Miscellaneous- NCLEX
The nurse is monitoring a client in DKA. Which arterial blood gas value would be expected? 1. pH 7.32 2. PCO2 47 3. HCO3 25 4. PO2 78
1. Correct: The pH should be acidotic, less than 7.35. 2. Incorrect: The PCO2 can be either normal (35-45) (or low if they began Kussmaul breathing <35). 3. Incorrect: The HCO3 must be less than 22 to show the ketoacidosis. 4. Incorrect: PO2 normal or increased with ketoacidosis. **Extra: pH: 7.35-7.45 PCO2: 35-45 HCO3: 22-26 PO2: 80-100
Blood should hang no longer than _______ hours.
4
While examining a client's health history, which data indicates to the nurse that the client is at increased risk for developing cancer? 1. Family history 2. Alcohol consumption 3. Spicy diet 4. Human papillomavirus 5. Tobacco use
1., 2., 4., & 5. Correct: Family history of cancer increases the risk for having the same type of cancer. Alcohol and tobacco use increase the risk of cancer. When used together, they have a synergistic effect. Human papillomavirus increases the risk of cervical cancer. 3. Incorrect: Spicy diet does not necessarily increase the risk of cancer.
A client is diagnosed with new onset grand mal seizures. Which nursing interventions should the nurse implement for this client? 1. Have an unlicensed assisitve personnel (UAP) stay with the client. 2. Pad the side rails with blankets. 3. Place the bed in low position. 4. Keep a padded tongue blade at the bedside. 5. Instruct client to call for help when ambulating.
2., 3., & 5. Correct: These interventions will help to protect the client from injury.
Where is insulin produced?
Pancreas
What is warfarin sodium used for? Precautions?
This medication is used to treat blood clots (such as in deep vein thrombosis-DVT or pulmonary embolus-PE) and/or to prevent new clots from forming in your body. Preventing harmful blood clots helps to reduce the risk of a stroke or heart attack. Known as a blood thinner (anticoagulant). Avoid sudden large increases or decreases in your intake of foods high in vitamin K (such as broccoli, cauliflower, cabbage, brussels sprouts, kale, spinach, and other green leafy vegetables, liver, green tea, certain vitamin supplements).
What are three things the LPN's can't do?
assess, evaluate, and teach
Which action by a nurse would require the charge nurse to intervene? 1. Walking in the hallway outside the operating room without a hair covering. 2. Putting on a surgical mask, gown and cap before entering the operating room. 3. Wearing a surgical mask into the holding area. 4. Wearing scrubs from home into the nursing station.
1. Correct: The area outside the OR is restricted to personnel with surgical attire and coverings. 2. Incorrect: Putting on a surgical mask, gown and cap are all appropriate prior to entering the OR. 3. Incorrect: Surgical mask may be worn in the holding area, but is not required. 4. Incorrect: Wearing scrubs into a nursing station is appropriate.
The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which group of clients should she assign to the medical surgical nurse? 1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. 2. C-section planning discharge, post-partal infection, mastectomy. 3. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 4. 28 week gestation of bed rest, post-partal with HELLP syndrome, breast reconstruction.
1. Correct: This group of clients is primarily med surgical. 2. Incorrect: This group of clients needs specific teaching. 3. Incorrect: This group of clients needs specialized care. 4. Incorrect: No, the monitoring is too specific for the med-surg nurse.
Which signs/symptoms should the nurse monitor for in a client admitted with a diagnosis of pheochromocytoma? 1. Headache 2. Hypotension 3. Hyperglycemia 4. Bradycardia 5. Polycythemia 6. Leukopenia
1., & 3. Correct. This disease is characterized by hypertension, hypermetabolism, hyperglycemia, and headache due to increased release of epinephrine and norepinephrine. 2. Incorrect. Hypertension, rather than hypotension would be seen in this client. 4. Incorrect. The heart rate will increase rather than decrease. 5. Incorrect. Polycythemia is elevated red blood cell count, which is not seen with this disease. 6. Incorrect. Leukopenia is a low white blood cell count, which is not seen with this disease. **Extra: Pheochromocytome: A hormone-secreting tumor that can occur in the adrenal glands.
The nurse is caring for a client on the psychiatric unit with a diagnosis of obsessive-compulsive disorder. The client has frequent hand washing rituals. Which nursing interventions would be advisable for this client? 1. Allow time for ritual. 2. Provide positive reinforcement for nonritualistic behavior. 3. Provide a flexible schedule for the client. 4. Remove all soap and water sources from the client's environment. 5. Create a regular schedule for taking client to bathroom.
1., 2. & 5. Correct: Initially meet the client's dependency needs as required to keep anxiety from escalating. Rituals may interfere with client elimination needs. Establishing a regular schedule may prevent constipation. 3. Incorrect: A structured schedule is needed for this client. 4. Incorrect: Sudden and complete elimination of all avenues for dependency would create intense anxiety in the client.
A client in labor is placed on an external fetal monitor. Which interventions should the nurse perform if a late fetal heart rate deceleration occurs? 1. Turn the client to the left side. 2. Administer oxygen. 3. Start an intravenous line. 4. Prep the mother for cesarian section. 5. Notify the primary healthcare provider.
