LPN Practice question

A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts, "You think you're so perfect, pure and good." How should the nurse respond?

"You sound angry right now."

A 12 year-old child, admitted with a broken arm, is waiting for a scheduled surgery. The nurse finds the child crying and unwilling to talk. What would be the most appropriate initial response by the nurse? Reassure the child that the surgery will go fine with no problems Provide privacy with encouragement to work through feelings Distract the child with a choice of activities to do while waiting for surgery Make arrangements for friends to visit as soon as possible

A 12 year-old child needs the opportunity to express emotions privately. The incorrect responses may provide distraction and are not client-focused to deal with the observed behavior of crying. b.

A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer feedings and medications. Which nursing action is best to ensure patency of the tube? Encouraging the client to cough to relieve abdominal bloating prior to or following a feeding Adequately flushing the tube with water before and after use Completely crushing all medications prior to administration Squeezing the tube to dislodge obstructions

A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer feedings and medications. Which nursing action is best to ensure patency of the tube? Encouraging the client to cough to relieve abdominal bloating prior to or following a feeding Adequately flushing the tube with water before and after use Completely crushing all medications prior to administration Squeezing the tube to dislodge obstructions b.

The registered nurse (RN) has initiated the administration of an intravenous vesicant chemotherapeutic agent to a client. Which finding during the care by a practical nurse (PN) would require the PN to immediately notify the RN? A rash on the client's extremities Complaints of pain at the infusion site Stomatitis lesions in the mouth Severe nausea and vomiting

A vesicant is a chemotherapeutic agent capable of causing blistering of tissues and possible tissue necrosis if there is extravasation. These agents are irritants that cause pain along the vein wall, with or without inflammation. When deciding on the best response, think about which option would create the worst outcome for the client receiving IV medication. b.

A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse's explanation should include which of these comments? "It tells us how far along your pregnancy is." "It can help identify potential neurological defects." "The results help determine if the baby is growing normally." "The placental exchange of oxygen is measured."

AFP is a substance made in the liver of the fetus. A fetus with neural tube defects, such as spina bifida and anencephaly, loses AFP to the amniotic fluid and, consequently, to maternal blood. The blood test is performed between the 15 and 17 weeks of pregnancy and can be used as part of a screening test to find chromosomal problems, such as Down sydrome. b.

A nurse is caring for a client who has been diagnosed with acute sickle cell vaso-occlusive crisis. Which intervention by the nurse would be most important?

Administer analgesic treatment as ordered

When reinforcing teaching about a new prescription for nortriptyline to a client diagnosed with depression. What information should the nurse emphasize?

Alcohol use is to be avoided

Where should the nurse administer the annual purified protein derivative (PPD) to the client with a left arm Permcath™?

Always avoid using the arm with a shunt so as to prevent restriction of blood flow and possible clotting or rupture of the fistula. Using the opposite forearm for the PPD administration also reduces the chance for infection.

The nurse is caring for a 75 year-old client with type 2 diabetes mellitus. The client should be instructed to contact the outpatient clinic immediately if which findings are present?

An open wound on the heel with minimal discomfort

A client has a diagnosis of heart failure. Which intervention is most important for the nurse to implement prior to the administration of digoxin?

Assess the apical pulse, counting for a full 60 seconds

A practical nurse (PN) team member identifies that the fundus is boggy for a woman who is gravida 4 para 4 and is two hours after a spontaneous vaginal delivery. The fundus is displaced slightly above and to the right of the umbilicus. What should be the initial nursing action?

Assist the woman to empty her bladder

A nurse gathers data related to delayed gross motor development in a 3 year-old client. Which observation by the nurse should confirm this finding? Cannot ride a bicycle Cannot catch a ball Cannot skip on alternate feet Cannot stand on one foot

At this age, gross motor development allows a child to balance on one foot. A child who is 3 years old should be able to hop, ride a tricycle and throw a ball (but they would have trouble catching it). Most young children with fetal alcohol syndrome, for example, show delays in motor skill development (both fine and gross motor). d.

A child has severe burns to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse should care for this client with the knowledge that the most important reason for such a diet is to achieve which result? Provide a well-balanced nutritional intake Promote healing and strengthen the immune system Spare protein catabolism to meet metabolic and healing needs Stimulate increased peristalsis and nutrient absorption

Because of the severe burn injury, the child has an increased metabolism and catabolism. By providing a high-carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then used to restore and aid in the healing of tissues. Notice that the correct response includes a word used in the question ("protein"). c.

The nurse is caring for a client who is diagnosed with chronic renal failure with hemodialysis three times per week. The client becomes confused and irritable six hours before the next treatment. Which of these findings might explain the reason for the client's behavior? Low potassium level Elevated blood urea nitrogen (BUN) Low calcium level Metabolic alkalosis

Confusion and irritability are findings of renal encephalopathy secondary to elevated levels of BUN and creatinine in the blood. Potassium levels are generally high in renal failure along with phosphate levels. Calcium may be low in chronic renal failure. However, the side effects of low calcium levels are exhibited as abdominal or muscle cramping, parasthesias of the extremities, and hyperactive reflexes. Metabolic acidosis, not alkalosis, results from renal failure.

In checking a postpartum client, the nurse palpates a firm fundus. However, the nurse also observes a constant trickle of bright red blood from the vaginal opening. What should the nurse suspect? Retained placenta Clotting disorder Vaginal lacerations Uterine atony

Continuous bleeding in the absence of a boggy fundus indicates undetected vaginal tract lacerations. If you are not sure about the correct response, re-read the responses and you should note that three of the (incorrect) options would result in excessive bleeding, and not a "trickle." c.

Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment?

Decreased lethargy

The nurse is caring for a postoperative client. What is the priority nursing intervention the nurse will reinforce for preventing atelectasis? Turn, cough and breathe deeply Ambulate client within 12 hours Maintain adequate hydration Splint incision when moving or coughing

Deep air excursion by turning, coughing and deep breathing will expand the lungs and stimulate surfactant production. This is the best way to prevent atelectasis. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in prevention of atelectasis following surgery. However, they are not the priority. a.

