten. 3. Drinking excess amounts of milk may lead to iron deficiency because the calcium in milk blocks iron absorption. 4. Broccoli is rich in calcium, not iron.

The nurse on a large surgical unit needs to collect data on several clients returning from procedures. Which client should the nurse monitor first? 1. Lumbar puncture reporting a headache. 2. Cystogram reporting burning on urination. 3. Thoracentesis reporting shortness of breath. 4. Cardiac catherization with a decreased pedal pulse below insertion site.

A: 3 Rationales 1. A lumbar puncture involves removing cerebral spinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. Headache following this procedure is a potential side effect and not be the priority concern for the nurse. 2. The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a drops. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. This client is not the priority at this time. 3. A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. This client should report an improved respiratory, not shortness of breath. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should monitor this client first. 4. A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catherization. This invasive procedure results in some edema to the vessel used for the procedure but monitoring only one pedal pulse does not provide sufficient data to verify a complication.

How closely monitored is access to a facility's health information system? 1. No monitoring, password protected. 2. Monitored intermittently. 3. Monitored closely and constantly of inappropriate use. 4. Monitored only during business office hours when the system usage is the highest.

A: 3 Rationales 1. Access is monitored closely and constantly as explained above. Password protected is not enough. 2. Access is monitored closely and constantly not intermittently. 3. Access to a health care facility's computerized health information system is monitored closely and constantly. Records of each health care teach member's time and date of access, as well as the information that was accessed, are kept by the information technology services department. Access can be suspended, restricted or revoked for unauthorized or inappropriate use of the health information system. 4. Access is monitored closely and constantly as explained above.

The nurse is providing post-operative care to the craniotomy client. Diabetes insipidus is suspected when the client's urine output suddenly increases significantly. Which action takes highest priority? 1. Continue to monitor urine output 2. Check pulse 3. Check blood pressure 4. Check level of consciousness

A: 3 Rationales 1. Continuing to monitor U/O is important but I need to find out if they are already shocky. 2. Checking the pulse is a good thing, but not as important as checking the BP. 3. This is the best answer because we are "worried" this client is going into SHOCK. So... you better be checking BP. This is a time where checking the BP is appropriate. (If we "assume the worst" I better check blood pressure. It could have dropped out the bottom.) 4. If my client is going into shock, the highest priority is to assess the BP.

Two nurses are checking a unit of packed red blood cells (PRBCs) for client compatibility prior to infusion. What action should the primary nurse take after completing this process? 1. Initiate the PRBCs transfusion at 25mL/hour for the first 15 minutes. 2. Ask blood bank personnel to type and cross match for PRBCs sent to unit. 3. Send unit of PRBCs back to the blood bank. 4. Notify the primary healthcare provider.

A: 3 Rationales 1. Do not give uncrossed matched blood. This unit is not the one that was cross matched to the client. The unit numbers are different. 2. It takes a while to cross match blood and the blood cannot stay out of the refrigerator that long. And what if it is not compatible. A unit of blood has not been wasted. 3. The blood compatibility label does not match the PRBCs unit sent to the unit. Note that the donor numbers are not the same. So, this unit needs to be sent back to the blood bank and the correct unit needs to be obtained. 4. The wrong unit of PRBCs has not been hung. There is no need to contact the primary healthcare provider.

A client prescribed oral iron medication is reporting nausea after administration. What should the nurse teach the client to decrease this symptom? 1. Take the iron with a glass of milk. 2. Eat bran cereal immediately after ingesting iron. 3. Drink orange juice with the iron medication. 4. Take docusate sodium at bedtime.

A: 3 Rationales 1. Do not take iron with milk, calcium and antacids as they bind with iron to decrease amount delivered to the body. The client should wait at least two hours after having these before taking iron supplement. 2. Foods that affect absorption and should not be eaten at the same time as iron is taken include: high fiber foods such as whole grains, bran, and raw vegetables. 3. Iron is best absorbed on an empty stomach, however, if nausea and vomiting occur, drink orange juice with the iron. It will help decrease nausea and vomiting, and will enhance absorption of the iron. 4. Docusate sodium is a stool softener used to treat constipation which can occur with iron intake. But it does not help nausea.

