NCLEX PN ARCHER REVIEW

The nurse is providing education to a group of pregnant women regarding the prevention of postpartum thrombophlebitis. Which statement by one of the expecting mothers would indicate a correct understanding of the teaching? Select all that apply.

"After we give birth, we are at an increased risk of clots for 6 to 8 weeks." "We shouldn't go on car rides longer than 4 hours for a few weeks after giving birth." "After delivery, we should get up and walk as soon as we are able." "Avoiding crossing our legs will help prevent clots from forming." Rationale: Mothers are at an increased risk for clots for about 6 to 8 weeks after delivery. This is due to a natural increase in clotting factors in the body at this time. When there are increased clotting factors, clots form more readily. Mothers should avoid going on car rides longer than 4 hours for a few weeks after they give birth, as the increase in clotting factors after birth puts them at higher risks for clots. Sitting still in for longer than 4 hours could be dangerous due to the likelihood of developing a clot. This is excellent advice to share with expecting mothers. One of the essential ways to prevent postpartum thrombophlebitis is early ambulation. By encouraging them to get up and walk as soon as they are able, the likelihood of them developing clots will decrease. When legs are crossed for a prolonged period, increased pressure and immobility can lead to clot development. These mothers should be encouraged to avoid crossing legs and ambulate as soon and often as they are able.

The nurse is doing follow-up teaching with a client who has diabetes mellitus. Which of the following information should the nurse include? Select all that apply.

"Annual visual examinations are recommended." "Check your blood sugar if you start to feel shaky." Rationale: A client with diabetes mellitus should be advised to have annual eye examinations because of the risk of diabetic retinopathy. Finally, the nurse should emphasize the client checks their blood glucose for any symptoms of HYPOglycemia such as palpitations, drowsiness, and feeling shaky.

The nurse reinforces teaching to a client with congestive heart failure (CHF). Which of the following information should the nurse include? Select all that apply.

"Foods such as canned vegetables and luncheon meat should be avoided." "Annual immunizations such as the influenza vaccine are recommended." Rationale: Congestive heart failure (CHF) is a chronic condition that causes a decrease in cardiac output. The client will need to maintain a low sodium diet, so processed foods such as luncheon meat should be avoided. Annual immunizations are recommended because of the increased risk of complications from influenza. Complications from influenza are higher in those with co-morbidities such as CHF.

The nurse is reinforcing education to a pregnant client with the hepatitis C virus (HCV). Which of the following statements by the client would require follow-up? Select all that apply.

"I will be unable to breastfeed my baby." "I will have to deliver my baby by cesarean to decrease the risk of transmission." "I can continue my antiviral drugs while I am pregnant." "My baby will need to be isolated while in the hospital." Rationale: These client statements require follow-up by the nurse because they are not accurate. Hepatitis C is a blood-borne pathogen and is not transmitted in breast milk. It is safe for a woman to breastfeed if she has the hepatitis C virus. If her nipples should crack and start to bleed, breastfeeding should be halted. Vaginal delivery is approved for a client with HCV. Cesarean delivery is not advised because of the increased risk of blood exposure unless indicated for other reasons. Unlike HIV infection, antiviral drugs for HCV are unsafe during pregnancy and must be suspended during the pregnancy. Isolation for an individual with hepatitis C is unnecessary (standard precautions are used).

The nurse reinforces discharge teaching to the parents of a 17-year-old male diagnosed with a moderate concussion. Which of the following statements by the parents would indicate effective understanding?

"I will drive him to school until his follow-up appointment." Rationale: Strenuous activity, sports, and intense cognitive tasks should be delayed until the client has approval from the physician. Concussions vary in severity, but what they all have in common is that rest is necessary for the first two to three days. This includes taking it easy with restful sleep and taking naps as necessary. Intense physical and cognitive activities (contact sports, taking an exam, driving, excessive screen time) should be avoided for two to three days or until the physician has provided medical clearance.

The nurse is providing education for a diabetic client who is given a terbinafine prescription for onychomycosis. Which statement(s) by the client demonstrates a good understanding regarding treatment with terbinafine? Select all that apply.

"I will have to take terbinafine for 3 to 6 months." "I will need liver function tests before starting terbinafine." "It may cause taste or vision changes and, I will report vision changes to my doctor." "Dark urine, pale stools, and persistent nausea may indicate a serious side effect Rationale: Onychomycosis, also known as Tinea unguium, is a fungus infection of the nails (fingernails, toenails) that causes the nails to look thick, discolored, opaque, and crumbling. Dermatophytes cause 90% of these toenail infections. Remaining 10% are caused by non-dermatophytes (Saprophytes), and yeast (Candida). Treatment involves topical antifungals and systemic antifungals (Terbinafine, Lamisil).

The nurse has reinforced education to a client diagnosed with obstructive sleep apnea (OSA). Which client statement would indicate a correct understanding of the teaching?

"I will plan on exercising at least 150 minutes a week." Rationale: A crucial part of mitigating the symptoms of obstructive sleep apnea is for a client to lose weight. Weight reduction is a pivotal part of the treatment plan for an individual with OSA, as being overweight or obese causes fat deposits in the upper airways. Reducing these fat deposits improves muscle activity and allows for better ventilation. The client stated that they plan on exercising 150 minutes a week is a favorable response because that is the national recommendation.

The nurse has taught a client about a scheduled intravenous (IV) urography (pyelogram). Which of the following statements by the client would indicate a correct understanding of the teaching?

"I will take a laxative the night before to clear my bowels." Rationale: An IV urography (pyelogram) is a diagnostic test used to gather urinary tract imaging that views the collecting ducts and renal pelvis and outlines the ureters, bladder, and urethra. The client must perform a bowel cleansing the night before to ensure adequate visualization of the urinary tract. During this procedure, the client will empty their bladder, and then an intravenous injection of contrast medium is given, and a series of x-ray films and fluoroscopy is used to observe the passage of urine from the renal pelvis to the bladder. The use of this test has decreased because of computed tomography scans of the urinary tract.

The nurse is caring for a client who is struggling with severe depression. Which of the following statements would demonstrate effective therapeutic communication with this client? Select all that apply. "Great work today in group therapy Steve, you were really talkative today!" "I'd like to just sit with you for a while Steve." "Tell me how you're feeling Steve. I'd like to understand." "Why are you feeling depressed today Steve?" "I know exactly how you feel. I've been through the same thing."

"I'd like to just sit with you for a while Steve." "Tell me how you're feeling Steve. I'd like to understand." Rationale: In this scenario, the nurse offers to sit in silence with the client. Therapeutic silence with individuals struggling with depression can create a safe and reflective space, foster deeper communication, encourage self-reflection and emotional processing, reduce pressure and anxiety, enhance active listening, and promote self-expression. Effective therapeutic communication aims to establish trust, provide support, and encourage the client's expression of thoughts and feelings. Asking open-ended questions in a supportive, non-judgmental way offers support to the depressed client.

Which of the following statements indicates body image distortion in a client with anorexia nervosa?

"I'm so overweight." Rationale: Clients with anorexia perceive themselves to look differently than they do. Despite being too thin, this client will not eat in hopes of getting the perfect body.

The nurse is reinforcing teaching a client about prescribed lisinopril for hypertension. Which of the following information should the nurse include? Select all that apply.

"Limit your intake of salt in your diet and season your foods naturally." "You must have your potassium monitored from time to time." "You may notice a change in your sensation of taste." Rationale: Sodium intake should be limited to no more than 2 grams daily for a hypertension client. Increased sodium causes fluid retention, therefore, raising blood pressure. Salt substitutes should be avoided for a client taking an ACE inhibitor because they are potassium based and would increase the serum potassium. ACE-I's raise potassium, and this combination may lead to life-threatening hyperkalemia. Potassium and renal function tests are commonly monitored while a client receives this medication because both may become elevated. ACE-I's may cause an altered taste sensation which is expected.

The nurse is caring for a client who is receiving prescribed mirtazapine. Which of the following statements, if made by the client, would indicate a therapeutic response? Select all that apply.