The nurse is reinforcing information about the side effects of fluoxetine to a client. Which group of findings should be included?

Diarrhea, dry mouth, weight loss, reduced libido

The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery?

Dry off infant with a warm blanket or towel

A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What should be the next action of the nurse? Arrange to change client-care assignments Discuss with the parent the appropriate use of "time-out" Explain to the mother that the child needs extra attention Explain to the parent that this behavior is expected

During normal development, fear of strangers becomes prominent beginning around age 6 to 8 months. Such behaviors include clinging to parent, crying and turning away from the stranger. These fears and behaviors extend into the toddler period and may persist into preschool.

A nurse is discussing with a client the precautions with warfarin. The nurse should tell the client to avoid foods with excessive amounts of what substance? Iron Calcium Vitamin E Vitamin K

Eating foods with excessive amounts of vitamin K (often contained in green leafy vegetables) may affect anticoagulant effects.

A nurse discusses the healthy use of both conscious and unconscious defense mechanisms with a group of clients. An appropriate goal for these clients would be to use these mechanisms for which purpose? Foster independence with better communication Protect the ego and diminish anxiety Eliminate anxiety and apprehension Avoid conflict and unpleasant consequences

Ego defense mechanisms are unconscious proactive barriers that are used to manage instinct and affect the presence of stressful situations. Healthy reactions that use both types of defense mechanisms are those in which clients admit that they are feeling various emotions.

A client is admitted with newly diagnosed hypothyroidism. A nurse would expect the client to exhibit which finding until the client achieves a euthyroid state with therapy? Heat intolerance Diarrhea Tachycardia Lethargy

Euthyroid is the state of having normal thyroid gland function. Hypothyroidism produces manifestations of a slowed metabolism, including lethargy. Heat intolerance, diarrhea and tachycardia are manifestations of increased metabolism, hyperthyroidism. The key words in this question are "hypothyroidism" and "antated findings." As you read each answer option, ask yourself if it sounds like a "hypo" function of the body - only one option is related to "slowing down." d.

A client diagnosed with head trauma is in a non-responsive state. Vital signs are stable and breathing is regular and spontaneous. What should the nurse document to accurately describe the client's status?

Glasgow Coma Scale 8, respirations regular

A pregnant client comes to the clinic for a first visit. A nurse gathers data about her obstetric history, which includes: three year-old twins at home and a miscarriage at 12-weeks gestation 10 years ago. Which documentation should the nurse make?

Gravida 3 para 1

A 6 year-old child is hospitalized with findings of moderate edema, gross hematuria and mild hypertension associated with the diagnosis of acute glomerulonephritis (AGN). Which nursing intervention would be appropriate for this client? Weigh the child twice per shift Relieve boredom through physical activity Institute seizure precautions Encourage the child to eat protein-rich foods

If AGN is untreated, renal failure, seizures and heart failure may result. Clients with AGN should restrict salt intake during the acute phase to control edema and volume-related hypertension. A protein-restricted diet may also be indicated. Underlying infections would be treated with antibiotics. Nursing care would include frequent monitoring of blood pressure, daily weights, intake and output, and seizure precautions. c.

The nurse has been reinforcing information about cardiac risks to adult clients when they visit the hypertension clinic. What would be the best way to determine if learning has occurred? Performance on written tests Completion of a mailed survey Responses to verbal questions Reported behavioral changes

If a client alters any behaviors, such as smoking, drinking alcohol and stress management, this would suggest that learning has occurred. d.

A child is admitted to the unit with findings of nasal congestion and cough with periods of cyanosis and dehydration. The suspected diagnosis is pertussis (whooping cough). What is the priority nursing intervention for this child?

Implement droplet precautions along with standard precautions

A nurse is assigned to care for a 10 month-old infant with the new diagnosis of anemia. Which of these findings should the nurse anticipate? Behavior consistent with hyperactivity Slow heart rate when sleeping Pale mucosa inside the mouth High hemoglobin level

In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing child with mild to severe tachycardia. The skin may have a waxy appearance. Anemia that is severe can cause a lack oxygen to the body, causing the skin color to become an ashen, dusky gray instead of the classic skin color of cyanosis with oxygen deficiency. The hemoglobin level would be low rather than high in anemia. c.

A nursing student asks the licensed practical nurse (LPN) to explain the forces that drive health care reform. When responding to the student's question, what information should the nurse emphasize?

Increase in health care spending that's growing faster than the economy

A client is diagnosed with a severe mental illness. What is the priority goal of involuntary hospitalization? Protection from harm to self and others Return to independent functioning Elimination of negative findings Reorientation to reality

Involuntary hospitalization may be required for clients considered dangerous to self or others, or for individuals who are considered severely disabled by their illness. Remember that safety is always a priority. Although one of the goals of hospitalization is to restore maximum independent living as quickly as possible, this the reason why a person is involuntarily hospitalized. a.

When reviewing the medication lithium with a client, the client asks, "How long will it take before I can feel the effects of the medication?" Which response by the nurse is the best? "About two weeks" "One month" "Immediately" "Several days"

Lithium is a fast-acting mood stabilizer and quite effective in controlling mania soon after starting the medication. But it may take several weeks for it to reach maximum effectiveness. a.

When a client returns from surgery after an open reduction with cast application for a femur fracture, a small blood stain is noted on the cast by the nurse. Four hours later, the nurse observes that the stain has doubled in size. What is the initial action for the nurse to take at this time? Ask the family members to call you when they notice the spot getting larger Record the findings in the nurse's notes Outline the spot with a pen and note the time and date on the cast Report the finding to the registered nurse (RN) charge nurse

Marking the outline of the drainage is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive; some bleeding is expected with open reduction surgeries. The nurse should inform the RN and then record the finding. c.

A hospitalized infant is receiving gentamicin. Which nursing intervention should receive priority in the plan of care?