A client with a history of intolerance to fatty foods is admitted to the hospital with a sudden onset of severe right upper quadrant pain radiating to the right shoulder. What should be included in the nurse's initial assessment of this client? 1. "Do you have pain in the middle of your stomach that is relieved by vomiting?" 2. "Have you noticed any red splotches on your skin?" 3. "Please describe your bowel habits and stool." 4. "Tell me how often you eat high fat meals."

A: 3 Rationales 1. Epgastric pain relieved by vomiting is found with clients who suffer from peptic ulcers. 2. Spider angiomas are seen in clients with liver disease. 3. Clay colored stools are a sign of biliary obstruction and are due to lack of bile in the stool. Bile adds a darker color to the stool. Asking the client to describe stool is open ended and will give the nurse more detail. 4. This does not relate to the client's pain and will not obtain needed information about the client's current condition.

A child presents to the client nurse with left knee pain after suffering a fall. What should the nurse do first? 1. Instruct the child to extend the affect knee. 2. Perform range of motion exercise on both knees. 3. Compare the appearance of the left knee to the right knee. 4. Have the chid soak the affected knee in warm water..

A: 3 Rationales 1. Extending the affected knee may cause further damage. 2. Range of motion exercises may cause further damage to the affected knee. 3. Comparing the appearance of the left knee to the right knee is the least invasive assessment and allows the nurse to assess if the there is a change in the appearance of the affected knee to the unaffected knee. 4. Soaking the affected knee in warm water will not help the nurse determine whether or not an injury occurred.

A licensed practical nurse (LPN) in a long-term care facility assigns the task of feeding a client with dysphagia to certified nursing assistant (UAP) who is in orientation. Which action should be taken by the LPN to assign this task safely? 1. Verify that the UAP has experience in feeding clients with dysphagia. 2. Ask the UAP if he/she has any questions about the correct procedure. 3. Observe the UAP during the feeding to ensure that the correct technique is used. 4. Confirm that the UAP has the knowledge needed to feed a client with dysphagia by testing.

A: 3 Rationales 1. The LPN should observe the UAP feeding the client using the correct technique. Verifying that the UAP has experience would not ensure that the UAP is proficient at the assigned task. 2. The LPN should observe the nursing assistant feeding the client using the correct technique. Simply asking if the UAP has questions would not ensure that the UAP is proficient at the assigned task. 3. The LPN should observe the UAP during the feeding to ensure that the correct technique is sued. Actually observing the UAP's performance of the task is necessary to validate that correct technique is used. 4. The LPN should observe the nursing assistant feeding the client using the correct technique. Confirming that the UAP has the necessary knowledge through testing would be too time-consuming.

A nurse is caring for clients when a new admit arrives on the unit. What action y the 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 the nurse can get there. 3. Request a nurse on the floor to initiate the assessment process. 4. Ask the unit secretary to make the client and family comfortable until the nurse can complete the present task.

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

A client who underwent a laparoscopic cholecystectomy is being discharged from an outpatient surgical center. Which statement by the client shows the LPN/VN that the RN's discharge teaching has been effective? 1. I will need to eat a low fat diet since I no longer lave a gallbladder. 2. I can expect drainage from the incision for a few days. 3. I may have some mild pain from the procedure. 4. I should plan to limit my activities and not return to work for several weeks.

A: 3 Rationales 1. The client can resume their usual diet. The liver will produce enough bile to digest fats. The gallbladder stores bile. Without the gallbladder, the bile just drains from the liver. 2. The client should not have drainage from the incisions. There are 2-3 small incisions on the abdomen that do not normally have drainage. 3. After laparoscopic procedure the client can expect to have some mild pain. Severe pain, however, would indicate a problem. 4. The client can return to normal activities in 2 to 3 days. This not considered a major surgical procedure with a large abdominal incision. Recover time is much shorter, allowing the client to return to normal activities sooner.