"My depression has gotten better." "I am sleeping eight hours a night." Rationale: Mirtazapine is a tetracyclic antidepressant that causes an increase in serotonin and norepinephrine. This medication is used for depressive and anxiety disorders. Mirtazapine is quite sedating and is often used for insomnia associated with depressive disorders.

When teaching medication safety to a toddler's parent, which statement by the parent would be a cause for concern?

"To get her to take her medicine, we tell her it's candy." Rationale: Children should never be told that medication is candy.

The nurse is reinforcing education to a client about newly prescribed aspart insulin. The nurse should instruct the client to self-administer this insulin

10-15 minutes before a meal. Rationale: Aspart insulin is a rapid actin insulin that should be administered to the client no greater than 10-15 minutes prior to the meal or while the client is actively eating. Prior to the administration of this insulin, the client's blood glucose should be obtained.

You are reinforcing counseling for two parents that are preparing for the birth of their first child. They decided to undergo genetic testing and find out that they are both carriers of sickle cell anemia. What is the chance of their baby having sickle cell anemia?

25% Rationale: Their baby has a 25% chance of having sickle cell anemia. The father and the mother are Ss because they are carriers.

The nurse is caring for the following assigned clients. Which client should the nurse follow up with first?

A client requesting diphenhydramine after starting an intravenous antibiotic. Rationale: A client requesting diphenhydramine following the initiation of an antibiotic requires immediate follow-up because the client could be experiencing an allergic reaction ranging from mild to severe. Thus, the nurse should quickly follow-up with this client.

The licensed practical/vocational nurse (LPN/VN) is reinforcing teaching to a group of students about medications and fall prevention. The nurse would be correct to identify which of the following medications can increase the risk for falls? Select all that apply.

Alprazolam Bumetanide Verapamil Rationale: Medications that may hasten the risk for falls include benzodiazepines such as alprazolam. This medication causes drowsiness and may impair judgment. Bumetanide is a loop diuretic; this medication may cause a client to experience orthostatic hypotension and the urgency to use the bathroom. Both of which pose a fall hazard. Verapamil is a calcium channel blocker and is utilized in the management of migraines and hypertension. This medication causes vasodilation; therefore, it will allow the client to become orthostatic if they do not shift positions slowly.

When assessing a client complaining of severe abdominal pain, the nurse would not be surprised to find which of the following assessments? Select all that apply.

An increased pulse rate. An increased respiratory rate. Rationale: The pulse often increases when a person is experiencing pain.

The nurse is caring for a client who has developed Malignant Hyperthermia. Which of the following actions should the nurse take? Select all that apply.

Apply a cooling blanket Insert indwelling urinary catheter Administer prescribed dantrolene Rationale: Malignant hyperthermia is a medical emergency and requires the nurse to intervene by applying a cooling blanket and ice to the axilla and groin. The nurse should also monitor the client's urinary output by inserting an indwelling urinary catheter. The nurse should be prepared to administer Dantrolene as this skeletal muscle relaxant is an effective treatment.

The nurse is caring for a seven-year-old client brought to the clinic by her parents Item 4 of 6 The nurse creates a plan of care for the client Click to specify if each intervention is indicated or not indicated

Apply hydrogen peroxide solution to the affected area (Not Indicated) Educate the client on appropriate hand hygiene (Indicated) Education on warm baths with baking soda for itching (Indicated) Administration of prescribed acetaminophen (Indicated) Collection of blood cultures (Not Indicated) Rationale: Interventions that are indicated include appropriate hand hygiene. Frequent hand sanitation will decrease the likelihood of cellulitis if the skin is broken by itching. Educating on comfort measures such as warm baths with baking soda or oats is indicated to soothe itching. Acetaminophen would be helpful if the client has a fever.

The nurse cares for a client immediately following a shoulder reduction procedure with moderate sedation. The nurse assesses the client as restless and irritable. The nurse should take which priority action?

Assess the client's oxygen saturation Rationale: Assessing the client's oxygen saturation is essential because this client is demonstrating manifestations of hypoxia. Early signs of hypoxia include altered mental status and restlessness. Moderate sedation uses multiple medications, such as fentanyl and propofol, to achieve a state of altered consciousness, so procedures like shoulder reductions may be completed with very little pain. These medications are CNS depressants, and during the procedure, the client is often given supplemental oxygen. Post-procedurally, the nurse will monitor the client's vital signs very closely.

The nurse is caring for a client with the following clinical data. Based on the vital signs, which medications would the nurse clarify with the primary healthcare provider (PHCP) before administration? See the exhibit. Select all that apply.

Atenolol 50 mg PO Daily Spironolactone 50 mg PO Daily Fentanyl 50 mcg IV Push q 6 hours PRN Pain Rationale: The vital signs show hypotension (90/60 mm Hg). The nurse should clarify the prescriptions of atenolol, spironolactone, and fentanyl. All these medications decrease blood pressure, and considering how low the client's blood pressure is; it would be highly detrimental.

The nurse cares for a client with polycystic kidney disease (PKD). Which of the following would indicate the client is achieving treatment goals?

Blood Pressure 128/63 mmHg Rationale: Treatment goals for a client with polycystic kidney disease (PKD) include maintaining normotension, the glomerular filtration rate (GFR), and the prevention of sodium wasting, which is evidence of a decline in renal function. Hypertension is a cardinal finding in PKD, and if a client is achieving the treatment goals, they will maintain regulated blood pressure.

Which procedures necessitate the use of surgical aseptic techniques? Select all that apply.

Central line intravenous medication administration. Donning gloves in the operating room. Foley catheter insertion. Rationale: Surgical asepsis is used when managing central line intravenous medication administration when donning sterile gloves in the operating room and inserting an indwelling Foley catheter. Asepsis is the freedom from disease-causing microorganisms. To decrease the possibility of transferring microorganisms from one place to another, the aseptic technique is used.

*NGN* The nurse is caring for a 47-year-old male in the outpatient clinic Orders Discharge home Schedule a follow-up appointment in four weeks Sertraline 50 mg PO Daily Clonidine 0.1 mg PO Daily Zolpidem 5 mg PO, PRN insomnia The nurse reviews the orders and formulates a teaching plan for the newly prescribed medications For each medication, select the appropriate option for drug classification and client teaching that should be reinforced

Clonidine - alpha2-adrenergic agonist This medication may cause you to become dizzy or tired. Sertraline - selective serotonin reuptake inhibitor Diarrhea is a common side effect of this medication. Zolpidem - Hypnotic Do not take this medication with alcohol Rationale: - Clonidine is indicated in the treatment of hypertension. The medication may be administered as a pill or transdermal patch for seven days. It should not be abruptly discontinued because of the risk of rebound hypertension due to a catecholamine surge. Clonidine has a sedative effect, and the client should not take this medication with alcohol or while driving/performing tasks requiring a high degree of concentration. - Sertraline is a potent, selective serotonin reuptake inhibitor. Sertraline is indicated in treating anxiety, obsessive-compulsive, and depressive disorders. SSRIs typically cause gastrointestinal distress once they are started and may be lessened by taking the medication with food. - Zolpidem is a non-benzodiazepine sedative-hypnotic indicated in the treatment of insomnia. This medication should not be taken with alcohol or other CNS depressants because of the risk of respiratory depression.

While working in the emergency department the nurse assesses a 3 day old infant brought in by his mother. She states "he is always so sweaty and hot, and just doesn't want to eat! I think something is wrong." The nurse is unable to palpate a femoral pulse, but notes +3 brachial pulses. Which congenital heart defect does the nurse suspect? A. Hypoplastic left heart syndrome B. Patent ductus arteriosus C. Transposition of the great arteries D. Coarctation of the aorta

Coarctation of the aorta Rationale: The nurse suspects that this infant has coarctation of the aorta. In this defect, there is a stricture in the aorta preventing blood flow out of the left ventricle. It usually occurs beyond the blood vessels that branch off to your upper body and before the blood vessels that lead to your lower body. So blood flow to the upper body is abundant, but hardly any can make it to the lower part of the body. Therefore, there are decreased lower extremity pulses and increased upper extremity pulses.