Monitor the infant's urine output

A 6 month-old infant is being treated for developmental hip dysplasia and has been placed in a hip spica plaster cast. Which discharge information is important for the nurse to reinforce with the parents? Turn the baby every two hours using the abduction stabilizer bar Check frequently for swelling in the baby's feet Gently rub the skin with a cotton swab to relieve itching Place favorite books and push-pull toys in the crib

Notice that only two of the options focus on cast care. Of those two options, the crossbar on the cast should never be used to lift or move the child. The parents of a child in an initial hip spica cast must check for circulatory impairment. The nurse should reinforce the importance of observing the extremities for swelling, discoloration, movement and sensation. Remember to look for the six Ps of impaired tissue perfusion: pain, paresthesia, pallor, pulselessness, paralysis and poikilothermia (coolness). Sometimes blowing cold air (never warm or hot) from a hand-held hair dryer into the cast can help with itching, but care should be taken never to insert anything into the cast. b.

The client underwent a total hip arthroplasty 48 hours ago. The client has been up in a chair and is prescribed physical therapy twice daily. What type of nursing care is needed for this client? (Select all that apply.) Remind the client not to bend the knee of the affected leg when sitting Empty the wound suction drainage device every 4 hours Place a soft foam triangular pillow between the client's legs when in bed Assist the client with a clear liquid diet Provide a seat riser for the toilet or commode Encourage client to perform leg exercises when in bed

On the first post-operative day following a total hip arthroplasty, the client will be up in a chair. The client should bend the affected leg at the knee when sitting in a chair - not keep it straight. Two days after surgery, the client will be walking in the hallway. When in bed, the client should continue to perform leg exercises and use a pillow or foam wedge between his or her legs (to keep the legs abducted.) The drain is usually removed the second day after surgery; there should be little-to-no drainage on the second post-op day. The client can eat a regular diet after surgery. c.e.f.

A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What should the nurse understand about the purpose of this procedure? a. The surgical repair of a diseased coronary artery b. An noninvasive radiographic examination of the heart c. A process to compress arterial plaque to improve blood flow d. The placement of an automatic internal cardiac defibrillator

PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization. c.

The client is diagnosed with Parkinson's disease (PD) and takes more than one hour to dress for scheduled therapies. Based on this finding, what is the most appropriate nursing intervention? Allow the client the time needed to dress Encourage the client to dress more quickly Ask family members to dress the client Demonstrate methods on how to dress more quickly

Parkinson's disease is a degenerative neurological disorder resulting from nerve cells in the brain not producing enough dopamine, which regulates movement. People with PD experience tremors, muscle stiffness, slow movement, rigidity and poor balance and coordination. With careful planning and activity modification, the client can maintain his ability to safely care for himself. The nurse should plan for and allow enough time for the client to meet his own needs when dressing, toileting and bathing. a.

A nurse is caring for a child being discharged after a tonsillectomy. Which instruction is appropriate for the nurse to reinforce with the parents? Report a persistent cough to the health care provider The child can return to school in four days Administer chewable medication for pain The child may gargle as necessary for discomfort

Persistent coughing should be reported to the health care provider because this may indicate bleeding. a.

A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The nurse comments to a colleague: "I wonder if he has any idea how ridiculous he looks - he's a grown man!" The nurse's comment is an example of what type of attitude?

Prejudice

A newborn has hyperbilirubinemia and is being treated with a biliblanket. Which intervention is indicated during this therapy?

Provide more frequent feedings

The nurse is caring for a postoperative client following a closed reduction of distal tibia and mid-femur fractures. The client has a long leg plaster cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 F (39.4 C). What should be the first action by the nurse? Check the distal circulation of the casted extremity Obtain the pulse oximetry reading Measure the client's blood pressure in the supine and Fowler's positions Check the orientation to time, place and person

Restlessness, confusion, irritability and disorientation may be the first signs of fat embolism syndrome. The nurse needs to confirm or rule out hypoxia first and then check for infection or sepsis. Fat embolism most often occurs 24 hours after the fracture of the long bones. b.

A nurse is caring for a client with pneumococcal pneumonia. Which breath sounds would the nurse expect to disappear as the client responds to the antibiotic treatment?

Rhonchi

The nurse assists with the reinforcement of information about breast self-examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement?

Right after the period, when your breasts are less tender."

A nurse is caring for a woman two hours after a vaginal delivery. Documentation indicates that the membranes ruptured 36 hours prior to delivery. Which of these nursing diagnoses should the nurse expect the charge nurse to list as a priority at this time?

Risk for Infection

A client is diagnosed with a Salmonella infection. What is a primary nursing intervention to be taken to minimize the transmission of disease from this client? Double glove when in contact with feces or emesis Wash hands thoroughly before and after any client contact Wear gloves when disposing of contaminated linens Use gloves when in contact with body secretions

Salmonella is usually transmitted to humans by eating food contaminated with animal feces. Thorough hand washing can help prevent the spread of Salmonella. Note that the question asks for the primary action. Also note that it does not state a geographic location, such as in a home or in an acute care agency. b.

A newly admitted client reports taking phenytoin for several months. Which of the following assessments should the nurse be sure to include in the admission report? (Select all that apply.) Report of unsteady gait, rash and diplopia Report of any seizure activity Serum phenytoin levels Report of anorexia, numbness and tingling of the extremities

Serious adverse outcomes of antiseizure medications such as phenytoin (Dilantin) are unsteady gait, slurred speech, extreme fatigue, blurred vision or feelings of suicide. Increased hunger (not anorexia), increased thirst or increased urination are additional serious side effects. a.b.c.