What is the only acceptable use of restraints by the nurse? 1. An elderly male client had a chest restraint applied after crawling over the bed rails several times. 2. An Alzheimer client's room door is closed to prevent wandering using shift change. 3. A confused client with a closed head injury had hand mitts applied after pulling out IV. 4. A dementia client is in a Geri-chair with lap belt at nurse's station at night.

A: 3 Rationales 1. There are several problems here. The client had side rails up, which are considered a form of restraint and in many facilities are no longer permitted. By applying a chest restraint, the client has been restrained twice. Just because a client is elderly does not mean restraints are needed. This restraint is not acceptable. The nurse should provide regular toileting periods and determine why this client is climbing out of bed. 2. Closing a client into a room is overly restrictive and unsafe. This Alzheimer's client needs to be observed and closing the room door prevents visual access. Additionally, closing the door may violate fire safety codes in certain facilities. At shift change, when staff is occupied with report, special arrangements should be made so that the client can be observed and not restrained. 3. Restraints are considered a last resort when caring for a client, whether soft cloth or chemical restraints. The most acceptable use is to prevent a client from harming self or others. In this sentence, a confused client has previously pulled out an ordered IV. Therefore, the use of hand mitts is the most appropriate, least restrictive method to prevent the client from further self harm. 4. Depending on the facility, placing a client upright at night, using a Geri-chair and a lap belt is overly restrictive. A client with dementia is challenging, particularly at night. However, keeping a client upright all night, belted into a chair or the purpose of observation, is neither safe nose healthy for the client.

Which client is at the greatest risk for ineffective oral hygiene? 1. A client who has just had knee surgery after a skiing accident. 2. A right-handed client who has had a stroke causing mild weakness on the left side of the body. 3. A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. 4. An independent, elderly client having elective surgery.

A: 3 Rationales 1. This client can perform oral hygiene with minimal assistance. 2. This client an perform oral hygiene with minimal assistance. 3. A client with severe nausea and vomiting after chemotherapy is at an increased risk for ineffective oral hygiene problems due to vomiting, decreased oral intake, and the effects of the chemotherapy on the normal bacterial flora of the mouth. 4. This client can perform oral hygiene with minimal assistance.

A client admitted to the Coronary Care Unit (CCU) following a myocardial infarction (MI) expresses fear of the equipment and noise in the busy unit. What is the most therapeutic response by the nurse? 1. "Everyone gets scared here at first." 2. "Why are you so afraid of equipment?" 3. "This all seems frightening to you." 4. "You won't have to be here very long."

A: 3 Rationales 1. This is a belittling response in which the nurse is focusing on everyone, rather that this specific client. It is a closed, non-therapeutic reply that discourages further interaction with the client and does not allow to further expression of feelings. 2. When a client expresses emotions, asking why demands an explanation that is necessary nor therapeutic. In most cases, clients may not be able to provide any explanation and the need to do so further restricts the potential for open communication. 3. The nurse is making a statement that reflects back the feeling of fear expressed by the client. This therapeutic communication tool acknowledges that the nurse has heard the client while providing an open-ended approach which will allow the client to continue to communicate emotions. Encouraging the client to express feelings is important. 4. Instead of focusing on the client's feelings, the nurse has changed the topic and blocked the potential for the client to communicate further. Therapeutic communication should provide open-ended opportunities in which the clients can freely express concerns.

A nurse is caring for a client who was brought into the ED with a gunshot would to the chest. There is an occlusive dressing in place and the client is receiving high flow oxygen. The nurse notes a deviated trachea, asymmetrical chest wall movement and decreased breath sounds bilaterally. What action should the nose take first? 1. Elevate the head of the bed. 2. Initiate CPR. 3. Remove the occlusive dressing. 4. Notify the primary healthcare provider.