1., 2. & 5. Correct: Late fetal heart rate decelerations are associated with fetal hypoxia and acidosis. Positioning the mother on her left side prevents compression of the vena cava. Oxygen administration increases maternal, then fetal blood level, thus treating current and preventing further development of hypoxia and acidosis. Failure to recognize fetal monitoring strip abnormalities and failure to report abnormalities to the primary healthcare provider are deviations from the standard of care. 3. Incorrect: Intravenous line would already be in place. 4. Incorrect: Prepping the mother for cesarian section is premature.
The nurse is working with a committee at the local school to develop an emergency preparedness plan for tornados. What should be included in the plan? 1. Identification of safe zones. 2. Methods for accounting for all people present in the building. 3. Warning system activation. 4. Identification of the gymnasium as the routine safe place. 5. Regular practice protocols.
1., 2., 3. & 5. Correct: Everyone should be aware of safe zones within the school. Personnel should be given this information and signs posted in safe zones. There must be systems in place to accurately determine the number of people in the building at any given time. There also must be a system in place to alert personnel and students of tornado warnings. Regular practice prepares everyone for an actual event. 4. Incorrect: Gymnasiums are not considered safe places due to wide expanse of roof. Safe zones should be on interior walls, no windows, strong concrete floor if possible.
Which tasks could the nurse working on a cardiac unit delegate to an unlicensed assistive personnel (UAP)? 1. Bathe the client who is on telemetry. 2. Apply cardiac leads and connect a client to a cardiac monitor. 3. Assist with a portable chest x-ray. 4. Feed a client who is dysphagic. 5. Collect a stool specimen.
1., 2., 3., & 5. Correct: Remember the RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to the UAP. The UAP could bathe the client who is on telemetry. This is an appropriate assignment. The UAP can apply cardiac leads and connect the client to a cardiac monitor. The UAP can assist with helping the client sit up for a portable chest x-ray as long as the UAP is not pregnant and wears a shield. The UAP can collect specimens, such as a stool specimen. 4. Incorrect: This client is at risk for choking and is not stable; therefore, the nurse should not allow the UAP to feed this client.
Which signs/symptoms does the nurse expect to see in a client diagnosed with Bell's Palsy? 1. Drooping of one side of the face. 2. Inability to wrinkle forehead. 3. Excessive tearing. 4. Decreased sensitivity to sound. 5. Inability to taste. 6. Numbness of affected side of face.
1., 2., 3., 5., & 6. Correct. Symptoms of Bell's palsy include sudden weakness or paralysis on one side of the face that causes it to droop (main symptom), drooling, eye problems (such as excessive tearing or a dry eye), loss of ability to taste, pain in or behind ear, numbness in the affected side of face, increased sensitivity to sound. 4. Incorrect. There would be increased sensitivity to sound with Bell's Palsy. **Extra: Bell's palsy is a paralysis or weakness of the muscles on one side of your face. Damage to the facial nerve that controls muscles on one side of the face causes that side of your face to droop. The nerve damage may also affect your sense of taste and how you make tears and saliva. This condition comes on suddenly, often overnight, and usually gets better on its own within a few weeks
Which signs/symptoms would lead a nurse to suspect Fifth disease in a child brought into a pediatric clinic? 1. Erythema on the cheeks. 2. Joint pain. 3. Temperature 102°F (38.88° C). 4. Swollen knees. 5. Pruritic rash on soles of feet.
1., 2., 4., & 5. Correct. These are common signs/symptoms of Fifth disease. **Extra info: Fifth disease, which is especially common in kids between the ages of 5 and 15, usually produces a distinctive red rash on the face that makes a child appear to have a "slapped cheek." The rash then spreads to the trunk, arms, and legs. Viral illness, caused by parvovirus B19. Fifth disease begins with a low-grade fever, headache, and mild cold-like symptoms (a stuffy or runny nose). These symptoms pass, and the illness seems to be gone until a rash appears a few days later. The bright red rash usually begins on the face. Several days later, the rash spreads and red blotches (usually lighter in color) extend down to the trunk, arms, and legs. The rash usually spares the palms of the hands and soles of the feet. As the centers of the blotches begin to clear, the rash takes on a lacy net-like appearance. Kids younger than 10 years old are most likely to get the rash.
What should a nurse teach family members prior to them entering the room of a client who has agranulocytosis? 1. Meticulous hand washing is needed. 2. Do not visit if you have any infection. 3. The client must wear a mask. 4. Children under 12 may not visit. 5. Flowers are not allowed in the room.
1., 2., 4., & 5. Correct: Protective isolation is needed for this client. We are protecting the client, who has a low white count, from acquiring an infection. So, any visitors will need to have meticulous hand washing prior to entering. The visitor should not enter if he or she has any type of infection. To decrease the risk of infection, small children should not visit. Even the mildest symptom of infection could be detrimental to the client. Flowers have bacteria, so should not be brought into the room. 3. Incorrect: A mask must be worn by the visitor, not the client. **Extra: agranulocytosis: a deficiency of granulocytes in the blood, causing increased vulnerability to infection.