The nurse cares for a 48-hour-old newborn who has not yet passed stool since delivery. The nurse understands that the client is at highest risk for which conditions? Select all that apply.

Cystic fibrosis Anorectal anomalies Hirschprung's disease Rationale: Cystic fibrosis is a generalized dysfunction of the exocrine glands leading to increased mucus secretions, particularly in the pancreas and lungs—about 10 to 20% of clients with cystic fibrosis present with meconium ileus. Meconium ileus refers to small bowel obstruction by thickened (inspissated) meconium. Meconium ileus is one of the earliest manifestations of cystic fibrosis, and its symptoms include failure to pass meconium and abdominal distension with or without vomiting. Meconium ileus can be complicated with intestinal perforation, small bowel volvulus, and peritonitis. Anorectal abnormalities (imperforate anus) can be detected by physical examination at birth. Here, the mechanical obstruction from the structural anomaly results in failure to passage meconium. Hirschsprung's disease is a congenital anomaly that results in functional obstruction from inadequate motility (peristalsis) due to the absence of ganglion cells in the distal colon and rectum.

The nurse should recognize which of the following common physiological signs of aging. Select all that apply.

Decreased metabolism Reduced muscle mass and strength Changes in bone density Rationale: Decreased metabolism: As people age, their metabolic rate tends to decrease. This can result in a gradual decrease in energy levels and a potential increase in weight if dietary and exercise habits are not adjusted accordingly. Reduced muscle mass and strength: With aging, there is a gradual loss of muscle mass and strength, known as sarcopenia. This can lead to decreased mobility, balance issues, and an increased risk of falls. Changes in bone density: Bones tend to become less dense and more fragile with age, leading to an increased risk of fractures. Conditions like osteoporosis are more prevalent in older adults, especially postmenopausal women.

Which of the following steps is the final step used during the physical assessment of the abdomen?

Deep palpation Rationale: Deep palpation is cautiously done after light palpation when necessary because the client's responses to deep palpation may include tightening of the abdominal muscles. When this occurs, it could make light palpation less effective, particularly if an area of pain or tenderness has been palpated. A complete health assessment may be conducted starting at the head and proceeding systematically downward (head-to-toe evaluation). However, the procedure can vary according to the individual's age, the severity of the illness, the preferences of the nurse, the location of the examination, and the hospital's priorities and procedures.

The nurse is reinforcing teaching to staff about the use of warfarin. The nurse uses which medical conditions as examples of diagnosis that may lead to the use of warfarin. Select all that apply.

Deep vein thrombosis (DVT) Atrial fibrillation (AFib) Ischemic stroke Rationale: Deep vein thrombosis (DVT). This is a correct medical condition for which warfarin is commonly prescribed. Warfarin often prevents and treats blood clots, including deep vein thrombosis. It does not dissolve the clot. Atrial fibrillation (A-Fib). This is a correct medical condition for which warfarin is frequently prescribed. Warfarin helps prevent blood clots in individuals with atrial fibrillation, characterized by irregular heart rhythm. Ischemic stroke. This is a correct medical condition for which warfarin may be prescribed. Warfarin is commonly used as secondary prevention in individuals with an ischemic stroke to reduce the risk of recurrent clotting events.

S/sx in a 1-year-old w/ heart failure:

Diaphoresis Poor feeding Jugular vein distention Rationale: - Diaphoresis, or increased sweating, is an expected clinical manifestation of heart failure. As the heart works harder and harder to maintain cardiac output, the body starts to tire, which manifests in signs such as diaphoresis. Diaphoresis is possibly related to a catecholamine surge and can mainly display during feeding when the infant/child attempts to eat while in respiratory distress. Poor nutrition is an expected clinical manifestation of heart failure in infants and children. As the left side of the heart begins to fail, fluid backs up in the lungs (pulmonary edema). This causes dyspnea and makes eating increasingly tricky for clients. Venous congestion may result in liver enlargement, ascites, pleural effusion, peripheral edema, and jugular venous distension.

The primary healthcare provider (PHCP) prescribes a regular insulin infusion. The prescription is for 4.5 units/hr. The label on the medication reads 250 mL of 0.9% saline containing 100 units of regular insulin. How many mL/hr should the client receive? Fill in the blank. Round your answer to the nearest tenth. The formula of dose ordered / dose on hand x volume will be utilized to solve this problem.

Divide the prescribed amount of medication by what is on hand 4.5 units / 100 units = 0.045 units Next, take the amount of the medication and multiply it by the volume 0.045 units x 250 mL = 11.25 mL Finally, take the answer and round it to the nearest tenth. 11.25 mL = 11.3 mL

The nurse is caring for a client who is experiencing early decelerations. Which of the following actions should the nurse take?

Document the findings Rationale: Early decelerations are a reassuring finding and are caused by head compression, which is a normal part of labor.

The nurse is preparing to administer a scheduled intramuscular injection to an apprehensive child. Which therapeutic action should the nurse take?

Draw a "magic circle" on the area before the injection. Rationale: Techniques to make an intramuscular injection less traumatizing include drawing a magic circle around the area, and after the injection, the nurse may fill in a smiley face.

The nurse is caring for a client who is postpartum. Which of the following manifestations would be concerning for thrombophlebitis? Select all that apply.

Edema Tenderness Rationale: Indications of thrombophlebitis include localized areas of redness, heat, edema, and tenderness.

The nurse is caring for a client who is in Buck traction. Which of the following actions should the nurse take?

Elevate the foot of the bed to provide countertraction Rationale: The nurse should slightly elevate the foot of the bed to provide counter traction and prevent the client from being pulled downward.

COPD; Interventions to implement:

Encourage smoking cessation Reinforce education regarding pursed-lip breathing technique Rationale: Smoking is a major risk factor for the development and progression of COPD. Encouraging smoking cessation is an essential intervention to prevent further lung damage and improve the client's respiratory status. Pursed-lip breathing is a breathing technique that can help clients with COPD improve their breathing efficiency and control dyspnea

The nurse reinforces teaching to a client with hypertension about the newly prescribed furosemide. Which of the following should the nurse include in the teaching?

Take this medication in the early part of the day Rationale: Furosemide is a loop diuretic and may be indicated for conditions such as heart failure or hypertension. The client should be instructed to take this medication in the earlier part of the day to avoid nocturia.

Which of the following nonpharmacological interventions are appropriate for a 2-month-old with a fever of 39.2 degrees Celsius? Select all that apply.

Encouraging adequate fluid intake Dressing the child in lightweight clothing Using cooling techniques Providing a cool and comfortable environment Rationale: It is crucial to ensure that the 2-month-old with a fever stays well-hydrated. Offering fluids, such as breast milk or formula, helps prevent dehydration and supports the body's healing process. Dressing the baby in light, breathable clothing helps facilitate heat dissipation and prevents overheating. Avoiding excessive layers or heavy clothing promotes comfort and helps regulate body temperature. Employing cooling techniques like lukewarm sponge baths or placing cool, damp cloths on the baby's forehead and underarms can aid in reducing body temperature. These measures should be done gently to prevent chilling the baby. Creating a cool and comfortable environment by adjusting the room temperature, using a fan, or providing good air circulation can help lower the baby's body temperature and promote comfort.

Which action taken by the school nurse will have the most impact on the school's incidence of infectious disease?

Ensure that students are immunized according to national guidelines Rationale: The incidence of once-common infectious diseases such as measles, chickenpox, and mumps have been most effectively reduced by immunization of all school-aged children. School-aged children are at risk for problems such as exposure to viruses, respiratory infections, and parasitic infections (such as scabies or lice). Vaccination protects children from severe illness and complications of vaccine-preventable diseases, which can include amputation of an arm or leg, paralysis of limbs, hearing loss, convulsions, brain damage, and death.

The nurse is taking vital signs for a client who has a chest tube in place. While counting respirations, the nurse notes that the water in the water seal chamber is fluctuating. Which of the following actions are appropriate based on this finding?