A: 3 Rationales 1. Although elevating the HOB typically helps ease the efforts of respirations, in this case, it ll not fix the tension pneumothorax. 2. It is not necessary to start CPR at this point. The client has not arrested. The client needs emergency relief measures such as removal of dressing and possible needle decompression to prevent further deterioration and possible cardiopulmonary arrest. 3. The client has developed a tension pneumothorax as evidenced by these signs/symptoms. This developed as a result of the placement of an occlusive dressing over the chest wound. By removing the occlusive dressing the pressure pushing to the opposite side of the chest should stop. Dressings over "sucking chest wounds" should be taped down on 3 sides only to allow air to escape but not re-enter. A needle decompression may be required as an emergency measure. 4. Call the primary healthcare provider after removing the occlusive dressing. This is an emergency situation. Attempts to resolve the issue are crucial to prevent further deterioration of the client's condition.

A frightened client comes to the nurse's desk during the night and reports "I heard the voice of the devil speaking to me in my room." Which response by the nurse is priority? 1. "Could you have overheard the staff talking at the desk?" 2. "I will get you some medication for anxiety." 3. "What did the voice tell you?" 4. "You do not have to worry about this. You are safe."

A: 3 Rationales 1. In this question this is not the priority response. This is voicing doubt and also presenting reality. This response could come later in the interaction. 2. This is changing the subject. This is non-therapeutic. 3. The most important thing the nurs needs to find out is what the voice was telling the client. This is a safety issue. 4. This is giving reassurance. This can be a non-therapeutic response. However, it could be used later in the interaction if the nurse finds out the client is safe.

A woman who is 2 weeks postpartum calls the clinic stating "All I do is cry. I am so exhausted that I can't think clearly. I can't handle this anymore." What would be the most appropriate response by the nurse? 1. "You are being too hard on yourself. Being a mom is hard. Try to cheer up." 2. "It's normal to feel a little down after having a baby. Just give it some time." 3. "Have you had any thoughts of harming yourself or the baby?" 4. "When the baby starts sleeping better and you get some rest, your thinking will get better."

A: 3 Rationales 1. This belittles the client's feelings of hopelessness and gives inappropriate advice to correct the problem on her own. The client might not share any Rutherford with the nurse and the situation could become much worse, including harm to her or the infant. 2. Although many mothers do experience baby blues in the postpartum period, you would be missing critical signs that this situation is more than the baby blues if you make the statement that many mothers feel a little down and to just give it some time. During that time, this postpartum depression that was not identified could continue to worsen to the point of more severe symptoms and possible harm to herself or the infant. 3. This mother seems to be experiencing more than the baby blues that many new mothers experience. There are clues in the stem of this experience. There are clues in the stem of this question that you should recognize as warning signs of something more significant that the baby blues. The mother states that she no longer is thinking clearly and expresses that she can no longer cope with the existing situation. This mother seems to be experiencing postpartum depression that can include more sever symptoms such as suicidal thoughts of thoughts of causing harm to the baby. Therefore, it is crucial that the nurse ask a very straightforward, direct question to the mother to assess if the mother has any thoughts of harming herself or the infant. Failure to do so could put the mother and/or infant's life at risk for harm. 4. Although a lack of sleep may be a factor, telling the mother that it will get better later will not give this mother the help that she needs now. Never delay care when the health and well-being of the mother and infant could be at risk.

The nurse makes selections from the hospital menu for a client that is confused and suspicious of others. Which menu choice the best? 1. Ham and vegetables casserole 2. Cheese and crackers 3. Caffeine free tea 4. Packaged sugar free jello

A: 4 Rationales 1. A suspicious client needs to be able to identify the ingredients in the food that is being eaten. A casserole contains many ingredients and the client may fear that something has been added to the food. 2. Finger foods are best for clients that are manic. 3. Drinks and foods with no caffeine are okay for the confused and suspicious client but this menu choice is not the best choice from the list here. 4. A client that is suspicious needs foods that are packaged and can see them opened.