A nurse suspects that a client 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. Client report of abdominal pain
1., 2., 4., & 5. Correct: Sign of dehydration due to polyuria includes dry mucous membranes. Fruity breath odor is from the acetone (ketones). With DKA, the client would be spilling glucose into the urine. Vomiting and abdominal pain are frequently the presenting symptoms of DKA. 3. Incorrect: The client will have Kussmaul respirations. Biot's respiration is a respiratory pattern characterized by periods of rapid respirations, then apnea periods.
Which interventions are appropriate for the nurse to identify for a client admitted to the psychiatric unit for management of anorexia nervosa? 1. Weigh daily 2. Allow only 20 minutes of exercise daily 3. Allow the client to bargain for privileges as long as the client eats. 4. Stay with the client during the established time for meals. 5. Maintain visual observation for 1 hour following meals.
1.,4. & 5. Correct: Weigh daily, immediately upon rising and following morning void, using same scale if possible. The established time for meals is usually 30 minutes. This takes the focus off of food and eating and provides the client with attention and reinforcement. The hour following meals may be used to discard food stashed from tray or to engage in self-induced vomiting.
An unlicensed assistive personnel (UAP) reports to the charge nurse that a client's 8AM blood pressure is 200/104. What actions would be appropriate for the charge nurse to delegate? 1. Tell the LPN to assess for extremity weakness. 2. Have the LPN re-inforce the purpose of taking propranolol. 3. Ask the LPN to notify the primary healthcare provider of the current BP. 4. Instruct the LPN to give the client the 9AM dose of propranolol now. 5. Instruct the UAP to take the client's BP at 9AM and report the result.
2, 4., & 5. Correct. The LPN can re-inforce teaching. The client's BP is elevated and giving propranolol (a beta blocker) will decrease the client's BP. Having the UAP check and report the BP one hour after giving the beta blocker would be appropriate to see if the BP has come down to a normal range. 1. Incorrect. The LPN cannot assess, evaluate, or teach. 3. Incorrect. This is premature. The propranolol has been prescribed to lower the BP and should be done first and then have BP reevaluated.
Which interventions should the nurse include for a client with sickle cell crisis who is experiencing pain? 1. Apply cold compresses to affected joints. 2. Massage affected areas gently. 3. Support and elevate swollen joints. 4. Monitor pain level by looking for BP, respiratory, and heart rate elevation. 5. Administer acetacylic acid 325 mg every 4 hours in order to thin the blood.
2. & 3. Correct: Apply local massage gently to affected areas to help reduce muscle tension. This helps to decrease swelling, thus decreasing pain. 1. Incorrect: Apply warm, moist compresses to affected joints or other painful areas. Avoid use of ice or cold compresses. Warmth causes vasodilation and increases circulation to hypoxic areas. Cold causes vasoconstriction and compounds the crisis. 4. Incorrect: Although pain can cause the vital signs to elevate, it does not always. The nurse should assess pain with an objective scale such as having the client rate the pain on a scale of 1-10. Remember that pain is what the client says it is. 5. Incorrect: Acetacylic acid should be avoided because it alters blood pH and can make cells sickle more easily.
Which client should the nurse place in the room with a 6 year old with glomerulonephritis? 1. Twenty-two month old diagnosed with respiratory syncytial virus (RSV). 2. Four year old with nephrotic syndrome. 3. Six year old admitted with febrile seizures. 4. Two year old who has a fractured tibia.
2. Correct. This child is not infectious and could be placed in the room with the child who has glomerulonephritis. Both are school children (between the ages of 4-6) who will adapt well together. 1. Incorrect. Respiratory syncytial virus (RSV) is a common and highly contagious virus that infects the respiratory tract of most children before their second birthday. This client should not be in the room with the client who has glomerulonephritis. 3. Incorrect. Febrile seizures are a common childhood problem usually caused by a fever with a viral infection. This child should not be placed in the room with the client with glomerulonephritis. 4. Incorrect. Although this child is not infectious, the child is too young to be in the room with the 6 year old. Place children within the same age group together.
The nurse is caring for a hypertensive client who has been taking a loop diuretic while hospitalized. Upon discharge, the nurse must teach the client about the need for adequate electrolyte intake through foods and/or dietary supplements. Since the client is taking a loop diuretic, which foods should the nurse suggest to the client? 1. Cereals and breads 2. Avocados and milk 3. Table salt and spinach 4. Blueberries and summer squash
2. Correct: Avocados, milk, fruit juices, bananas and cantaloupe are good sources of potassium. Loop diuretics deplete the electrolyte potassium. 1. Incorrect: Cereals and breads are good sources of B vitamins. 3. Incorrect: Table salt and spinach are good sources of sodium, but the hypertensive client usually should limit intake of sodium. 4. Incorrect: Blueberries and summer squash both are very low in potassium.
The family member of a schizophrenic client asks the nurse why the client is receiving chlorpromazine and benztropin. What is the best response by the nurse? 1. The chlorpromazine makes the benztropine more effective so a smaller dose of both drugs can be used. 2. Benztropin is given to treat the side effects produced by the chlorpromazine. 3. Chlorpromazine is used for severe hiccups that can occur with the use of benztropin. 4. Chlorpromazine is used for psychosis and benztropin is used for preventing agranulocytosis.