A client is admitted to the mental health inpatient unit with a diagnosis of major depression after a suicide attempt. In addition to expressions of sadness and hopelessness, the nurse anticipates observing which characteristics? Meticulous attention to hygiene, grooming Anxiety, hostility Psychomotor retardation, agitation Guilt, indecisiveness

Somatic or physiologic findings of depression include fatigue, psychomotor retardation or psychomotor agitation, chronic generalized or local pain, sleep disturbances, disturbances in appetite, gastrointestinal complaints and impaired libido. Notice the data given in the stem relates to feelings and the question is asking: what findings other than feelings might be observed? Because two of the options deal with feelings or emotions, these can be eliminated. Compare the remaining options and determine which behavior is most likely to occur with a diagnosis of depression - attention to grooming and hygiene or psychomotor retardation and agitation. c.

The client undergoes a gastrectomy. Several hours after surgery, the nasogastric (NG) tube stops draining. What action does the LPN anticipate the RN will take first? Reposition the tube Increase the amount of suction Gently irrigate the tube with sterile normal saline Notify the surgeon

The RN will assess the position and patency of the NG tube, as well as the color and amount of gastric drainage. The RN can gently irrigate the NG tube with sterile normal saline if it becomes clogged. But if that does not resolve the issue or if repositioning the tube is needed, the RN must call the surgeon. The NG tube inserted in surgery should not be repositioned by a nurse because of the risk of disrupting any internal sutures. It would be contraindicated to increase the suction. c.

A nurse is observing an 8 month-old client. Which behavior would the nurse anticipate the infant to be able to display? Pull up to stand Use a spoon Say two words Sit without support

The age that a normal child develops the ability to sit steadily without support is from seven to eight months. d.

A client exhibits many delusional thoughts. As the nurse assists the client to prepare for breakfast, the client comments, "Don't waste good food on me. I'm dying from this disease I have." Which response by the nurse would be the best? "None of the laboratory reports show that you have any physical disease." "Try to eat a little bit. Breakfast is the most important meal of the day." "I know you believe that you have an incurable disease." "What has your primary health care provider told you?"

The correct response is one that does not challenge the client's delusional system and provides some reassurance of a desire to help the client. The comment does not confirm the client's comment but simply reflects that the nurse has listened and heard the comment. c.

The nurse is assessing a client who has been treated long-term with glucocorticoid therapy. Which finding might the nurse expect? Jaundice Peripheral edema Buffalo hump Increased muscle mass

The most common side effects of glucocorticoid therapy include increased appetite (and weight gain), increased blood sugar, change in body shape (increase in fatty tissue on the trunk with thinner legs and arms), acne, thinning of the skin and easy bruising. The client may also have a hump behind the shoulders; the hump is an accumulation of fat on the back of neck. c.

A nurse is providing home care for a client diagnosed with chronic heart failure and episodes of pulmonary edema. Which nursing diagnosis should the nurse expect as a priority in the plan of care? Activity intolerance related to an imbalance of oxygen supply and demand Imbalanced nutrition related to poor appetite Risk for impaired skin integrity related to dependent edema Constipation related to reduced activity level

The primary problem resulting from a decreased cardiac output in heart failure is activity intolerance. Dyspnea and fatigue are common, worsening as the heart function worsens; therefore, changes in activity tolerance are important indicators of problems with or improvement in the heart's condition. This option is the only nursing diagnosis that addresses both the cardiac and pulmonary aspects of the question. a.

A client tells a nurse about an Internet site that claims bupropion was taken off the market because it caused seizures. What would be an appropriate response by the nurse?

There were problems and the recommended dose was changed."

A nurse has reinforced teaching for a client who is being discharged after an arterial revascularization of the right lower extremity. Which statement made by the client is incorrect and requires further discussion with the nurse? "Smoking will decrease the circulation to my leg" "Coughing and deep breathing are important for a few weeks." "I will put my right leg through a full range of motion." "I might feel a throbbing pain in my right leg."

To prevent arterial occlusion after arterial revascularization, the nurse should have the client avoid full range of motion. This prevents stress or kinking of the grafts. A throbbing pain may indicate that the blood supply is increasing in the surgical area and this is a desired effect. Smoking causes vasoconstriction and will contribute to occlusion. Coughing and deep breathing are important after any surgery. c.

A nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness should the nurse recognize as being associated with an increased the risk for the development of Reye's syndrome?

Varicella

The licensed practical nurse is caring for a client with advanced cirrhosis of the liver. Which finding should receive immediate follow-up by the charge nurse? Jaundice Anorexia Hematemesis Ascites

Vomiting of blood may indicate hemorrhage, especially from esophageal varices. This condition can be life-threatening, requiring immediate intervention. c.

A nurse is caring for a client diagnosed with obesity and osteoarthritis of the knees. During reinforcement of the teaching given by the registered nurse (RN), the practical nurse (PN) should know that which health practice should have the greatest benefit on the client's outcome?

Weight reduction

A nurse is working with parents to plan home care for a toddler with a heart problem. What should be the priority nursing intervention on the plan of care? Assist the parents to plan quiet play activities with the toddler at home Stress to the parents that they will need relief care givers Instruct the parents for them and the toddler to avoid contact with persons with infection Encourage the parents to enroll in child cardiopulmonary resuscitation (CPR) class

While all suggestions are appropriate, the priority education focus of the parents/caregivers should include techniques of CPR in order to provide for emergency care for their child. When all the options are correct, you need to decide which option is the most important and most closely associated with the client or problem. You will also note that three of the options deal with play, the caregivers, and the parents/toddler respectively. Only the correct response relates to heart activity (CPR). d.

A 14 month-old child ingests a half a bottle of baby aspirin (81 mg) tablets. Which finding should a nurse expect to see in the child?

n/v

A pregnant woman has been advised to alter her diet during pregnancy by increasing the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet choice would best meet the woman's needs?

Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries

The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the priority action by the nurse to accurately assess correct placement of the G-tube? Listen for active bowel sounds in all four quadrants Measure the pH of stomach content aspirate Auscultate the abdomen while instilling 10 mL of air into the G-tube Measure the length of tubing from the insertion site each shift

When pH strips are available, the priority action is to measure the aspirate's pH. Prior to each intermittent feeding, gastric pH is usually less than or equal to 5. Do not use an auscultation method to check tube placement because it is not reliable. The nurse should also assess bowel sounds; in the absence of bowel sounds, the nurse should hold the feeding and notify the charge nurse. Additionally, the nurse should verify that the external length of the tube has not changed. b.

