NCLEX practice attempt 2

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

1 - allow time for defecation 2 - provide privacy for bowel elimination 3 - suggest increasing fluid intake 4 - encourage client to increase fiber in the diet

The nurse is caring for a client admitted to the psychiatric unit with a diagnosis of major depression. What behaviors could the nurse expect upon assessment of this client? 1. Withdrawn behavior 2. Sitting in room, lights out, drapes closed 3. Unkempt appearance 4. Overeating 5. Severe insomnia

1 - withdrawn 2 - sitting in dark room 3 - unkempt 5 - severe insomnia he client with severe depression has extremely low self-esteem and low energy levels and may just sit for hours. Depressed clients prefer to be alone and avoid social interactions. The room environment mimics the mood of the client (dark and gloomy). The client may not have the energy to bathe, change clothes, or even comb hair. The severely depressed person may have severe insomnia. However, sleeping too much is also a symptom of mild depression.

The nurse is caring for a client on the surgical unit. The primary healthcare provider prescribed morphine sulfate 20 mg IM one time dose. The nurse has available: morphine sulfate in a 20 mL vial, labeled 15 mg per mL. How many mL should the nurse administer? Record answer using one decimal place.

1.3 mL

The nurse is teaching a newly diagnosed diabetic about the action of regular insulin. The nurse verifies that teaching has been successful when the client verbalizes being at greatest risk for developing hypoglycemia at what time following the 8:00 a.m. dose of regular insulin? 1. 8:30 AM 2. 11:00 AM 3. 1:30 PM 4. 4:00 PM

2 - 11:00 Regular insulin peaks 2-3 hours after administration. Clients are at greatest risk for hypoglycemia when insulin is at its peak.

The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat for an adult client. What is the least amount of time that the nurse can safely administer this medication? 1. 1 minute 2. 2 minutes 3. 5 minutes 4. 10 minutes

2 - 2 minutes The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes.

The nurse is caring for a client diagnosed with herpes varicella zoster. What pharmacologic agent should the nurse anticipate the primary healthcare provider will prescribe? 1. Metronidazole 2. Acyclovir 3. Ceftriaxone 4. Ampicillin

2 - acyclovir Herpes varicella zoster is a virus that causes chickenpox in children and shingles in adults. An antiviral such as acyclovir, is indicated.

A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R 36. 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 - respiratory alkalosis Hyperventilation due to anxiety, pain, shock, severe infection, fever, liver failure can lead to respiratory alkalosis. With each of these, the client loses too much CO2. The reduction of CO2 creates an excessive loss of acid, resulting in an alkalotic state. Since the problem is respiratory, it is respiratory alkalosis.

Which clients would be appropriate for the RN to assign to an LPN/LVN? 1. Seventy four year old client with unstable angina who needs teaching for a scheduled cardiac catheterization. 2. Sixty year old client experiencing chest pain scheduled for a graded exercise test. 3. Forty eight year old client who is five days post right-sided cerebral vascular accident (CVA). 4. Eighty four year old client with heart disease and mild dementia. 5. Newly admitted ninety year old client with decreased urinary output, altered level of consciousness, and temperature of 100.8°F (38.2°C) 6. Sixty six year old client with chronic emphysema experiencing mild shortness of breath.

3 - 48 year old 5 days post right sided cerebral vascular accident 4 - 84 year old with heart disease and mild dementia 6 - 66 yo with chronic emphysema experiencing mild sob

A client was admitted to the psychiatric unit with delusions and a history of auditory hallucinations. The client reports, "The FBI has been watching my house and are going to raid it and arrest me." What is the nurse's best response? 1. The FBI would not be watching you unless there was a good reason. 2. I don't think that the FBI is watching your house. 3. I believe that your thoughts are very disturbing to you. 4. Tell me more about your thoughts

3 - i believe these thoughts are very disturbing to you he client's delusions can be very distressing. The nurse should empathize with the feelings of the client, but should not validate the belief itself. Empathy displays that the nurse is concerned, interested, and accepts the client but does not support the delusion.

A client comes into the emergency department (ED) and demands to be seen immediately, but refuses to tell the triage nurse the problem. During the assessment, the client starts yelling and shaking their fist. For the nurse's safety, what should be the nurse's initial action? 1. Tell the client to stay calm, and that treatment will be provided soon. 2. Explain that unless the client behaves, they will be sent away from the ED. 3. Notify the client that security will be called if they do not go to the waiting room immediately. 4. Find a safe place away from the client and then notify security.

4 - find a safe place away from the client and then notify security

Which client could the charge nurse assign to an LPN/VN? 1. Eight year old in diabetic ketoacidosis (DKA) 2. Six year old in sickle cell crisis 3. Two month old with dehydration 4. Five year old in skeletal traction

4 - five year old in skeletal traction

The nurse should question which prescription for a client diagnosed with acute heart failure? 1. 2 gram of sodium (Na) diet. 2. Digoxin 0.25 mg IV q 4 hours times 3 doses. 3. Furosemide 40 mg IVP stat. 4. Start IV with NS at 125 mL/hr.