2. Correct: Benztropin is used to treat parkinsonism of various causes and drug-induced extrapyramidal reactions seen with chlorpromazine.
A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus. Which of the following RNs should not be assigned to this baby? 1. A nurse just back from maternity leave. 2. A nurse who is 10 weeks pregnant. 3. A nurse who is breastfeeding her 4 month old. 4. A nurse who is on hormone replacement therapy
2. Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. 1. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. 3. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. 4. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. **Extra: Cytomegalovirus is a common virus that can infect almost anyone. Most people don't know they have CMV because it rarely causes symptoms. However, if you're pregnant or have a weakened immune system, CMV is cause for concern. Once infected with CMV, your body retains the virus for life. However, CMV usually remains dormant if you're healthy. CMV spreads from person to person through body fluids, such as blood, saliva, urine, semen and breast milk. CMV spread through breast milk usually doesn't make the baby sick. However, if you are pregnant and develop an active infection, you can pass the virus to your baby. There's no cure for CMV, but drugs can help treat newborns and people with weak immune systems.
A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R36. The client is extremely anxious and crying uncontrollably. Based on this assessment, the nurse should anticipate that this client is likely in which acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
2. Correct: Hyperventilation due to anxiety, pain, shock, severe infection, fever, liver failure can lead to respiratory alkalosis. With each of these, the client has an increased CO2 loss.
The nurse is caring for a client taking lithium. Which comment by the client indicates lack of understanding of the therapeutic regimen? 1. "I must keep my sodium intake steady over time. " 2. "If I miss a dose of lithium, I should make it up with the next dose." 3. "I must check with my primary healthcare provider before changing my diet for weight loss." 4. "I must keep my exercise routine the same or discuss with my primary healthcare provider. "
2. Correct: If a client misses a dose of lithium, the client should take the next dose as prescribed without doubling it. If the client adds the missed dose, toxicity may occur. If sodium intake is reduced or the body is depleted of its normal sodium (due to seating, fever, diuresis), lithium is reabsorbed by the kidneys, increasing the possibility of toxicity. 1. Incorrect: This comment indicates understanding. The client should keep sodium levels the same over time as lithium and sodium are both excreted by the kidney. 3. Incorrect: This comment indicates understanding. Food intake should remain constant. Therapeutic levels should be monitored closely while the client is losing weight. Sodium reduction can lead to lithium reabsorption in the body causing toxicity. 4. Incorrect: This comment indicates that the client does understand the treatment regimen. Any changes that would change the concentration of the drug in the bloodstream should be discussed with the primary healthcare provider. Activities that cause excess sodium loss, such as heavy exertion, exercise in hot weather, or saunas should be avoided. **Extra: Lithium- It can treat and prevent manic episodes of bipolar disorder.
What is the primary electrolyte that the nurse should be aware to monitor for in a client who is receiving an insulin infusion? 1. Sodium 2. Potassium 3. Calcium 4. Phosphorus
2. Correct: Insulin causes movement of potassium into the cells, which can lead to a severe reduction in serum potassium if not regulated appropriately. A severe decrease in serum potassium could be fatal. 1. Incorrect: Although insulin has been shown to increase sodium reabsorption in the kidneys, the change is not as rapid and not as life threatening as the change in potassium can be. 3. A significant change in the calcium level is not anticipated with the insulin infusion. 4. A significant change in the phosphorous level is not anticipated with the insulin infusion.
The nurse should teach the client with chronic pancreatitis how to monitor for which problem that can occur as a result of the disease? 1. Hypertension 2. Diabetes 3. Hypothyroidism 4. Graves disease
2. Correct: Insulin is produced in the pancreas. When the client has chronic pancreatitis, the pancreas becomes unable to produce insulin, thus resulting in diabetes. 1. Incorrect: No, not associated with chronic pancreatitis. 3. Incorrect: No, not associated with chronic pancreatitis. 4. Incorrect: No, not associated with chronic pancreatitis.
The nurse is assisting in decontaminating a client who was recently involved in a chemical exposure event. What should the nurse do first? 1. Rinse the client off with a copious amount of water. 2. Remove clothing from the client. 3. Wash the client with a saline solution. 4. Flush the skin with an antibacterial agent.
2. Correct: Significant decontamination can be accomplished by removal of clothing. Complete decontamination involves clothing removal, complete flushing of the skin with water, and wrapping the client in a sheet or protective cover. 1. Incorrect: Complete decontamination involves clothing removal, then complete flushing of the skin with water, and wrapping the client in a sheet or protective cover. 3. Incorrect: Soap and water is recommended for decontamination. 4. Incorrect: Antibacterial agents are not recommended.
The nurse is caring for a client who is receiving a prostaglandin agonist for the treatment of glaucoma. Which comment by the client indicates a lack of understanding of the treatment regimen? 1. I must only use the drops in the eye with the increased pressure. 2. My eyes may be different colors, so I will use the drops in both eyes. 3. I must be careful not to overmedicate even if it is just an eye drop. 4. The eyelashes in the eye with the higher pressure may get longer.