A client with testicular cancer has had a unilateral orchiectomy. Prior to discharge the client expresses his fears related to the prognosis. Which statement should be the initial response by a nurse? "Self-examination needs to be continued in order to prevent and detect recurrences." "Chemotherapy is most likely to be started right away." "Adoption may be a consideration if you want children." "Testicular cancer has a very high cure rate with early diagnosis and treatment."

With early detection, diagnosis and treatment, the cure rate in testicular cancer is around 95%. The other comments are correct about testicular cancer but would not be the initial response to the client's question. d.

The nurse is reinforcing dietary instructions to the parents of a child diagnosed with cystic fibrosis. The nurse will emphasize which of the following characteristics of this diet? A gluten-free diet, avoiding foods that contain wheat, rye and barley Balanced, high calorie diet with extra fat, salt, protein and calcium Foods low in sodium, potassium and phosphorus Carbohydrate counting, selecting foods from the bread/starch, fruit, or milk group

A child with cystic fibrosis needs a well-balanced, high calorie diet that includes extra fat, salt, and protein. Children with CF are at risk for osteoporosis, which is why they need full fat dairy products. Carbohydrate counting is recommended for children with diabetes. Foods low in sodium, potassium and phosphorus are tips for people with chronic kidney disease. A gluten-free diet is the only treatment for celiac disease. b.

The nurse is discussing an illness with a 10 year-old child. What should the nurse keep in mind about this child's ability to understand the information at this stage of development? Makes simple association of ideas Bases conclusions on abstract thinking Interprets events from own perspective Thinks logically to organize facts

According to Piaget, the child is in the concrete operational stage and is capable of mature thought when allowed to manipulate and organize objects or thoughts. School-age children tend to focus on "rules," which helps to organize facts. The other options are either too advanced or not advanced enough. d.

The client is diagnosed with heart failure and oral digoxin is prescribed. What is the priority nursing assessment for this medication? Monitor serum electrolytes and creatinine Measure apical pulse prior to administration Maintain accurate intake and output ratios Monitor blood pressure every 4 hours

Digoxin is an antiarrhythmic and an inotropic drug. It works to increase cardiac output and slow the heart rate, which is why the nurse should measure the apical pulse for one minute prior to administering the drug. The nurse will withhold the dose and notify the health care provider if the apical heart rate is less than 60 bpm (adult). Intake and output ratios and daily weights should be monitored for clients in heart failure, but this is not the priority. Impaired renal function may contribute to drug toxicity, which is why the nurse should monitor serum electrolytes, creatinine and BUN; the nurse should also monitor serum digoxin levels. b.

A client asks the nurse for information about a living will. Which statement made by the client demonstrates an understanding of a living will? (Select all that apply.) "It lists all my assets and how they should be divided among my family after I die." "I should sit down and discuss my wishes for end-of-life care with my loved ones." "A living will must be renewed by a designated family member each time I am hospitalized." "A living will is a legal document that becomes a permanent part of my health care record." "My wishes for end-of-life treatment are stated in writing." "I will need to identify someone to be my health care proxy."

An advance health care directive is also known as a living will. It is a legal document in which a person specifies his or her wishes concerning medical treatments at the end-of-life, when s/he is unable to make those decisions. Advance care planning involves sharing personal values and wishes with loved ones and selecting someone, (called a medical power of attorney or health care proxy) who will eventually make medical decisions on the client's behalf. A living will does not expire; it remains in effect unless it is changed. A living will does not include information regarding assets or a person's estate. b. d. e. f.

A client returns from the operating room after a right orchiectomy. What is the priority nursing intervention during the immediate postoperative period? Manage postoperative pain Maintain fluid and electrolyte balance Control bladder spasms with PRN medication Ambulate the client within a few hours after surgery

Due to the location of the incision, pain management is the priority. Bladder spasms are more related to postoperative prostate surgery than testes removal. a.

A nurse is monitoring the client's initial postoperative condition after a total thyroidectomy. Which findings should the nurse expect as complications and report immediately to the registered nurse (RN)? Paresthesia and muscle cramping Mild dysphagia and hoarseness Headache and nausea Irritability and insomnia

Because the parathyroid gland may be damaged in this surgery, secondary acute hypocalcemia may occur. Findings of hypoparathyroidism include tetany, paresthesia, muscle cramps and seizures. Mild dysphagia and hoarseness is an expected postoperative finding and may last for six to eight weeks after surgery. a.

The nurse is caring for a client who is one-day postoperative with a T-tube following a cholecystectomy. What color would the nurse expect the drainage from the client's T-tube to be? Dark brown Green Yellowish-brown Orange

Bile, which is yellowish-brown, is the expected drainage from a T-tube. Green is characteristic of normal gastric secretions. c.

A nurse is talking to parents about the side effects of routine immunizations. Which finding should the nurse reinforce about calling the health care provider if it occurs within 24 to 48 hours after a routine immunization? Localized tenderness at the injection site Tympanic temperature of 104 F (40 C) Some irritability and fussiness Swelling at the injection site

Body temperature greater than 104 F (40 C) should be immediately reported to the health care provider. Another adverse reaction to report is inconsolable crying (sustained crying for more than three hours). b.

An 80 year-old client is scheduled for a cardioversion. The nurse is reviewing the client's medication administration records for the previous 24 hours. Which medication would prompt the nurse to notify the health care provider? Diltiazem (Cardizem) Digoxin (Lanoxin) Nitroglycerine ointment Metoprolol tartrate (Toprol XL)

Digoxin increases ventricular irritability and increases the risk of ventricular fibrillation following cardioversion. The other medications do not increase ventricular irritability. b.