Which statement by a client would indicate to the nurse that the client understands important points about alendronate? 1. "It is recommended that I recline for 15 minutes after taking my medication." 2. "Food should be eaten immediately after taking alendronate." 3. "My medication tablet should be chewed for rapid absorption." 4. "I should drink a full 8 ounce glass of water with my medication."

A: 4 Rationales 1. After taking alendronate, the client should remain upright (sitting or standing) for 30-60 minutes. The client should not lie down until after eating. These actions help to decrease the likelihood of esophageal and GI associated side effects. 2. The client should wait at least 30-60 minutes before eating, drinking or taking any other medication, to increase absorption. 3. The client should not chew the medication tablet, mouth ulcers can occur when alendronate is chewed or dissolved in the mouth. 4. Alendronate is a diphosphonate drug used in the treatment of osteoporosis and other bone diseases. The client should take each tablet in the morning with a full glass of water (6-8 ounces or 180-240 mL) at least 30-60 minutes before the first food, beverage or medication of the day, to increase absorption.

A client with persistent omitting reports weakness and leg cramps. Which acid base imbalance would the nurse anticipate? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

A: 4 Rationales 1. No respiratory related, acid-base imbalance. 2. Not respiratory related, acid-base imbalance. 3. Not acidosis, there is loss of gastric acid and K with persistent vomiting. 4. Symptoms of alkalosis are often due to associated potassium loss and may include irritability, weakness, and cramping. Excessive vomiting eliminates gastric acid and potassium leading to metabolic alkalosis.

The nurse is caring for a client with fluid volume overload. What is the best position for this client? 1. Prone 2. Flat supine 3. Sims 4. Head of bed elevated

A: 4 Rationales 1. No! The prone position will not help with cardiac output or breathing difficulties from fluid volume overload. 2. No! The fat supine will not help with cardiac output or breathing difficulties from fluid volume overload. 3. No! The sims is a side lying position. This will not help with cardiac output or breathing difficulties from fluid volume overload. 4. Yes! Help the fluid move away from the heart and lungs when you sit people up cardiac output goes up - breathing is betting too!

An elderly client with a history of mild dementia and incontinence tells a nurse that an unlicensed assistive personnel (UAP) touched her private body parts in an inappropriate way. Which response by the nurse is most appropriate? 1. Inform the client that the UAP will be terminated. 2. Remind the child that dementia causes confusion, so this probably did not occur. 3. Till the client that you are sure the UAP was just perform required care. 4. Reassure the client that you will report this concern to the charge nurse and personally supervise care yourself.

A: 4 Rationales 1. The nurse does not have the authority to terminate the UAP, although the incident should be reported and thoroughly investigated, care should be taken not to falsely accuse another staff member. 2. The incident should be reported and investigated regardless of the client's medical diagnosis. 3. Any suspected abuse should be promptly reported and investigated. 4. Reassure the client that you will report this concern to the charge nurse and personally supervise care yourself. As a client advocate, the nurse must ensure that possible abuse is reported and the client is protected without falsely accusing another staff member.

The nurse is initiating the admission assessment on a client diagnosed with Parkinson's Disease. The client is slow to answer questions and appears to be frustrated trying to find the right words. Which communication technique by the nurse is appropriate? 1. Share with the client that all will be OK. 2. Introduce another health issue to discuss with the client. 3. Identify other clients who hav had communication issues. 4. Allow the client the opportunity to organize their response.

A: 4 Rationales 1. The nurse may be wanting to place the client at ease. By identifying the client's decreased communication ability the nurse may increase the client's anxiety. The nurse is using a reassuring cliche, a nontherapeutic technique, to reduce the nurse's anxiety when client's responses are delayed. 2. By abruptly changing topics with the client, the nurse is changing the direction of their communication. The nurse is leading the communication and not the client. This is a nontherapuetic communication technique of introducing an unrelated topic. 3. The nurse is utilizing the nontherapeutic communication technique of belittling feelings. The client is demonstrating their frustration after not being able to respond faster. The response by the nurse owes not identify what the client is feeling, but what others feel. This action will not reduce the anxiety of the client. 4. The nurse recognizes that the client needs additional time to communicate. By using silence, a therapeutic response, the nurse is providing the client the time to organize their thoughts. If the client is not rushed to respond, the client's anxiety may be reduced.