2. Correct: The color of the iris may darken in the eye being treated; however, it is important that the client understand that drops should not be placed in the unaffected eye. To do so may result in a subnormal intraocular pressure. 1. Incorrect: This comment shows adequate understanding. The client should only treat the eye with the increased pressure. 3. Incorrect: This comment demonstrates that the client does understand the treatment regimen. 4. Incorrect: This comment shows understanding. The lashes in the eye being treated will lengthen as opposed to the untreated eye.
A nurse is caring for a multipara client in active labor who received morphine 4 mg IVP for pain. Thirty minutes later, the client had a precipitous delivery. What should the nurse prepare to administer to the newborn first? 1. Oxygen 2. Naloxone 3. Glucose 4. Vitamin K
2. Correct: This newborn will need naloxone to reverse the effects of the narcotic that was given to mom 30 minutes earlier. 1. Incorrect: Give the naloxone first. Then if oxygen is needed, provide it. 3. Incorrect: Glucose is not warranted here. 4. Incorrect: Vitamin K is given to newborn, but it is not the priority here. **Extra: Naloxone: blocks or reverses the effects of opioid medication, including extreme drowsiness, slowed breathing, or loss of consciousness. An opioid is sometimes called a narcotic.
The parents of a 2 year old child diagnosed with autism spectrum disorder (ASD) ask the nurse what led the primary healthcare provider to diagnose this disorder for their child. What behaviors will the nurse indicate as signs of autism spectrum disorder? 1. Delusions 2. Twisting 3. Preoccupation with objects 4. A personal language 5. Changes are easily tolerated.
2., 3. & 4. Correct: All are behaviors seen in children with ASD. Additionally, they often do not form interpersonal relationships with others, or play well with others.
An elderly client living in a long-term care facility fell 8 hours ago causing a laceration on the occipital area of the skull and steri-strips were applied for closure. Which signs/symptoms would indicate to the nurse that the client should be transferred to the emergency department? 1. Purposeful movement. 2. Sudden emotional outbursts. 3. Client report of blurred vision. 4. Pupils equal, react to light, and accommodation. 5. Bright red blood oozing from the wound. 6. Headache unrelieved by acetaminophen.
2., 3., & 6. Correct. Signs/symptoms of increased ICP include: excessive sleepiness, inattention, difficulty concentrating, impaired memory, faulty judgment, depression, irritability, emotional outbursts, disturbed sleep, diminished libido, difficulty switching between two tasks, and slowed thinking. Abnormalities in vision and extraocular movements occur in the early stages of increased ICP. A headache that is unrelieved by acetaminophen would warrant further investigation. 1. Incorrect. This is a normal response and does not warrant further investigation. 4. Incorrect. This is a normal response and does not warrant further investigation. 5. Incorrect. The scalp is very vascular and oozing would be expected. Apply pressure to stop bleeding.
What assessments would be appropriate for the school nurse to perform when carrying out responsibilities for school safety practices and emergency preparedness? 1. Teach about gun control laws. 2. Observe for gaps or changes in levels of sidewalks. 3. Identify which students have special healthcare needs. 4. Locate all entrances and exits to buildings. 5. Identify historical threats and hazards in the school and surrounding community. 6. Perform a check of all fire extinguishers.
2., 3., 4., 5., & 6. Correct: One of the first things that a school nurse should do is to assess where an accident might happen. Observing for gaps or changes in the level of sidewalks is an example of this assessment. The school nurse should assess for special healthcare needs in the event that the school enters a time of extended lockdown. Some students would require attention during the time of lockdown, such as diabetics who could not wait to receive insulin or have food available. All entrances to the schools must be identified to know where a potential entry for intruder might could occur. Some access points may need to be changed to reduce risk to students. Becoming familiar with all exits is crucial to planning timely and safe evacuation of students if needed. The school nurse can draw upon a wealth of information that exists regarding threats or events that have occurred in the past at the school or in the local community in order to plan for possible future events. Fire extinguishers should be on a regular schedule for assessment of access, date of expiration, and functionality. 1. Incorrect: Teaching about laws of gun control is not an assessment that can be made by a school nurse regarding safety and emergency preparedness for the school.
What should the nurse include when teaching a client in renal failure about peritoneal dialysis? 1. Instill 250 ml of fluid into the peritoneal cavity over 30 minutes. 2. Use cool effluent when instilling into the peritoneal cavity. 3. Following the prescribed dwell time, lower the bag to allow the fluid to drain out. 4. The fluid that is returned should be clear in appearance. 5. If all the fluid does not drain out, place the bed in the trendelenburg position. 6. A sweet taste may be experienced when peritoneal dialysis is used.