There's a new order to apply one-inch of nitroglycerin paste to the client's chest every 12 hours, but the medication is not in the automatic medication dispensing system's drawer for this client. What should the nurse do next? Use another client's nitroglycerin paste until pharmacy sends a tube for this client Substitute an equivalent amount of nitroglycerin sublingual spray from the crash cart Call the pharmacy to send up a tube of nitroglycerin paste Call the prescriber and ask to substitute a different formulation of nitroglycerin

The nurse must call the pharmacy and ask to have the medication sent to the floor. It is never acceptable to borrow another client's medication; this is an example of at-risk behavior, commonly referred to as a "workaround." The nurse can never substitute one formulation of a medication for another, without a specific order to do so. Giving a medication without an order would be considered a medication error and is an example of working outside the nurse's scope of practice. c.

A 3 year-old child is brought to the health clinic. The grandmother reports that the child is always "scratching his bottom" and is "extremely irritable." Based on this information, which health issue would the nurse assess for initially? Pinworm Scabies Ringworm Allergies

Findings of pinworm infection include intense perianal itching. The itching is usually worse at night, which is why the child will also exhibit poor sleep patterns, general irritability, restlessness, bedwetting, distractibility and a short attention span. The eggs will stick to a piece of clear cellophane tape placed against the rectum and the eggs can be seen under a microscope. The nurse can also take some samples from under the child's fingernails to look for eggs. Recall tip: the "P in worms" are found where the "pooh" comes out - the anal/rectal area. Scabies is an itchy skin condition caused by a tiny mite that burrows under the skin, causing small, itchy bumps or blisters; the most commonly affected areas of the body are the hands and feet. Ringworm is a fungus with characteristic round, itchy irritations on the skin. a.

The family member tells an admitting nurse that the client values the practice of Chinese medicine. The nurse must understand that for this family and client a priority goal should take which focus? Achieve harmony Respect life in old age Maintain energy balance Restore yin and yang

For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang. The key here is the term "Chinese medicine." The word "restore" in correct option can be associated with the word "medicine" in the stem because medicine restores function. d.

The client is diagnosed with infective endocarditis of the tricuspid valve. Which finding suggests a complication of this condition? Pronounced wheezes Pain on deep inspiration Sudden back pain Sudden dyspnea

For the client with infective endocarditis, vegetation growing on the infected heart valves on the right side of the heart can break off and travel in the blood to lodge in a blood vessel in the lung. This is known as pulmonary embolism (PE). A significant piece of evidence of this is sudden dyspnea, as well as a sudden decrease in oxygen saturation. The breath sounds associated most with PEs are diminished or absent, not pronounced. A spike in temperature is more commonly from bacterial pneumonia, urinary tract infection, or otitis media than PE. Vegetation from the infected heart valves on the left side of the heart would lead to the complication of cerebral infarction or finding of a stroke, or ischemia of other peripheral blood vessels. d.

The client is receiving a thrombolytic agent to open a clot-occluded coronary artery following a myocardial infarction. Which finding would be the greatest concern and should be immediately reported to the registered nurse? Hematemesis Pink-tinged saliva Serosanguinous drainage from the IV site Slight rust-colored urine

Frank bleeding should be of the greatest concern. Even though the other options indicate bleeding and would be a concern, they are not as acute or severe as someone who is vomiting blood. a.

A client diagnosed with gout is admitted with severe pain, swelling and redness in the proximal toe joint of the right foot. The nurse should anticipate that the plan of care would include which focus? High-protein diet Fluid intake of at least 3000 mL/day Acetaminophen for inflammation Hot compresses to affected joints

Gout is a very painful condition in which uric acid crystals collect in a joint causing severe pain and inflammation. Fluid intake should be increased in the client with gout to prevent kidney stones from precipitation of urate in the kidneys. The diet should be low in purines to prevent uric acid formation. NSAIDs, such as ibuprofen or naproxen, are often prescribed to reduce inflammation and pain. If compresses are used, they would be warm, not hot. b.

The nurse is assisting in the application of a plaster cast for a client with a broken arm. Which action is a priority? The cast material should be dipped several times into warm water The cast should be uncovered until it dries The casted extremity should be placed on a supporting surface The wet cast should be handled with the palms of hands for 48 to 72 hours

Handle cast with palms of the hands and lift at two points of the extremity. This will prevent stress at the injury site and indentations that cause pressure areas on the cast. The other options are correct actions, but are not the most important. d.

A pregnant woman in the third trimester reports having severe heartburn. What action should a nurse remind the client to take? Drink small amounts of liquids frequently Eat the evening meal within two hours of going to sleep Sleep with head propped on several pillows Take a proton pump inhibitor either before or after eating

Heartburn is a burning sensation caused by regurgitation of gastric contents. It is best minimized by sleeping in a semi-upright position, eating small frequent meals, or eating at least three hours before sleeping. Drinking plenty of water will help with digestion but drinking too much water at one time may actually worsen heartburn symptoms. Medications need to be approved by the health care provider. c.

A nurse is reinforcing information about the administration of an albuterol inhaler to an adult diagnosed with asthma. What should be the priority comment made by the nurse? "Use this medication at bedtime to promote rest." "Notify the health care provider if your canister lasts only two weeks." "Inhale this medication after other asthma sprays." "Discontinue the inhaler if you are dizzy."

If the client notices a need to use the albuterol inhaler more frequently, the health care provider should be notified so that a change in dose or medication can be ordered. If the client is frequently using the inhaler, this may indicate an ineffective medication or subtherapeutic dosage. The first step is to notice that this question is asking for the best ("priority") option where all four options are conceivably correct. Then ask yourself what would be the most serious effect that can happen. If the client runs out of necessary medication, then respiratory distress is possible. b.

The nurse is giving a morning bath to a client who has a colostomy. While giving the bath, the nurse should reinforce that the collection pouch should be emptied at what time? Prior to going to sleep at night After each fecal elimination At the same time each day When it is one-third to one-half full

If the pouch becomes more than half full, it could put pressure on the seal, causing a leak. The pouch may also detach, causing the contents to spill. This will not only irritate the skin but also embarrass the client. d.