Finish counting the client's respirations Rationale: It is appropriate for the nurse to finish counting the client's respirations and continue to monitor them. Fluctuations of the water in the water-seal chamber with inspiration and expiration is a sign that the drainage system is patent. Normally, the water level will increase when the client breathes in, and decrease when they breathe out. This is due to changes in intrathoracic pressures.

When preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA, which PPE should the nurse plan to use? Select all that apply.

Gloves & Gown Rationale: A gown and gloves should be used when coming in contact with linens that may be contaminated by wound secretions. Approximately half of all MRSA infections are acquired in the hospital. One-fourth is associated with having received health care, but onset is in the community; the remainder is considered community-acquired. Due to aggressive health care emphasis on preventing MRSA transmission using standard and contact precautions, rates have decreased but are still unacceptably high. More Americans die each year from MRSA than from AIDS.

A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will you need to put on when preparing to assess the client? Select all that apply. Goggles Gown Gloves Shoe covers N95 respirator Surgical face mask

Gown Gloves N95 respirator Rationale: Since herpes zoster is spread through airborne means and direct contact with the lesions, contact and airborne precautions should be followed. This means the nurse should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves. Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus (VZV), the same virus that causes varicella (chickenpox). Primary infection with VZV causes varicella. Once the illness resolves, the virus remains latent in the dorsal root ganglia. VZV can be reactive later in a person's life and create a painful, maculopapular rash called herpes zoster. Active herpes zoster lesions are infectious through direct contact with vesicular fluid until they dry and crust over. People with active herpes zoster lesions should cover their injuries and avoid contact with susceptible people in their household and occupational settings until their wounds are dry and crusted.

The nurse is caring for a client who is newly prescribed cimetidine. The nurse understands that this medication is prescribed to treat which condition?

H. pylori Rationale: Cimetidine is a H2 receptor antagonist indicated in treating peptic ulcer disease, gastric esophageal reflux disease, or H. pylori infections. This older medication has widely been replaced with newer H2 receptor antagonists because this medication is known to cause significant drowsiness.

The nurse is caring for a client exhibiting signs of poor muscle coordination, stooped posture, and slow movements. Which medication is most likely to cause these symptoms?

Haloperidol Rationale: Haloperidol is a typical antipsychotic that may adversely cause extrapyramidal side effects (EPS). These effects include akathisia, dystonia, pseudo-parkinsonism, and/or tardive dyskinesia. Tardive dyskinesia is an adverse effect that occurs with antipsychotics and has an onset of months to years while on the medication.

The nurse is caring for a client with diabetes mellitus. Which of the following laboratory data requires follow-up? Select all that apply.

Hemoglobin A1C 8.5% [< 5.7%] Creatinine 1.9 mg/dL [0.6-1.2 mg/dL] BUN 25 mg/dL [10-20 mg/dL] Proteinuria Rationale: The client's hemoglobin A1C is elevated as the therapeutic goal for a client with diabetes is to attain less than 7%. This elevated level is causing the client to experience an insult to the kidneys, which is evident by the increased BUN (normal 10-20 mg/dL) and creatinine (normal 0.6-1.2 mg/dL). Finally, proteinuria is further evidence that this client is experiencing diabetic nephropathy.

Which of the following vital sign abnormalities is a clinical manifestation of a client with Wilms Tumor?

Hypertension Rationale: Hypertension is a clinical manifestation of Wilms Tumor. This tumor is located on the kidneys and causes an increased amount of renin. Increased renin levels lead to hypertension through sodium and water retention via the RAAS system.

he nurse is caring for a client with the following tracing on the electrocardiogram. When reviewing the client's medical history, which condition could be causing this dysrhythmia? See the image below. Select all that apply.

Hyperthyroidism Shock Rationale: The tracing shows sinus tachycardia. Sinus tachycardia may be caused by various conditions,,,, including febrile illness, dehydration, shock, anemia, and hyperthyroidism. Sinus tachycardia is a heart rate greater than 100 beats-per-minute, has a p-wave before each QRS complex, and is regular. The treatment of ST is the underlying cause, for example, if the client is febrile, the treatment would be prescribed fluids and antipyretics (acetaminophen).

A patient that has suffered a third-degree burn injury involving 27% of Total Body Surface Area (TBSA) a few hours ago has been rushed to the emergency room. Which of the following should the LPN expect to find in this patient? Select all that apply. Hyponatremia Hyperkalemia Hypotension Increased urinary output Severe hypophosphatemia Edema in burned areas

Hyponatremia Hyperkalemia Hypotension Edema in burned areas Rationale: Initial resuscitation period: This refers to the period between 0 to 36 hours from the time of burn injury. Due to the damage to the tissues and vessels in major burns, capillary/vascular permeability is significantly increased, and fluid and electrolyte shifts occur between the body compartments. Significant edema in the burn area occurs due to fluid accumulation in the burned tissues due to increased vascular permeability and increased interstitial osmotic pressure. Due to changes in cellular permeability, sodium ions enter the cellular compartment resulting in low levels of intravascular sodium (hyponatremia, Na < 135 mEq/L) Extensive tissue necrosis and cell lysis in major burns also lead to the exit of potassium ions from the cell into the intravascular compartment resulting in hyperkalemia (K > 5.1 mEq/L). Restoring sodium losses by using appropriate fluid and correcting severe hyperkalemia is necessary during this period. The body's initial response in a major burn is to shunt blood toward the brain and heart, and away from peripheral vasculature and other organs, resulting in a low circulating volume leading to hypotensionF

While reviewing the morning labs of your client, you see the following results from their thyroid panel. What diagnosis does the nurse suspect? TSH: 7 mU/L T4: 1.0 mcg/dL T3: 2.0 ng/dL

Hypothyroidism Rationale: Hypothyroidism would be manifested with an increased thyroid-stimulating hormone level and decreased T4 and T3, as shown in these labs. Because of the increased TSH level, the thyroid gland is tricked into thinking that there is enough thyroid hormone already in the body and does not secrete more. The decreased T3 and T4 levels cause hypothyroidism symptoms, such as weight gain and fatigue.

For the child experiencing a celiac crisis. which nursing intervention is the priority?

IV fluid administration Rationale: A Celiac crisis is a rare, life-threatening complication of Celiac disease. Infection, stress, or fasting may precipitate a Celiac crisis. The patient has severe, persistent watery diarrhea and vomiting. Due to a large volume of fluid losses, the patient is at risk for hypovolemia, decreased cardiac output, and, eventually, hypovolemic shock. IV fluid administration is the nursing priority to ensure adequate blood volume for circulation.

The nurse is caring for a client who is at risk of developing pressure ulcers. Which of the following would the nurse recognize as accurate statements regarding pressure ulcers? Select all that apply.

In a stage II pressure ulcer, part of the dermis and epidermis are lost. In a stage III pressure ulcer, there is a deep tissue injury that can expose fat. Rationale: Stage II pressure ulcers occur when the epidermis and a part of the dermis are lost. Stage III pressure ulcers expose subcutaneous fat but do not extend deep enough to expose the bone and muscle.

The nurse is discussing infection control with a group of nursing students. It would be correct to state that droplet precautions are used for which condition? Select all that apply.

Influenza Pertussis

The nurse is caring for a client with newly prescribed zolpidem. The nurse understands that this medication is indicated for which condition?

Insomnia Rationale: Zolpidem is a non-benzodiazepine indicated in the treatment of insomnia.

The nurse is caring for a ten-year-old diagnosed with gastroenteritis Based on the client assessment, the nurse should plan to take which actions? Select all that apply

Instruct the avoidance of sweetened drinks. Initiate oral rehydration therapy (ORT). Rationale: The assessment indicates that the client is dehydrated. Interventions for the dehydrated client are to instruct the client to avoid sweetened drinks as these drinks cause further dehydration. Additionally, the nurse should initiate oral rehydration therapy (ORT), which is clear liquids that are non-sweetened.

Verbal hand-off report; essential information should the nurse include in the report:

Involuntary admission status Rationale: Admission status is essential information in the hand-off report because involuntary admission status requires the client to stay in the healthcare facility. Involuntary admission status may also raise the client's risk of eloping.