4 - start IV with NS at 125 mL/hr The client is in fluid overload and does not need the normal saline (NS) at 125 mL/hr. NS is an isotonic solution. It goes in the vascular space and stays there without shifting out to the cells. This could cause additional overload in the vascular space as well as cause the BP to increase. The other prescriptions are acceptable.

Which immunizations obtained by the age of two would indicate to the pediatric nurse that the child is up-to-date on immunizations? 1. Diptheria-tetanus-pertussis (DTaP). 2. Inactivated polio (IPV). 3. Herpes zoster. 4. Meningococcal 5. Haemophilus influenza type B (Hib).

1 - DTaP 2 - inactivated polio 5 - haemophilus influenza type B By the age of two, the DTaP, IPV, MMR, Hib, varicella, pneumococcal, and rotovirus vaccines should have been received. The nurse should clarify this with the parent.

A client asked the nurse what could have caused them to develop right sided heart failure? What would be the best response by the nurse? 1. High blood pressure in the lungs. 2. Long term hypertension. 3. The inability of the mitral valve to close properly. 4. Narrowing of the aorta.

1 - High blood pressure in the lungs the right side of the heart pumps to the lungs. When the client has higher pressure in the pulmonary circuit from such things as emphysema, the pulmonary pressure can exceed the systemic pressure. The result is back flow to the right side of the heart and resulting right sided heart failure.

The parents of a 4 year old child are concerned about whether the child will adapt to the newborn baby they are expecting in two weeks. What suggestions should the nurse make to assist with sibling adaptation? 1. Allow child to be one of the first to see the newborn. 2. Have child stay with parents during labor and delivery. 3. Arrange for one parent to spend time with the child while the other parent cares for the newborn. 4. Provide a gift from the newborn to give to the child. 5. Have child care for a doll.

1 - allow the child to see the newborn first 3 - have the parent spend time with the child while the other parent cares for the newborn 4 - provide a gift from the newborn 5 - have the child care for a doll These are good recommendations for the nurse to make to the parents in an effort to promote sibling adaptation. Make the 4 year old part of the process as much as possible. Demonstrate the importance of the child by allowing the child to see the baby first. Provide personal time with the 4 year old. This shows that the 4 year old is important to the family. The baby is providing a gift to the child which promotes a bond between the two and demonstrates to the child that he or she is important. Having a 4 year old care for a doll gets the child involved in caring for another. The child can learn what a newborn needs both physically and emotionally by imitating the parents.

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 - allow time for ritual 2 - provide pos reinforcement for nonritualistic behavior 5 - create regular schedule for taking client to the bathroom Initially meet the client's dependency needs as required to keep anxiety from escalating. Anything that increases the client's anxiety tends to increase the ritualistic behavior. Positive reinforcement for nonritualistic behavior takes the focus off of the ritual. A lack of attention to ritualistic behaviors can help to decrease the ritual. By creating a regular schedule when the client goes to the bathroom, (where the handwashing ritual occurs most frequently) allows the client a structured but limited time for the ritual. This can help give the client a sense of control of the maladaptive behavior until the client can start setting own limits on the behavior and develop more adaptive coping mechanisms.

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client? 1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen

1 - alternating pressure mattress 2 - hospital bed 4 - suction equipment 5 - oxygen An alternating pressure mattress will help to prevent pressure ulcers. The risk of respiratory compromise increases as the neurologic status deteriorates. A hospital bed is needed so that the head of the client's bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. The client with hepatic encephalopathy is unresponsive due to accumulation of toxins and may need suctioning if unable to clear secretions from the oropharynx. Hepatic encephalopathy frequently has associated bleeding varices. The increasing ascites leads to hypovolemia. Both of these conditions can result in hypoxemia for the client at the end stages of liver disease; therefore, oxygen therapy is provided.

A client with a history of command hallucinations was admitted to the hospital yesterday. What questions are most important for the nurse to ask? 1. "Are you hearing voices today?" 2. "What are the voices saying?" 3. "How are you feeling today?" 4. "Did you have difficulty sleeping last night?" 5. "Are the voices telling you to harm yourself or anyone else?"

1 - are you hearing voices today 2 - what are the voices saying 5 - are the voices telling you to harm yourself or anyone else? The nurse must assess for hallucinations. The nurse needs to know what the voices are saying to determine the level of threat. The nurse needs to know if the command hallucination exists and whether it involves harming self or others which must be reported. These answers are important to know, as the client has a history of command hallucinations.

The nurse is advising the family of a client receiving palliative care on alternative methods for pain control to be used in conjunction with pain medications. Which method should the nurse include? 1. Providing a back massage 2. Administering pain medication when pain is rated at 5 out of 10 3. Distracting with music 4. Exercise 5. Prayer

1 - back massage 3 - distracting with music 5 - prayer

The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which clients would be appropriate for the nurse to assign to the LPN/VN? 1. In Bucks traction requiring frequent pain medication. 2. 24 hours post appendectomy. 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM. 4. Admitted 6 hours ago in adrenal insufficiency. 5. Client newly diagnosed with Type 2 diabetes.