A nurse is collecting data on a client who is reporting bone pain secondary to cancer with metastasis to the bone. What does the nurse determine is the most important information to gather at this time? 1. The physical symptoms of the client. 2. The hemoglobin and hematocrit levels. 3. The amount of pain medication the client is receiving. 4. The client's description of the pain.

A: 4 Rationales 1. The question is asking about the client's pain. The physical symptoms are important but does not address the client's perception of their own pain. 2. RBCs are produced in the bone marrow. The H&H might be affected but will not be the cause of the pain and can be monitored later with lab and diagnostics. 3. The amount of pain medication is important, but it is not the most important information to gather from a client who is reporting pain, particularly with cancer and metastatic bone pain. 4. The most important information to gather is the client's perception and description of the pain. Pain is subjective, based on the client's perception. This is also the primary complaint of the client at this time.

The LPN is caring for a four month old infant diagnosed with respiratory syncytial virus (RSV) and placed in contact isolation. What personal protection equipment (PPEs) should the LPN use when providing care to the baby? 1. Double glove when changing the infant's soiled diapers. 2. Place face mask on infant when transported for x-rays. 3. Only gloves are necessary in order to provide infant care. 4. Wear gown and mask during feeding or burping of the baby.

A: 4 Rationales 1. There is no need for double gloving since the child's infection is spread by oral secretions. The virus is not present in either stool or urine. 2. Children in contact isolation are not to be taken outside of the room until declared infection free or the primary healthcare provider orders isolation discontinued. If an x-ray is required, that department must take ordered films in the isolation room with appropriate covers on equipment. 3. Occasionally gloves are adequate in isolation situations; however, this child's illness is spread through droplets. Therefore, the LPN should wear a gown to protect the uniform, which may come in direct contact with secretions. The tasks of feeding or burping could easily allow droplets to come in contact with the LPN's uniform and be transmitted to other client rooms. 4. The main concern is to prevent the spread of the infection, which is transmitted by respiratory secreions. This baby would be bottle fed and require burping. The potential exsists for oral secretions from burping, or even spitting up, to contaminate the LPN's uniform. Without a gown or mask, these secretions would be transmitted to other clients to whom the LPN provides care.

A fully alert and component client is in the end-stage cardiac disease. The client says, "I'm ready to die," and refuses to take nourishment. The family urges the client to allow the nurse to insert a feeding tube. What action should the nurse take? 1. Tell the family that the feeding tube will be inserted after the client becomes unresponsive. 2. Ask the primary healthcare provider to insist the client have a feeding tube. 3. After sedating the client, insert a feeding tube. 4. Inform the client that no feeding tube will be inserted.

A: 4 Rationales 1. This is inappropriate as it does not follow the client's wishes and would be a violation of client rights. 2. This again is inappropriate. The client has made the decision to refuse nourishment so this action ignores this decision and violates client rights. 3. The nurse should honor the client's wishes first. The family would only need to meet if they client became unable to make decisions on their own. Even so, these decisions could not violate any advance directives that were in place. 4. This client is alert and competent, and has the right to make healthcare decisions and the right to die with dignity. The nurse should provide any additional information as requested by the client.

The client needs assistance to apply anti-embolism stockings each day in the long-term care facility. Today, as the nurse enters the room to apply the stockings, she finds that the client has been walking about the unit for 30 minutes. What should the nurse do first to lessen the risk of swelling of the lower extremities? 1. Ask the client to lie down and place the stockings on the legs. 2. Ask the client to sit no the bedside and place the stockings on the legs. 3. Tell the client that the nurse will return later to assist with the application. 4. Elevate the extremities in bed for 30 minutes before application.