The nurse reviews a client's medication record who takes prescribed sildenafil. Which medication should the nurse clarify with the primary healthcare provider (PHCP)?

Isosorbide Isosorbide is a nitrate medication and should not be taken concurrently with phosphodiesterase inhibitors such as sildenafil. The combination of the two may result in profound hypotension.

The nurse is attending a staff development conference about the causes of labor dystocia. It would be correct for the nurse to identify which of the following may cause a delayed progression during labor? Select all that apply.

Magnesium sulfate infusion Uterine overdistention Hypoglycemia Epidural analgesia Rationale: Magnesium sulfate relaxes the uterus and may decrease the intensity of uterine contractions. A decrease in intensity will decrease the progression of labor. Often when magnesium sulfate is infused, oxytocin may be used in conjunction. Uterine overdistention is a cause of labor dystocia because when the uterus is stretched, it does not contract properly. Hypoglycemia is a cause of delayed labor progression because of the maternal fatigue it induces. While epidural analgesia provides effective pain control, the decrease in sensation will also decrease the woman's drive to push and interfere with the internal rotation mechanism.

*NGN* A 22-year-old is evaluated in the emergency department for recurrent seizure activity For each physician order, click to specify the appropriate nursing intervention

Magnetic Resonance Imaging (MRI) of brain NI: Assess if the client has claustrophobia prior to the exam Loading dose of intravenous (IV) phenytoin NI: Establish continuous cardiac monitoring during the infusion Electroencephalogram (EEG) NI: Instruct the client how to remove the adhesive after the test Rationale: Claustrophobia is a concern for the client scheduled to undergo an MRI because most MRIs are closed. Claustrophobia may impede an effective exam as the client may move. While some MRIs are open, a remedy to this problem may be the physician prescribing a benzodiazepine or antihistamine prior to the exam. For a client receiving phenytoin, continuous cardiac monitoring must be established and maintained because of the risk of arrhythmias. This medication must be infused in a large-bore IV catheter because of the risk of thrombophlebitis. An electroencephalogram (EEG) is a non-invasive diagnostic test utilized to look at brain waves. In this test, the client has electrodes placed around their head for a set period of time. Fasting is avoided because hypoglycemia may alter the brain waves. Additionally, the nurse should clarify the administration of central nervous stimulants and depressants prior to this exam, as this will alter brain waveforms. Finally, the nurse should instruct the client to avoid the use of hair creams, gels, and conditioners prior to the exam, as this will prevent the electrodes from adhering to the skin. The adhesive gel can be removed at the end of the procedure.

The nurse is developing a plan of care for a client admitted to the mental health unit with significant paranoia. Which of the following should the nurse include in the client's plan of care? Select all that apply.

Maintain consistent caregivers. Involve the client in decision-making. Rationale: A client experiencing paranoia may be very conspiratorial, and while it is important to reinforce reality, it would be appropriate to acknowledge their feelings. Involving the client in the decision-making process and avoiding any surprises is essential. Consistent caregivers are recommended because this cements the therapeutic relationship with staff.

*NGN* The medical-surgical nurse is planning care for a client Admission Note 65-year-old female was admitted for stage IV ovarian cancer. The client decided to forego further treatment and decided on comfort measures only. The client is drowsy and reports nausea and generalized pain. She makes little eye contact and reports increasing discomfort when the head of the bed is elevated. Skin is cool and mottled. The client is experiencing urinary incontinence. For each client need, click to specify the potential nursing intervention that would be appropriate for the client's care. Each category must have at least one option selected.

Nutritional Keep the client nothing by mouth (NPO) Use moist swabs to the mouth and lips Thermoregulation Layer the client with warm blankets Comfort Play soothing music and aromatherapy Position the client on their side for gurgling Elimination Offer an indwelling catheter for comfort Give an enema for nausea caused by constipation Rationale: For the client receiving hospice services and comfort measures only, the nurse must collaborate with the interprofessional team to maintain the client's comfort. This client experiences discomfort when the head of the bed is elevated and drowsy; thus, the nurse should keep the client nothing by mouth (NPO). This would prevent aspiration and would cause significant distress and discomfort. The nurse should use moist swabs to the mouth and lips to prevent chapping and maximize comfort. Layering the client with warm blankets is appropriate, considering the client's appearance is cold and mottled. Comfort measures can be achieved by playing soothing music and offering aromatherapy. This would be helpful for the client's nausea. Placing the client on their side for any gurgling would help prevent aspiration. Offering a urinary catheter is an appropriate comfort measure. This would minimize discomfort as urinary incontinence would cause skin breakdown. The client's complaints of nausea may be caused by constipation; if this is the case, an appropriate nursing intervention would be administering an enema to alleviate constipation.

The LPN is reinforcing education regarding advance directives with the client. Which of the following statements are not true regarding advance directives? Select all that apply.

Only one physician must determine when a client is unable to make medical decisions for himself. Advance directives must be reviewed and re-signed every ten years to remain valid. An advance directive is legally valid in every state, no matter which state it was initially created. Rationale: Once a client arrives at a hospital, physicians will need to evaluate the client and implement the advance directive, if necessary. Two physicians, not one are required to determine whether a client cannot make decisions for themself. Advance directives do not expire and remain in effect until they are changed. It is not true that they need to be signed every ten years to stay valid. Some states do not honor advance directives created in other states. So, if a client moves, he/she should check with his/her new state policies on the topic.

*NGN* The following scenario applies to the next 1 items The nurse cares for a client with disseminated intravascular coagulation (DIC) and prescribed multiple blood products Select the most likely option for the missing information in the table below by choosing from the list of options. Each option may only be used once.

Packed Red Blood Cells: 2-4 hours; Give product with 0.9% saline with y-type tubing Fresh Frozen Plasma (FFP): Administer over 15-30 minutes; Reassess PT/INR after transfusion Platelets: 15-30 minutes; Give through short tubing and small filter Rationale: Packed Red Blood Cells are indicated for hemoglobin of 7 g/dL or less. Additionally, the transfusion time for PRBCs is 2-4 hours. The blood product should be type-specific, but if not possible, O negative may be administered as it is the universal donor. When infusing PRBC's, 0.9% saline should be spiked with the blood product using y-type tubing. Fresh Frozen Plasma is indicated for clotting factor replacement and volume expansion. FFP must be type specific and is administered over 15-30 minutes. To determine efficacy, the nurse should reassess the PT/INR after the transfusion. Platelets are used to treat platelet dysfunction and thrombocytopenia. Platelet transfusions are indicated once the platelet count reaches 20,000-25,000 mm3. Platelets do not have to be type specific as they are pooled from as many as ten donors. The infusion time is 15-30 minutes.

The emergency department (ED) nurse cares for a client with severe intrabdominal bleeding. The client has tachycardia, hypotension, and a thready pulse. The nurse anticipates the primary healthcare provider (PHCP) will prescribe which blood product?

Packed red blood cells (PRBCs) Rationale: The client is experiencing intraabdominal bleeding with manifestations confirming shock. The client will need to have the blood volume replaced with emergent surgery. Type-specific PRBCs would be preferred; however, if the client is critical, O-negative blood may be transfused.

Guillain Barre syndrome; Expected finding:

Paresthesia Rationale: Guillain Barré is a polyneuropathy that is manifested by paralysis, paresthesia, autonomic disturbances, and depressed or absent reflexes. The paresthesia is typically found in the peripheral extremities and may persist for quite some time even after the return of motor function.

What should the nurse look for when evaluating a 2-year-old client for possible neglect? Select all that apply.