The nurse is caring for a client diagnosed with acute angina. The client reports substernal chest pain, diaphoresis and nausea. What should be the first action by the nurse? Administer PRN pain medication as ordered Determine the origin of the pain Draw blood for for troponin/CK and CBC per standing orders Order ECG per standing orders

In a client with a diagnosis of acute angina, chest pain means the heart is deprived of oxygen. The priority action would be to give the prescribed pain medication, which will improve oxygenation to the heart. Detailed assessment of the pain, lab tests and ECG can be done once the medication is given. Mostly likely this client would also have a standing order for nitroglycerin. a.

The client undergoes a laparoscopic removal of the appendix. Which postoperative instructions will the nurse reinforce? (Select all that apply.) No showering for 48 hours after surgery Maintain bedrest for 24 hours before gradually resuming regular activities Some shoulder discomfort can be expected Use 2 tablespoons of Milk of Magnesia if no bowel movement 3 days after surgery Restrict diet to bland, easily digestible food for a few days Gently scrub off the "skin glue" when you feel able

Laparoscopic surgery involves using carbon dioxide gas to open the inside of the abdomen, which pushes up the diaphragm; this may cause shoulder discomfort postoperatively. Clients should keep the dressings clean and dry for 48 hours before they can shower, but no tub baths for a few weeks. If "skin glue" is used over the incision(s), the client should not try to scrub it off because it will wear off on its own. Clients may resume normal activities as soon as they are able but no heavy lifting or aerobic exercise for about 2 weeks. If they do not have a BM after 2-3 days, clients can take 2 tablespoons of MOM several times a day until they have a BM. Diet can be advanced as tolerated but it's best to stick to non-greasy, non-spicy foods for a few days. a.c.d.e.

The client calls the clinic nurse and reports nausea, headache and fatigue. The client also reports seeing yellow halos around lights. What is the best response by the nurse? "Do your eyes appear bloodshot and is there any itching?" "Tell me about your prescription for digoxin. Are you still taking the medication?" "Call back in a week and schedule an appointment if your symptoms don't improve." "Is there anyone else at home who has the same symptoms?"

Nausea, headache and fatigue are vague symptoms that could be associated with many different causes. However, seeing yellow halos around lights is an early sign of digitalis toxicity. The nurse should ask the client if s/he is still taking digoxin. If s/he is still taking the medication, the nurse should ask the client to come in to the clinic right away for further assessment, as well as lab tests (serum digoxin level, electrolytes and renal function studies) and an ECG. b.

A nurse is caring for a child who has been recently diagnosed with cystic fibrosis. Which finding should the nurse anticipate? Dry, nonproductive cough Poor appetite Frequent urinary infections Ribbon-like stools

Noisy respirations and a dry nonproductive cough are usually the first respiratory findings to appear in a newly diagnosed cystic fibrosis client. Because the question relates to a respiratory condition, you should select a respiratory option (and there is only one option related to the respiratory system). a.

A 28-year-old is transferred to the emergency department (ED) via ambulance with a traumatic head injury. The client is awake and reports having a headache and some amnesia. What are the priority nursing interventions for this client? (Select all that apply.) Assess the wound for presence of drainage or bruising on the head Assess vital signs and neurological function Assess the airway Prepare for CT imaging of the head Position this client in high Fowler's position

Remember primary emergency trauma assessment using "A, B, C, D and E". The ED nurse will assess airway, breathing, circulation, and disability/neurological function on a person who has experienced a traumatic head injury. The nurse will also examine the client for the presence of any bruising or drainage, particularly of the ears and nose. A supine position is best; the head of the bed may be elevated slightly if not contraindicated. A CT scan is required if the client presents with an abnormal mental status, clinical signs of skull fracture, history of vomiting, or headache. a.b.c.d.

A practical nurse (PN) is observing an 8 month-old infant in the clinic waiting room. Which activity should be reported to the registered nurse (RN)? Lifts head from the prone position Rolls from abdomen to back Falls forward when sitting Responds to parents' voices

Sitting without support is normal for infants between seven to nine months of age. You will note that the question implies there is a problem. As you read each answer, ask yourself if the behavior is normal for an 8 month-old child. You will also note that there are two options with neurologic components and two options focusing on musculoskeletal development. Because the nervous system would be a priority over the musculoskeletal system, you should then identify the 8 month-old who cannot sit up as the abnormal condition. c.

An 18 year-old client is admitted to intensive care from the emergency department after a diving accident. The injury to the spinal cord is suspected to be at the level of the second cervical vertebrae (C-2). When collecting data, which issue should be the priority focus? Muscle weakness Respiratory function Bladder control Peripheral sensation

Spinal injury at the C-2 level results in quadriplegia, with compromise of the neurologic control of breathing. Clients with this type of injury require mechanical ventilation to support their breathing. While the client will experience all of the problems identified, respiratory function is the highest priority. b.

The LPN is assisting the RN to provide care for a client diagnosed with a traumatic brain injury. Using the Glasgow Coma Scale, when the client does not obey verbal commands to move, which technique will the RN use to evaluate motor function?

Squeeze the trapezius muscle firmly

A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes lost when outside of the home. Which statement would provide the best reality orientation for this client? "Hello. My name is Elaine Jones and I am your nurse for today." "Good morning. You're in the hospital. I am your nurse Elaine Jones." "How are you today? Remember, you're in the hospital. I will be your nurse all day. My name is Elaine Jones." "Good morning. I am Elaine Jones, your nurse. Do you remember where you are?"

The best statement is one that provides information in a short and direct manner. Nurses should simply establishes the time, location and state their name. With reality orientation, nurses should be brief and to the point; you will note that each statement uses five or fewer words. These types of statements will enhance recall and memory. For clients who are confused, it's best not to engage in a guessing game and ask if they know where they are, or why they are in the hospital. b.