A: 4 Rationales 1. To place the stockings on immediately will cause further venous stasis and swelling. 2. The extremities should be elevated for a period of time before application. 3. This instruction alone does not give the client adequate information about the need to keep the lower extremities elevated before applying the stockings. 4. The client should have extremities elevated to encourage venous return and reduce the risk of swelling before the stockings are applied.

The night nurse on a step down unit suspects another nurse may be intoxicated. What initial action should the nurse take? 1. Ask another nurse to confirm suspicions. 2. Call supervisor to report the intoxication. 3. Confront the ruse privately in person. 4. Discuss suspicions with unit nurse manager.

A: 4 Rationales 1. When dealing with ethical or legal issues, the chain of command start with the nurse manager of the unit in question. Asking another staff nurse for a personal opinion would not provide any pertinent date and instead amounts to gossip. 2. In order to avoid undue conflict, the nurse needs to immediately alert the unit manager and not facility supervisor. The nurse manager must then manage any conflict that may result and bears the responsibility to control possible disruption resulting from re-assigning the impaired nurse's clients. 3. Direct confrontation of the allegedly impaired nurse would most likely result in denial or defensive behaviors which could place the clients at further risk. The chain of command for this staff nurse with the unit nurse manager who would be more qualified to deal with conflict resolution in the matter. 4. The greatest concern at this time is the safety of the clients to whom the intoxicated nursing is providing care. The nurse Code of Ethics dictates safe, effective care for the public with protection from incompetent or unethical practice. The chain of command for this floor nurse is to report directly to the unit nurse manager.

A military veteran with a history of post-traumatic stress disorder (PTSD) has arrived at the Crisis Center reporting an increase in nightmares, depression and anxiety. The nurse is aware the client would obtain the most immediate Rolf with what intervention? 1. Increase dose of anti anxiety medications. 2. Greater family support interaction. 3. Referral to community support group. 4. Opportunity to verbalize memories.

A: 4 Rationales 1. While it is true that a component of PTSD treatment involves either antianxiety or antidepressant medications, these drugs take several weeks to become effective. The nurse needs to provide an intervention that will give the client more immediate relief. 2. Clients with PTSD generally do benefit from family support and interaction, especially during periods of increased symptoms. However, the question requests a nursing action that would assist the client in crisis now. 3. Support groups are always beneficial for individuals experiencing long term problems, and are an invaluable resource to both client and family members. However, this question asks how the Crisis Center nurse could intervene to assist at this moment. This choice is a long term solution. 4. PTSD is an emotional response to a traumatic event, usually beginning within several months of the event, although it can be delayed for years. When a client in severe distress arrives at the Crisis Center, the priority intervention must focus on relief of client's symptoms. The best noninvasive method to alleviate symptoms is encouraging the client to verbalize both memories and feelings. Though some individuals want to forget the incident, most clients experience a decrease in anxiety by discussing the event.

A 3 year old child is being treated for asthma. The child weighs 31.5 lb (14.3 kg). The primary healthcare provider has prescribed Albuterol syrup 5 mg PO every 8 hours. What action should the nurse take? 1. Administer the dose immediately to relieve respiratory efforts. 2. Split the dose in two equal part and administer every 4 hours. 3. Notify the charge nurse that the child needs a different type of medication. 4. Notify the primary healthcare provider.