Poor hygiene Frequent unexplained injuries Malnourishment or extreme hunger Developmental delays

*NGN* The nurse cares for a 75-year-old client who arrives at the emergency department History And Physical 1900: The client arrives with left facial droop, inability to move her left arm and leg, and expressive aphasia. According to the husband, they were out eating dinner, and the symptoms started suddenly, and she fell to the ground. The symptoms started 45-minutes-prior to arrival at the ED. Past medical history includes atrial fibrillation, hypertension, diabetes mellitus, and hyperlipidemia. Vital Signs: Temp 99.5; Pulse 86; Respirations 18; BP 181/109; O2 95% Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress

Potential Conditions: Cerebral Vascular Accident Action to Take: Obtain lab work (PT, INR, aPTT, troponin, CBC, CMP, Capillary Glucose) and Transport the client to CT scan Parameters to Monitor: Glasgow Coma Scale and Vital Signs Rationale: The client's history of atrial fibrillation substantially increases the risk for an ischemic stroke. Considering the sudden evolution of symptoms, this stroke is most likely embolic (which is a form of an ischemic stroke). The signs and symptoms of expressive aphasia, no motor function on the left side, and left-sided facial drooping are cardinal symptoms of a CVA. An immediate priority for a client experiencing a CVA is transporting the client to a CT scan to determine if the CVA is hemorrhagic or ischemic. The nurse should also obtain laboratory work, including capillary blood glucose, as hypoglycemic symptoms mimic stroke symptoms. The parameters to monitor include a neurological assessment which includes the Glasgow Coma Scale. Additionally, hypertension is expected during a stroke, and permissively, it is preferred to keep the blood pressure elevated to allow for perfusion to the affected area of the brain. The target blood pressure for an ischemic stroke is 185/110 mmHg or less.

*NGN* The nurse in the clinic is caring for a 46-year-old female Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress

Potential Conditions: Wernickle Encephalopathy Actions to Take: Start a peripheral vascular access device and obtain a prescription for thiamine Parameters to Monitor: Gait and lower extremity paresthesias Rationale: The client is experiencing Wernicke encephalopathy. Nystagmus, ataxia, and paresthesias of the lower extremities are classic findings. The client's escalation in her drinking is the cause of this encephalopathy which is due to a thiamine deficiency. Prompt treatment is necessary as some of the neurological impairments may be irreversible. The nurse needs to obtain an order to start a vascular access device and obtain a prescription to administer parenteral thiamine. Administering the prescribed thiamine will hopefully alleviate the client's neurological impairments. Oral thiamine is not recommended, as parenteral replacement is necessary to treat the neurological impairments, which may be permanent if prompt treatment is not sought. The nurse should monitor the client's gait because it is disturbed. This puts the client at risk for falls and injury. This also would show improvement with prescribed treatment (thiamine) and the reduction of lower extremity paresthesias.

Which of the following symptoms should the nurse monitor for in her patient with a suspected diagnosis of intussusception? Select all that apply

Red currant jelly stool Palpable, sausage-shaped mass in the RUQ Vomiting partially digested food Rationale: Red, currant jelly stool is a classic finding of intussusception. When the bowel telescopes into another portion of the intestine, it causes intestinal obstruction and subsequently red, currant jelly stools. A palpable, sausage-shaped mass in the RUQ is a classic finding of intussusception. This is due to the physical telescoping of the intestine, and the mass can sometimes be felt upon palpation. The child may vomit bile or partially digested food, which can be a result of the obstruction caused by the intussusception.

The Maternal Serum Screen 4 (MMS4) of an obstetrics client shows decreased maternal serum alpha-fetoprotein and estriol along with increased hCG. What strategy should the nurse include in the plan of care?

Refer to the physician. Rationale: The combination of results presented in this situation may be the result of a fetus with Down syndrome. The physician needs to be notified of the results, and the nurse would anticipate a referral for an amniocentesis. The Maternal Serum Screen 4 (MSS4) is a blood test performed during pregnancy to identify potential risks to the developing fetus. Its purpose is to screen for possible neural tube defects, Down syndrome, and trisomy 18 in the developing baby.

The nurse is caring for a client with a serum magnesium level of 3.2 mg/dL(1.5-2.5 mEq/L). Which of the following could be a contributing factor in this abnormal electrolyte level? Select all that apply.

Renal failure Adrenal insufficiency Rationale: The normal magnesium level is 1.6-2.6 mg/dL. This client has a level of 3.2 and is experiencing hypermagnesemia. Renal failure can cause hypermagnesemia since the process that keeps the levels of magnesium in the body at normal levels does not work properly in people with kidney dysfunction. The adrenal glands play a role in regulating magnesium levels in the body. If the adrenal glands are not functioning properly, magnesium levels can increase, leading to hypermagnesemia.

The nurse is caring for a 45-year-old client who has undergone electroconvulsive treatment (ECT) for severe depression. Which of the following nursing interventions is appropriate following the treatment? Select all that apply. Position the client supine with the head of the bed at 30 degrees. Reorient the client frequently. Remain with the client at all times. Promote bedrest for 12-24 hours. Ambulate the client as soon as possible.

Reorient the client frequently. Remain with the client at all times. Rationale: It will be a critical nursing intervention to frequently reorient the client who has just received electroconvulsive therapy (ECT). This is because temporary memory loss is associated with this procedure, so they will likely be confused and disoriented. Due to this disorientation, they will probably be scared; the nurse must frequently reorient them to their place and situation to make them feel safe and secure. It will be a critical nursing intervention to remain with the client who has just received electroconvulsive therapy. A side effect of electroconvulsive treatment is temporary memory loss. They will be disoriented and confused, so the nurse must remain with them to keep them safe.

The nurse is reinforcing teaching with a client with Graves' disease regarding self-management. Which of the following should the nurse emphasize?

Report any weight gain while taking the antithyroid medication. Rationale: Graves' disease is the most common cause of hyperthyroidism. When a client takes antithyroid medication, such as methimazole, the nurse should emphasize the warning signs of hypothyroidism (weight gain, constipation, anorexia). This could indicate that the antithyroid medication dose needs to be decreased.

The nurse is assessing a 7-month-old infant. At this age, which of the following reflexes would the nurse expect to no longer be present? Select all that apply.

Rooting Moro Palmar Tonic neck Rationale: - The Rooting reflex should disappear by 3-4 months of age. It occurs when the infants turn their face toward stimulation (such as stroking their cheek) and make sucking (rooting) motions with the mouth. This reflex helps to ensure successful feeding. - The Moro reflex should disappear by 5-6 months of age. This reflex is a response to a sudden loss of support. When support is removed, the infant spreads out the arms and cries. - The Palmar reflex should disappear by 2-3 months of age. When an object is placed in an infant's hand, and the palm is stroked, the fingers will close reflexively. - The tonic neck reflex disappears around 4 months of age. This reflex is elicited by turning the infant's head to one side and is considered positive if the infant extends the extremities on the side that the head is turned toward, and flexes the extremities on the opposite side.

*NGN* The nurse performs a home safety survey for an older adult Click to specify the findings that require intervention by the nurse

Scatter rugs at the end of the stairs Smoke detector present without a battery Extension cord covered with an anti-skid area rug Unlabeled household chemicals under the sink Rationale: Scatter rugs at the bottom of the stairs: scatter rugs should not be used because they reduce the traction on the ground, and the edges of these rugs may cause a client to fall. Smoke detector present without a battery: the smoke detector should have a functioning battery. The battery should be tested every six months. Extension cord covered with a rug: a rug should not cover an extension or electrical cord because of the fire risk. Instead, electrical and extension cords should be against a wall behind furniture. Unlabeled household chemicals under the sink: household chemicals should be labeled to avoid accidental mixing (for example - bleach being mixed with ammonia) that may create a significant hazard. Medications mixed in various containers: medications should not be mixed in containers. This may cause a client to take the wrong medication inadvertently. Medications should be in their original labeled container, and the client may request labels that have a bigger font size.

An LPN is working with a client who has a spinal cord injury. Which of the following symptoms would indicate autonomic dysreflexia in a client who has suffered a spinal cord injury? Select all that apply.

Severe headache Flushing or redness of the skin above the level of injury Abdominal distention Rationale: Severe headache. This is a right symptom of autonomic dysreflexia. A sudden, severe headache is a common manifestation of autonomic dysreflexia resulting from an overactive autonomic nervous system response. Flushing or redness of the skin above the level of injury. This is a correct symptom of autonomic dysreflexia. Flushing or redness of the skin above the level of injury occurs due to the dilation of blood vessels caused by the abnormal autonomic response. Abdominal distention.This is a correct symptom of autonomic dysreflexia. Abdominal distention can occur due to increased intra-abdominal pressure resulting from autonomic dysreflexia, which a full bladder or bowel impaction may cause.