3, 4, & 6 Correct: Once the prescribed dwell time has ended, the bag is lowered and the fluids, along with the toxins, are drained out into a bag over a period of 15 - 30 minutes. The fluid should be clear in appearance (should be able to read a paper through it). Cloudy return could indicate infection. Since the dialysate has a lot of glucose in it, the client frequently reports a constant sweet taste. 1. Incorrect: The amount of fluid used in peritoneal dialysis is about 2000 to 2500 ml at a time. This filling of the peritoneal cavity is often completed in 10 minutes. 2. Incorrect: Cool fluids would cause vasoconstriction. The effluent should be warmed to body temperature to promote blood flow to enhance the exchange (the more blood flow, the more toxin removal.) 5. Incorrect: If all of the fluid does not come out, the client should turn side to side to promote drainage. The Trendelenburg position would cause the fluids to pool in the upper peritoneal area and not drain adequately.
A client is admitted to the emergency department reporting abdominal discomfort and constipation lasting 3 days. Which abdominal assessment data would the nurse report to the primary healthcare provider? 1. Striae. 2. Borborygmi. 3. High-pitched bowel sounds at 8/min. 4. Tympany noted on percussion.
3. Correct. High-pitched bowel sounds fewer than 10 per minute indicate a blockage. 1. Incorrect. Striae on the abdomen may be a sign of past weight changes or pregnancy. 2. Incorrect. Borborygmi are normal, loud, and easily audible bowel sounds. 4. Incorrect. This is a normal finding in the abdomen. Tympany is usually present in most of the abdomen caused by air in the gut (a higher pitch than the lungs).
An elderly client receives instructions regarding the use of warfarin sodium. Which statement indicates to the nurse that the client understands the possible food interactions which may occur with this medication? 1. "I'm going to miss having my evening glass of wine now." 2. "I told my daughter to buy spinach for me. I'll have to eat more servings now." 3. "I will have to watch my intake of salads, something that I really love." 4. "I am going to begin eating more fish and pork and leave beef alone now."
3. Correct: Clients taking warfarin sodium must watch their intake of vitamin K, which is present in leafy green vegetable and tomatoes. 1. Incorrect: Wine does not affect the use of warfarin sodium. 2. Incorrect: These clients need to watch intake of spinach, which is a source of vitamin K. 4. Incorrect: These clients need to watch intake of fish, which is a source of vitamin K.
Donepezil has been prescribed to a client with cognitive impairment. Which statement by the family member indicates understanding of the nurse's instructions on this medication? 1. This medicine will control agitation and aggression. 2. This medication should be given at bedtime since it is for insomnia. 3. Notify the primary healthcare provider if the client is vomiting coffee ground material. 4. This drug is given as needed for confusion.
3. Correct: Rare but very serious side effects occur: black stools, vomit that looks like coffee grounds, severe stomach/abdominal pain. Notify the primary healthcare provider immediately. 1. Incorrect: An antipsychotic medication such as risperidone is used for agitation, aggression, hallucinations, thought disturbances, and wandering. 2. Incorrect: Donepezil should be given in the evening just before bedtime, however, it is not for insomnia. Sedative/hypnotics such as zolpidem and temzaepam are given for insomnia. 4. Incorrect: Donepezil should be given regularly in order to get the most benefit from it. Do not stop taking it or increase the dosage unless the primary healthcare provider changes the dose. It may take a few weeks before the full benefit of this drug takes effect. **Extra: Donepezil is used to treat confusion (dementia) related to Alzheimer's disease. It does not cure Alzheimer's disease, but it may improve memory, awareness, and the ability to function.
A nurse invites a friend to her home one evening. On arrival, the friend sees the nurse's large, white, long-haired cat sitting on the couch. She begins to experience palpitations, trembling, nausea, shortness of breath, and a feeling of losing control. What should the nurse do first? 1. Stay with the friend until she feels better. 2. Have the friend breathe into a paper bag. 3. Remove the cat from the room. 4. Dim the lights in the room.
3. Correct: Remove the source of the panic attack first. 1. Incorrect: This is a correct answer, but remove the cat first. 2. Incorrect: This will help hyperventilation if it occurs. 4. Incorrect: This is a correct answer, but remove the cat first.
The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation? 1. Clots in urine 2. Bladder pressure 3. Clear urine 4. Bladder spasms
3. Correct: The irrigation is regulated so that the urine is free of clots and slightly pink tinged. 1. Incorrect: The irrigation should be increased if you see clots in order to keep the catheter patent 2. Incorrect: Bladder pressure may mean that the indwelling urinary catheter is obstructed. Either increase flow or manually irrigate catheter. 4. Incorrect: No, bladder spasms occur with clots you do not want to slow. **Extra: transurethral resection of the prostate (TURP)- a type of prostate surgery done to relieve moderate to severe urinary symptoms caused by an enlarged prostate. During TURP, a combined visual and surgical instrument (resectoscope) is inserted through the tip of your penis and into the tube that carries urine from your bladder (urethra). The urethra is surrounded by the prostate. Using the resectoscope, your doctor trims away excess prostate tissue that's blocking urine flow and increases the size of the channel that allows you to empty your bladder. Continuous bladder irrigation is a procedure usually required for two common reasons. One is that it is done in order to decrease the chances of the formation of blood clots in the bladder right after certain kinds of surgery. Second is to administer medication into the bladder in order to ward off an infection.
While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and black collection of blood. What is the nurse's next action? 1. Leave the scabbing area alone and apply extra ointment. 2. Notify the primary healthcare provider. 3. Gently remove the debris and re-dress the wound. 4. Apply skin softening lotion for 3 hours and then re-dress.