A: 4 Rationales 1. Although this option for administering the dose immediately to relive respiratory efforts sounds good, could we cause more harm to the client by administering this dose of albuterol? Yes! Relieving respiratory efforts is a goal of therapy, but hound be accomplished using safe dosages of the medication. This dose of medication should not be administered. 2. You may have realized that the single dose as prescribed was too much. But old splitting the dose in two equal parts and administering it every 4 hours be safe? No! First of all, the maximum safe dose would still be exceeded. And, as a nurse, it would be out of your scope of practice to alter an existing prescription. 3. What came to your mind when you looked at this? Did you consider if the medication is appropriate for use in a child with asthma? Albuterol acts as a bronchodilator, causing relaxation of the bronchial smooth muscles in the airways and is used to manage asthma and acute broncospasm. The exhibit provides safe dosing information for a 3 year old child, so it is an appropriate agent for use in this child with asthma. Notifying the charge nurse that the child needs a different type medication would not be appropriate. 4. The nurse is responsible for assuring that medications are administered safely. One aspect of safe medication administration is to assure that the prescribed dose is safe for administration. For this child, the maximum dose that should be administered is 0.2 mg/kg PO every 8 hours. So, we need to determine how much albuterol this child, weighing 14.3 kg can safely have. To calculate this, we would first use the child's weight in this recommended dose formula: the maximum amount is 0.2 mg X 14.3 kg = 2.86 mg every 8 hours. The exhibit also says not to exceed 4 mg every 8 hours, which is prescribed amount exceeds. Remember, the maximum dose based on the individual child's weight is the safest guideline to use. The prescription for this child is to receive 5 mg PO every 8 hours. Is this a safe dose? No! Therefore, the nurse should not administer the medication and should promptly notify the primary healthcare provider. Administering the prescribed dosage could be dangerous to this child.

The nurse is talking with a parent regarding childhood immunizations. What vaccination is recommended for children at 12 months? 1. Pertussis 2. Rotovirus 3. Tuberculosis 4. Varicella

A: 4 Rationales 1. The 4th dose of pertussis is given at 15 months in the US and 18 months in Canada. 2. Rotovirus is recommended in the US at 2, 4, and 6 months and at 2 and 4 months in some areas of Canada. 3. Bacille Calmette-Guerin (BCG) is a vaccine for tuberculosis (TB) disease. This vaccine is not widely used in the United States or Canada, but t is often given to infants and small children in other countries where TB is common. 4. The first varicella vaccine is recommended at 12-18 months in the US and 12-15 months in Canada.

Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is in the acute phase of mania? 1. Sit with the client during meals to encourage the client to eat all foods on the tray. 2. Assess the client's food preferences and provide only those foods for the client at meal time. 3. Allow the client to eat in the dining room with other clients. 4. Provide high-protein, high calorie snacks on the nursing unit between meals.

A:4 Rationales 1. The client in the acute phase of mania may have difficulty sitting still long enough to eat a meal. By offering finger foods or foods that can be eaten on the run the client's food intake may increase. 2. The client's diet will include the client's food preferences, but not just those foods. 3. The client will be easily distracted when manic. Eating in the dining room with other clients may decrease the amount of food intake. 4. Having nutritious foods available between meals may help to increase the client's food intake. Nutritious intake is required on a regular basis to compensate for increased caloric requirements due to the hyperactivity.

The nurse is assigned five clients on a medical floor. When planning care, the nurse recognizes which clients to be at greatest risk for ineffective oral hygiene? 1. A client who has just had knee surgery taking opioids for pain. 2. A right handed client who had a stroke affecting the right hemisphere of the brain. 3. A client with breast cancer who is experiencing sever nausea and vomiting after chemotherapy. 4. An elderly client experiencing loss of appetite. 5. A client who takes phenytoin for partial seizures.

A; 3, 5 Rationales 1. This client can perform oral hygiene with minimal assistance. Knee surgery and opioid pain medication do not interfere with oral hygiene. 2. Movement for one side of the body is controlled by the opposite side of the brain. If stroke affects the right side of the brain, then you will have trouble with the left side of your body. Since this client is right handed and his left side is affected, the client can perform oral hygiene. 3, 5. A client with severe nausea and vomiting after chemotherapy is at an increased risk for ineffective oral hygiene problems due to vomiting, decreased oral intake, and the effects of the chemotherapy on the oral mucosa. Phenytoin causes gingival overgrowth, swelling and bleeding of the gums. This can make oral hygiene more difficult. 4. This client can perform oral hygiene with minimal assistance. There is no information in this option that would put this client at risk for ineffective oral hygiene.