The nurse is assessing a 6-year-old client with asthma. Which of the following findings is of highest concern?

Silent chest Rationale: Silent chest is the assessment finding of most concern. This refers to the inability to auscultate any lung sounds. There is complete obstruction of the client's airway, and therefore the inability to move air. When complete obstruction occurs, this is a medical emergency. This assessment finding is of most concern because the client has lost their airway.

The nurse is caring for a seven-year-old client brought to the clinic by her parents Item 1 of 6 The nurse reviews the history and physical and vital signs Which findings are most significant? Select all that apply

Temperature Papules and vesicles Reports of burning and itching Location of the lesions Rationale: The clinical findings that are the most significant include the client's temperature, which indicates a fever. The presence of papules and vesicles that burn and itch is a common characteristic of varicella. Additionally, the location of the lesions as varicella characteristically has a centripetal outbreak starting at the trunk and working outward.

*NGN* The nurse in the medical-surgical unit cares for a client who is postoperative Complete the sentence below from the list of options

The client is at highest risk for paralytic ileus as evidence by the client's hypokalemia and infusion of fentanyl. Rationale: The client is at the highest risk for paralytic ileus related to persistent hypokalemia and the infusion of fentanyl the client is getting via PCA. Paralytic ileus is concerning for clients who have undergone any abdominal surgery. Combine this with hypokalemia and an opioid that reduces peristalsis, making the client's risk for paralytic ileus quite credible.

While you are in the NICU, an infant is being brought to the unit who is small for gestational age. Which of the following defines this term?

The infant's weight is below the 10th percentile. Rationale: When an infant's weight is below the 10th percentile, it is considered small for gestational age.

The nurse cares for a client on the oncology floor Admission Note The client was admitted for observation after reporting increasing fatigue, dyspnea, malaise, and a fever of 102oF (38.8oC). The client is currently being treated with doxorubicin for uterine sarcoma. The initial diagnostic testing revealed pneumonia and neutropenia. Physician Orders: Admit for observation Regular diet Acetaminophen 500 mg PO q 4 hours PRN fever/pain Start peripheral vascular access 100 mL/hr of normal saline Continue all home medications Complete the following sentences by choosing from the list of options

The nurse recognizes that this client is at increased risk for developing systemic infection therefore, the nurse should implement neutropenic precautions which involves washing hands frequently. Considering the client has a fever, the nurse anticipates an order for collecting blood cultures. Rationale: Neutropenia is classified when the neutrophil count is less than 1,500. Neutropenia can be caused by various factors, including medications, disease, or congenital causes. The biggest threat to a client with neutropenia is the risk of bacterial, fungal, or viral infection. This infection can be localized or, at worse, become systemic. Sickle cell anemia is not a consequence of neutropenia, nor is chronic renal failure.

While on your first shift at a Sleep clinic, you are reviewing the stages of sleep. Place the following steps or phases of sleep in an appropriate sequential order of the sleep cycle. The stage of the sleep cycle that is characterized by a 10 to 20-minute duration. The stage of the sleep cycle that is characterized by delta waves. The stage of the sleep cycle that is characterized by vivid dreams. The stage of the sleep cycle that is characterized by a brief period of very light sleep.

The stage of the sleep cycle that is characterized by a brief period of very light sleep. The stage of the sleep cycle that is characterized by a 10 to 20-minute duration. The stage of the sleep cycle that is characterized by delta waves. The stage of the sleep cycle that is characterized by vivid dreams. Rationale: Several clients suffer from sleep-related disorders and insomnia. Knowing the sleep cycle and the stages of the sleep cycle helps the nurse to understand the sleep pattern disturbances better. Each Sleep cycle lasts 90 to 120 minutes and repeats throughout the night.

You are witnessing a nurse waste available morphine. You should be aware of which of the following correct legal mandates in terms of controlled substances?

The verification of the narcotic count at the beginning and the end of the shift. The secure locking of controlled substances to prevent diversion and theft. Rationale: The verification of the narcotic count at the beginning and the end of the shift (Choice D) and the secure locking of controlled substances to prevent diversion and theft (Choice F) are legal mandates in terms of narcotics and controlled substances.

A patient presents to the emergency department with a dissecting aortic aneurysm. The patient needs immediate surgery to save his life. He is unconscious and there is no family contact information on file. Which action is appropriate for obtaining informed consent for the surgery? A. There is no need for obtained consent. Send the client to surgery. B. Call the hospital lawyer. C. Search for people who may know the patient and can provide informed consent. D. Notify the on-call nursing supervisor and request her permission to waive informed consent.

There is no need for obtained consent. Send the client to surgery. Rationale: When emergency surgery is needed, delaying the surgery to obtain informed consent may result in the patient's morbidity or death. In such urgent cases, informed consent is unnecessary. It is most appropriate to begin the surgery to save the patient's life.

As a practical nurse, what educational points should you reinforce with the parents of a toddler diagnosed with an imperforate anus? Select all that apply.

Toilet training will take longer for your child. Normal bowel habits can be established for your toddler over time. "Bowel irrigations may help your toddler achieve normal bowel function." Teach parents how to recognize signs of complications Rationale: Toilet training for a toddler diagnosed with imperforate anus will take longer than for children who do not have this diagnosis (Choice A). Imperforate anus is usually diagnosed in infancy, but treatment will continue into their toddler years, affecting toilet training. To achieve toilet training, they will need to establish bowel habits and bowel management programs. Regular bowel habits can be established for toddlers diagnosed with imperforate anus over time (Choice B), but they will need to establish bowel habits and bowel management programs. Bowel irrigations will help the toddler achieve normal bowel function (Choice D). They may not need them every day, but bowel irrigations will likely be needed frequently to achieve regular bowel function. Teach parents how to recognize signs of complications (Choice E), such as fever, abdominal distension, or bloody stools, and when to seek medical attention.

*NGN* The nurse is reviewing the assessment of a term newborn one hour following birth Click to highlight the body systems in the assessment that requires follow-up

Vital signs Pulse 184/minute; Temperature of 95.7°F; Respiratory rate 65/minute Eyes Positive corneal and pupillary reflex; negative red reflex Neuromuscular Floppy, poor head control, hypotonic movements in all extremities Skin Generalized cyanosis; vernix caseosa present in skin folds; lanugo present on back Cry Weak, jittery cry Rationale: Vital signs: the pulse is high (normal 110-160/minute; may go to 180/minute when crying). The temperature of 95.7°F (35.3°C) is low (normal 36.5°-37°C [97.7°-98°F]). The infant has tachypnea (normal respiratory rate 40-60/minute). These findings strongly suggest cold stress. Neuromuscular: floppy, poor head control; hypotonic movement in all extremities is abnormal. The expected finding would be the extremities in some degree flexion with good muscle tone. The infant should be able to turn their head from side to side when prone. Hypotonia may suggest hypoglycemia which could be potentially caused by cold stress. Eyes: the eyes should have a positive pupillary and corneal reflex. It is normal for the lids to be edematous for 2 days after birth. The red reflex should be positive. The red reflex is the reflection of light on the vascular retina. The absence of the red reflex may indicate glaucoma, retinal abnormality, retinoblastoma, or cataracts. Skin: generalized cyanosis is a concerning finding for cold stress. The expected integument finding is bright red, puffy, smooth, and some facial edema. The presence of vernix caseosa (a white, oily substance that coats the term infant's body and is often found in the creases of the axillae and groin) and lanugo (fine, downy hair found especially on the forehead, cheeks, shoulders, and back) is a benign finding. Cry: the cry should be vigorous. A weak, jittery cry is concerning for hypoglycemia.

*NGN* The nurse cares for a 20-year-old with schizophrenia in the outpatient clinic The nurse reviews the clinical data Which two (2) findings from the clinical data requires follow-up?