3. Correct: What likes to live in the scabs and dried blood? Bacteria. 1. Incorrect: No. What is living in there and reproducing? Bacteria, so don't leave it! 2. Incorrect: No need to notify primary healthcare provider at this time. 4. Incorrect: We don't put lotion in the wound.
A client has been taking tranylcypromine for approximately two weeks. The client is visiting the nurse at the local mental health center for follow up and group therapy. Which client comment indicates a lack of understanding of the medication that could result in a medical emergency? 1. I know that I must take this medication until my primary healthcare provider tells me to stop. 2. It is frustrating to have to follow dietary restrictions. 3. I am getting a cold, and I am going to take some over the counter cold medicine. 4. I am going to have broccoli salad and roasted turkey for lunch today.
3. This is an MAOI medication. OTC cold medications could result in hypertensive crisis when combined with the monoamine oxidase inhibitor. Warnings are placed on cold preparations and other medicines that are not to be taken with the MAOIs.
The lactation consultant is preparing to make rounds on the breastfeeding clients on the LDRP. Which client should the consultant see first? 1. The mother who is nursing her newborn every 2-3 hours for 15-20 minutes at a time. 2. The mother who stated that her newborn sucks in short bursts and has audible swallowing. 3. The mother who reported blisters on her nipples and pain whenever the newborn latches on. 4. The mother who stated that her baby was so good that she has to wake him for each feeding.
4. Correct: A baby who is so sleepy that he doesn't wake on his own for feeding is at high risk for dehydration and malnourishment. 1. Incorrect: Desirable finding in breastfeeding. 2. Incorrect: Desirable finding in breastfeeding. 3. Incorrect: Blisters and pain are concerns that need to be assessed, but the sleepy baby situation has first priority.
Case managers use clinical pathways in the process of evaluating and coordinating client care with the multidisciplinary team. What is a clinical pathway? 1. A decision-making flowchart that uses the if/then method to address client responses to treatment. 2. A set of practice guidelines developed by a professional medical organization such as the American Nurses Association or the American College of Surgeons. 3. A standardized set of preprinted primary healthcare provider orders for client care, which expedite the order process and can be customized to individual clients. 4. A set of practice guidelines based on a specific client diagnosis, which provides an overview of the multidisciplinary plan of care.
4. Correct: A clinical pathway is a set of multi-disciplinary client care guidelines for a specific diagnosis or condition. It can be used to guide the plan of care and to identify deviations from the plan of care. 1. Incorrect: A decision-making flowchart that uses the if/then method is the definition of an algorithm. 2. Incorrect: A set of practice guidelines developed by professional medical organizations is the definition of a practice guideline. 3. Incorrect: A standardized set of preprinted primary healthcare provider orders is the definition of a primary healthcare provider preprinted order set.
Which client must the nurse assign to a private room? 1. Primiparous client who delivered twins at 28 weeks gestation two days ago 2. Postpartum client on IV Ampicillin and Gentamicin for chorioamnionitis 3. Postpartum client whose 2 hour old infant is being worked up for sepsis 4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C)
4. Correct: A temperature of 100.5 ° F (38.05 ° C) or greater in a client more than 24 hours postpartum is likely an indication of infection. This client should be kept separate from other mothers and babies. 1. Incorrect: The preterm twins are in the NICU and not in their mother's room (a client with term twins would need a private room because of space considerations). 2. Incorrect: Chorioamnionitis is not contagious. 3. Incorrect: The infant may have an infection and will remain in the NICU. The mother is not infected. **Extra: Chorioamnionitis: is a complication of pregnancy caused by bacterial infection of the fetal amnion and chorion membranes. S/S: Maternal fever (intrapartum temperature >100.4°F or >37.8°C): Most frequently observed sign. Significant maternal tachycardia (>120 beats/min) Fetal tachycardia (>160-180 beats/min) Purulent or foul-smelling amniotic fluid or vaginal discharge Uterine tenderness Maternal leukocytosis
A pregnant woman who has just been admitted to the labor and delivery room states that her "water just broke". What should the nurse do immediately? 1. Confirm that fluid is amniotic fluid with nitrazine paper test. 2. Obtain maternal vital signs. 3. Observe amniotic fluid color. 4. Check fetal heart rate (FHR) pattern.
4. Correct: Check FHR immediately following the rupture of membranes. Changes in FHR pattern may indicate prolapsed umbilical cord. 1. Incorrect: The first thing the nurse should do is check FHR pattern. Changes could indicate prolapsed cord. 2. Incorrect: FHR is the priority as a change could indicate prolapsed cord. 3. Incorrect: After checking FHR.
What should the chemotherapy infusion nurse recognize as the major barrier of chemotherapy success in treating cancer clients? 1. Inadequate knowledge of the side effects of chemotherapy 2. Difficulty obtaining an IV access 3. The development of alopecia 4. Toxicity to normal tissues
4. Correct: Chemotherapy is toxic to both cancerous and non-cancerous cells. Widespread destruction of non-concancerous "normal" cells can limit the use of chemotherapeutic agents. 1. Incorrect: Inadequate knowledge can be addressed and is not considered a major barrier for chemotherapy treatment. 2. Incorrect: Implantable ports are most often used for chemotherapy administration and eliminate the difficulty of obtaining a repeated peripheral IV site. 3. Incorrect: Alopecia is an adverse effect of chemotherapy but does not affect the success of chemotherapeutic agents.