A client is scheduled to have blood drawn for serum cholesterol and triglycerides tomorrow morning. What information should the nurse reinforce to the client about the test? "Be sure to eat a fat-free diet until the test, and drink lots of water." "Stay at the laboratory so that two blood samples can be drawn an hour apart." "Do not eat or drink anything but water for 12 hours before the blood test." "Have the blood drawn within two hours of eating breakfast."

The client should fast (no fluids or foods, except for water) for 8 to 12 hours prior to sample collection for serum lipid levels (cholesterol, triglycerides, HDL, LDL).

A client has completed a renal biopsy. Which nursing intervention is appropriate after a renal biopsy? Ambulate the client within four hours after procedure Change the dressing when it becomes saturated Monitor vital signs using post-op protocols Maintain client on NPO status for 24 hours

The potential complication of this procedure is internal hemorrhage. Monitoring vital signs is critical to detect early indications of bleeding. The dressing should have no drainage, nor should it become saturated. No reason exists to keep the client NPO for 24 hours or to walk within four hours. c.

The mother of a hospitalized 2 year-old child asks a nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The best advice by the nurse would include which approach? Explain that this behavior will stop with in a few days Suggest that the mother "sneak out" of the child's room when the child is asleep Request for the mother to remain with the child at all times Help the mother understand that this is a normal response to hospitalization

The protest phase of separation anxiety is a normal response for a child this age. Separation anxiety is at its peak during toddler years of 12 to 36 months. d.

A nurse is caring for a client with a sigmoid colostomy. The client requests assistance in removing the flatus from a one-piece drainable ostomy pouch. Which intervention should the nurse use? Pierce the plastic at the top of the ostomy pouch with a pin to vent the flatus Pull the adhesive seal around the ostomy pouch to allow the flatus to escape Open the bottom of the pouch to allow the flatus to be expelled Assist the client to ambulate to reduce the flatus in the pouch

The only correct way to vent the flatus from a one-piece drainable ostomy pouch is to instruct the client to obtain privacy (the release of the flatus will cause odor), and to open the bottom of the pouch, release the flatus and then close the bottom of the pouch. Because the colostomy is at the sigmoid level, the stool will most likely be formed stool. Sometimes the bags will have a charcoal filter in the top where flatus can be expelled on a constant basis with minimal odor. Piercing the ostomy pouch is never an option because it could allow stool to leak from the pouch. Although ambulation will help to reduce flatus, this does not address the flatus currently in the pouch. c.

The client is diagnosed with asthma. What information should the nurse reinforce that the client should monitor on a daily basis? Peak air flow volume Respiratory rate Pulse oximetry Skin color

The peak air flow volume decreases about 24 hours before clinical findings occur for acute asthma attacks. A peak flow meter is a small, hand-held device used to manage asthma by monitoring air flow through the bronchi and thus the degree of restriction in the airways. The peak flow meter measures the client's maximum ability to expel air from the lungs, or peak expiratory flow rate (PEFR or PEF). Peak flow readings are higher when clients have normal airways and lower when the airways are constricted. Most have colors to help explain the results: green = good or 80 to 100% of normal air flow; yellow = therapy (inhaler) needed 50 to 80% of normal air flow; and red = rapid response needed/medical alert or less than 50% of normal air flow. a.

The nurse calls for help after finding an unresponsive adult client in a hospital room. What action should the nurse take next for the client who has no pulse and is not breathing? Open the airway and deliver two breaths followed by 30 compressions Provide continuous chest compressions until someone comes with the crash cart Provide a cycle of 30 compressions followed by two breaths Provide 15 compressions and then pause while someone delivers one "breath" using an ambu bag

The sequence of CPR should now be C-A-B, emphasizing circulation - providing chest compressions to maintain perfusion of the brain and vital organs. The nurse should first perform chest compressions, followed by opening the airway and then breathing. The ratio is 30 compressions to two breaths, regardless of how many rescuers there are (adult CPR). The American Heart Association promotes compression-only CPR for lay persons. c.

The nurse is assisting a withdrawn client to begin to develop relationship skills. Which nursing intervention should be most effective? Assist the client to analyze the meaning of behaviors Remind the client frequently to interact with other clients Offer the client frequent opportunities to interact with the nurse Initiate client interactions with one or two other clients

The withdrawn client is uncomfortable in social interaction. The nurse-client relationship is a corrective relationship in which the client learns both tolerance and skills for relationships within safe realms. To offer frequent interactions initiates the development of relationship skills. c.

The medication benztropine mesylate (Cogentin) is ordered, but the nurse incorrectly administers carvedilol (Coreg). What are the most important actions the nurse should take after making this medication error? (Select all that apply.) Document the administration of carvedilol (Coreg) Notify the nurse manager Notify the client Monitor and document the client's blood pressure Notify the health care provider

When a nurse makes a medication error, the client's safety and well-being are the top priority. The nurse will document giving the beta-blocker carvedilol and as well as any effects the medication has on the client. The health care provider must be notified; the nurse will document that the provider was called and that orders were implemented. The nurse manager must also be notified. Once the client is stable, the nurse will complete an incident/variance/quality-assurance report (usually within 24 hours of the incident.) The initial disclosure of the medication error with the client should occur as soon as reasonably possible after the event (usually within 1-2 days after the event). a.b.d.e.

A client becomes acutely short of breath with an SpO2 (oxygen saturation) of 82%. Which oxygen delivery system should the nurse apply that would provide the highest concentrations of oxygen to the client? Simple face mask Partial rebreather mask Venturi mask Non-rebreather mask

When a tight seal is achieved using a non-rebreather mask, up to 100% of oxygen is available. The venturi mask, partial rebreather mask and simple mask cannot deliver oxygen concentrations as high as the non-rebreather mask. If you are unsure of the correct response, you should know that because the question is asking for the highest concentration of oxygen delivery, it would be unlikely that something with the words "partial" and "simple" would be correct, so you can eliminate those options. A Venturi mask can deliver a fixed concentration of oxygen, but in increments no higher than 40%. d.