Weight Reports of thirst Rationale: Olanzapine is an atypical antipsychotic, and a concerning trend was noted with the client's increasing weight. Olanzapine may cause significant metabolic problems, including increased blood glucose, weight, and dyslipidemia. The other concerning factor is the client reporting thirst, which may suggest elevated blood glucose. The client's flattened affect and altered speech patterns are expected findings with schizophrenia.

The nurse is caring for a seven-year-old client brought to the clinic by her parents Item 6 of 6 The nurse reinforces discharge teaching to the client Click to specify the information the nurse should reinforce? Select all that apply

Your child may return to school once all the lesions have crusted. Warm baths with baking soda or oats may help with the itching. Contact the school to report your child's infection. Watch for signs of skin infection including swelling, drainage, and pain. Rationale: Once all of the lesions have crusted over the child may resume attending school. The school should be notified of the infection to initiate appropriate notification to those who could be infected. Treatment of varicella is primarily symptomatic through antipyretics and antihistamines. Warm baths with baking soda or oats may provide additional relief from itching. Cellulitis is a complication of varicella caused by bacteria that enters the skin that is excessively itched.

The nurse is caring for a client who was prescribed a clear liquid diet. Which dietary items would be appropriate for the nurse to include? Select all that apply.

apple juice fat-free bouillon with added salt clear hard candy gelatin hot tea with added sugar Rationale: A clear liquid diet is usually transparent (to light) dietary items that do not contain dairy or pulp. Items such as water, gelatin, fat-free bouillon, hot tea, apple juice, seltzer, lemonade, and ginger ale are acceptable. Clear hard candy is acceptable because it is a clear liquid when melted. Salt and sugar are food additives that are permitted.

The nurse is collecting data on a client with suspected infectious mononucleosis (IM). Which of the following findings would support a diagnosis of mononucleosis?

cervical lymph node enlargement and tenderness Rationale: IM is a condition caused by the Epstein-Barr virus (EBV) and causes a client to experience fatigue, rash, fever, headache, cervical lymph node enlargement and tenderness, and splenomegaly. The symptoms may persist for weeks. IM is primarily spread by saliva (hence, this condition was also known as the kissing disease).

The nurse is caring for a client who is receiving prescribed risperidone. Which of the following findings would indicate a therapeutic response? The client demonstrates

decreased thoughts of persecution. Rationale: Risperidone is an atypical (second generation) antipsychotic indicated in psychotic disorders such as schizophrenia. If the client reported decreasing thoughts of persecution (and was observed to have fewer thoughts of persecution), this would be a therapeutic effect.

The nurse is assessing a male client taking prescribed risperidone. Which of the following findings would indicate the client is having an adverse effect?

gynecomastia Rationale: Risperidone is an atypical (second-generation) antipsychotic indicated in treating disorders such as schizophrenia, autism with behavioral disturbances, delusional disorder, and bipolar disorder. Risperidone is notorious for causing increased prolactin levels. This increase in prolactin levels may cause a client to develop gynecomastia and/or galactorrhea.

The licensed practical vocational nurse (LPN/VN) assists a quality improvement nurse in planning initiatives to reduce fall risk factors in the acute care environment. Which of the following risk factors should the nurse recommend be addressed? Select all that apply.

inadequate client assessment communication failures dim lighting Rationale: The nurse should recommend addressing inadequate assessment because this is a significant risk factor for falls that may lead to client injury. The nurse can recommend a standardized fall risk assessment tool and monitor its execution. Communication failures between staff are a significant contributor to falls. The nurse should recommend addressing this by standardizing the handoff report and placing signals outside a client's room (a particular light, fall risk bands, or pictures outside of the client's room). The nurse can plausibly recommend the repair of dim environmental lighting, which is a risk factor for falls, especially when the client is ambulating within their room.

The nurse is collecting data on a client who has suspected Raynaud phenomenon/disease. Which of the following findings would support a diagnosis of Raynaud phenomenon/disease? A. unilateral swelling of the leg B. painful vasospasms C. crepitus of the joints D. claudication in feet and lower extremities

painful vasospasms Rationale: Raynaud phenomena is a condition causing painful vasospasms in response to emotional stress and cold temperatures. These painful vasospasms occur in the digits. Raynaud phenomena may be associated with autoimmune conditions such as systemic lupus erythematosus (SLE) and scleroderma.

The nurse reinforces education to a family with a child that has phenylketonuria (PKU). It would be appropriate for the nurse to recommend that the child avoid which foods? Select all that apply.

pork tenderloin cheese omelets ice cream Rationale: It is appropriate to inform the family to avoid pork tenderloin. Since pork tenderloin is high in protein and phenylalanine, the nurse should advise the family to avoid this food. It is appropriate to inform the family to avoid foods with eggs, such as cheese omelets. Foods high in protein have this amino acid and should be avoided. It is appropriate to inform the family to avoid dairy products, including milk, cheese, yogurt, and ice cream. The nurse should recommend sorbet or Italian ice as an alternative.

The nurse is observing infection control practices in the nursing unit. Which of the following findings require follow-up? A client with Select all that apply.

rubella and their door is kept closed. Legionnaires' disease placed on contact precautions. Rationale: These observations are inappropriate and require follow-up. The door should be closed in airborne isolation precautions, not droplet precautions. A client with rubella should be placed on droplet precautions. The minimum PPE required for droplet precautions is a surgical mask. Legionnaires' disease is not transmitted person-to-person but rather through infected water or soil. This bacterium requires standard precautions.

The nurse is caring for assigned clients. The nurse should initially prioritize the client who was admitted for

syndrome of inappropriate antidiuretic (SIADH) and has developed disorientation within the last two hours. Rationale: SIADH is characterized by fluid retention with edema. This is caused by excessive antidiuretic hormone. A significant complication of SIADH is hyponatremia, and considering sodium's considerable role in neuromuscular functions, a client exhibiting disorientation signifies severely low sodium levels, which warrants immediate follow-up, especially since this development was quite recent (within the last two hours).

The licensed practical/vocational nurse (LPN/VN) is collecting data on a client experiencing serotonin syndrome. Which of the following findings would be expected by the LPN/VN? Select all that apply.

tachycardia altered mental status Rationale: Tachycardia, altered mental status, increased blood pressure, altered mental status, hypertonia, and fever are manifestations of serotonin syndrome. Serotonin syndrome (or toxicity) is commonly caused by two serotonergic agents causing very high serotonin levels, which may lead to death in rare situations. The causes of serotonin syndrome primarily stem from the client being exposed to excessive serotonergic agents, including tramadol, SSRIs (citalopram, paroxetine, etc.), and MAOIs.

The nurse is instructing unlicensed assistive personnel (UAP) on how to modify activities of daily living for a client receiving a continuous infusion of heparin. The nurse should instruct the UAP to Select all that apply.

use a soft-bristled toothbrush for oral care. use an electric razor when shaving. use a lift sheet when repositioning the client. use an emery board instead of nail clippers. Rationale: This risk of bleeding is substantial for a client receiving a continuous infusion of heparin. The UAP should be instructed to perform oral care with a soft bristle toothbrush to prevent gingival bleeding. An electric razor is preferred over a traditional razor because of the decreased risk of trauma. A lift sheet should be used to reposition the client over sliding the client, reducing the risk of shearing injuries. Nail clippers may cause skin trauma. Thus, an emery board is preferred.

The nurse is caring for a client with schizophrenia and has received a new prescription for clozapine. Prior to administering the first dose, the nurse plans on obtaining the client's A. weight. B. pulmonary function tests. C. urine analysis. D. visual acuity.

weight Rationale: Clozapine is an atypical (second-generation) antipsychotic indicated in treating schizophrenia. Clozapine causes the worst metabolic disturbances, including hyperglycemia, weight gain, and hyperlipidemia. These manifestations may drive the client into metabolic syndrome. The nurse must obtain a baseline weight to trend at future visits. Additional baseline data needed prior to starting clozapine include the client's neutrophil count, liver function tests, fasting blood glucose, and hemoglobin.