While a nurse was in shift report, four clients called the nurses' station. Which client should the nurse see first? 1. Child whose colostomy bag is leaking. 2. Three day post op client requesting pain medication. 3. Child admitted with failure to thrive, whose mother requested formula. 4. Client who needs a peak blood level drawn because the antibiotic just finished infusing.
4. Correct: The most urgent task is the peak medication level that needs to be drawn. If the level is not drawn at the appropriate time, the results may not give an accurate report of whether the medication is at the appropriate dosage or not, and if the dosage is safe. 1. Incorrect: Not most urgent-can follow peak blood level timing. 2. Incorrect: This is high priority, but client is 3 days post op, so can follow peak blood level timing. 3. Incorrect: This is a priority request, but not as urgent as peak blood level timing.
What laboratory result would you most likely see in those with renal function disorder?
Increase creatinine levels. Creatinine levels increase when 50% of renal function is lost.
A client has a prescription for digoxin 0.125 mg IV push every morning. Prior to administering digoxin, the nurse notes that the digoxin level drawn this morning was 0.9 ng/mL. Which action would be most important for the nurse to take?
This is a normal digoxin level. The nurse would administer the prescribed digoxin. The therapeutic serum levels of digoxin range from 0.5 to 2 ng/mL.
The nurse at the wellness clinic is teaching a client newly diagnosed with insulin-dependent diabetes mellitus. The client asks about beginning an exercise program. The nurse bases her response on the fact that exercise has what effect on the body? 1. Lowers the blood glucose 2. Provides more energy 3. Increases insulin need 4. Reverses complications of diabetes 5. Increases the workload of the liver
1. & 2. Correct: In the presence of adequate insulin, exercise lowers the blood glucose. Exercise releases endorphins, providing the client with increased energy and feelings of well-being. 3. Incorrect: Exercise does not increase insulin need, it decreases it. 4. Incorrect: Exercise does not reverse complications. Exercise helps prevent microvascular and macrovascular changes/complications. 5. Incorrect: Exercise does not increase the workload of the liver.
The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection? 1. Color Changes 2. Drainage 3. Odor 4. Fever 5. Bleeding 6. Increased Pain
1., 2., 3., 4. & 6. Correct: Infections may cause color changes, drainage, odor, fever, & increased pain. 5. Incorrect: Bleeding is not sign of infection.
How often should v/s be taken when transfusing blood products?
A baseline set of vital signs are taken, then again 5 minutes after the initiation of the transfusion, then 15 minutes after transfusion started and every 15 minutes for one hour, then every 30 minutes for one hour, then hourly until infusion complete.
A healthy newborn has just been delivered and placed in the care of the nurse. What nursing actions should the nurse initiate? Place in the correct priority order: Assess newborn's airway and breathing. Administer sterile ophthalmic ointment containing 0.5% erythromycin. Assess newborn's heart rate. Place identification bands on newborn and mom. Bulb suction excessive mucus.
First, Assess newborn's airway and breathing. Second, Bulb suction excessive mucus. Third, Assess newborn's heart rate. Fourth, Place identification bands on newborn and mom. Fifth, Administer sterile ophthalmic ointment containing 0.5% erythromycin.
The nurse is caring for a client post coronary artery bypass grafting. The nurse educates the client that the prescribed medication indomethacin is used to manage which symptoms?
Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID). Used to treat pain, inflammation, and fever.
A client prescribed oral iron medication is reporting nausea after administration. What should the nurse teach the client to decrease this symptom?
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. Don't take iron with milk, calcium and antacids. Foods that affect absorption and should not be eaten at the same time include: high fiber foods such as whole grains, bran, and raw vegetables. Also avoid foods and drinks with caffeine.
A client's last two central venous pressure (CVP) readings were 23 cm of water. The nurse would expect the client to manifest which associated signs and symptoms? 1. Dry oral mucus membranes 2. Tachypnea (rapid breathing) 3. Orthostatic hypotension 4. Rales in the posterior chest 5. Jugular vein distention 6. Weight gain
Lab value for CVP: 2-6mmHg, 5-10cmH2O 2., 4., 5. & 6. Correct: The CVP is high, indicating fluid volume excess. These signs and symptoms indicate fluid volume excess. 1. Incorrect: The CVP is high and correlates with fluid volume excess. This sign indicates fluid volume deficit. 3. Incorrect: The CVP is high and correlates with fluid volume excess. This sign indicates fluid volume deficit.
The client with ulcerative colitis calls the clinic and reports increasing abdominal pain and increased frequency of loose stools. He asks the nurse to clarify the type of diet he is to follow. Which diet is best for clients with ulcerative colitis?
Low fiber. This client should not have much fiber. A low residual diet decreases irritation of the GI tract.