1 - bucks traction w/ frequent pain meds 2 - 24 hours post appendectomy 3 - diagnosed with cholelithiasis and scheduled for surgery in the am These clients are stable and require predictable care that can be done appropriately by the LPN/VN.

Two hours after a gastrectomy, a client has pink tinged drainage from the nasogastric (NG) tube, and the tube appears occluded. What is the nurse's initial action at this time? 1. Call the primary healthcare provider. 2. Reposition the client. 3. Increase the suction level. 4. Irrigate the tube.

1 - call the primary healthcare provider Do not tamper with fresh surgery tubes. Call the primary healthcare provider for blood draining from the NG tube after gastrectomy.

An RN on the general pediatric unit has been reassigned to the spinal/neurology unit. What assignment by the charge nurse would be appropriate for this RN? 1. Child with spina bifida with a previous shunt revision 2. Adolescent who is 4 days post op from a spinal fusion 3. Child with a ventriculoperitoneal shunt one day post-op 4. Child with spinal muscle atrophy who is ventilator assisted 5. Child with cerebral palsy who had a tracheostomy performed this AM

1 - child with spina bifida with a previous shunt revision 2 - adolescent who is 4 days post op from a spinal fusion The child who had a previous shunt revision and the adolescent who is 4 days post spinal fusion will be the most stable and will require the least skill level when compared with the other choices. On a general pediatric unit, the nurse would be familiar with checking for increased ICP, which would be necessary for caring for any client with a previous shunt revision. Immediately postop, the adolescent with spinal fusion would require special turning and lung assessment to prevent and observe for congestion/pneumonia, skills not acquired on a general floor. However, at 4 days postop this client should be ambulating and will not need specialized turning, so the nurse from the general pediatric unit could care for this client.

The nurse is planning care for a pediatric client reporting acute pain with sickle cell crisis? What should the nurse identify as an appropriate goal for this client? 1. Client will report a pain level of less than 2 on a Faces scale. 2. The nurse will administer prescribed pain meds around the clock. 3. Client will only take breakthrough pain medication. 4. Client will use distraction instead of pain medication.

1 - client will report pain level of less than 2 on a faces scale having a pain level of less than 2 is the best goal for pain and the use of a Faces scale, instead of a numerical scale is age appropriate. Sickle cell crisis is extremely painful, and often times, the pain is not completely relieved during the acute stage.

A nurse is planning to provide information regarding suicide to a high school assembly. What information should the nurse include? 1. Do not keep secrets for the suicidal person. 2. Express concern for a person expressing thoughts of suicide. 3. Teens often don't mean what they say, so only take suicide seriously if grades are dropping as well. 4. Inform group of suicide intervention sources. 5. Do not leave a suicidal person alone.

1 - do not keep secrets for the suicidal person 2 - express concern for a person expressing thoughts of suicide 4 - inform group of suicide intervention sources 5 - do not leave suicidal person alone

A client diagnosed with rheumatoid arthritis has been prescribed celecoxib. What should the nurse include in the client's education regarding this medication? ' 1. Do not take celecoxib with ibuprofen. 2. GI complaints and headache are among the most common side effects. 3. Drink a lot of water to offset the dehydration that may occur. 4. Notify the healthcare provider immediately if black stools are noted. 5. This medication provides relief of pain and swelling so you can perform normal daily activities.

1 - do not take celecoxib with ibuprofen 2 - GI complaints and headaches are among the most common side effects 4 - notify the healthcare provider immediately if black stools are noted 5 - med provides relief of pain and swelling so you can perform normal daily activities Concomitant use of celecoxib with aspirin or other NSAIDs (for example, ibuprofen, naproxen, etc.) may increase the occurrence of stomach and intestinal ulcers. This would increase the risk of GI bleeders. GI complaints and headache are two of the most common side effects. The client should stop taking celecoxib and get medical help right away if the client notices bloody or black/tarry stools. This would be an indication of GI bleeding. This medication is a nonsteroidal anti-inflammatory drug (NSAID), which relieves pain and swelling. It is used to treat arthritis. The pain and swelling relief provided by this medication should help the client perform normal daily activities.

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

1 - don't cross legs 2 - do not bend more than 90 degrees 3 - do not turn affected leg inward 5 - sleep with pillow between the legs One of the most common problems after hip surgery is dislocation. Until the hip prosthesis stabilizes, it is necessary to follow these instructions for proper positioning to avoid dislocation. Flexion and movement of the leg on the affected side past midline should be avoided.

An 82 year old client tells the nurse at the clinic, "I have lived a good, successful life and married my best friend". Which of Erikson's developmental tasks does the nurse recognize that this client has probably accomplished? 1. Ego Integrity versus Despair 2. Generativity versus Stagnation 3. Intimacy versus Isolation 4. Industry versus Inferiority

1 - ego integrity vs. despair Ego Integrity versus Despair is the major task of those 65 and over: The developmental task for this age involves the individual reviewing one's life and deriving meaning from both positive and negative events, while achieving a positive sense of self. If the individual considers accomplishments and views self as leading a successful life, a sense of integrity is developed. On the contrary, if life is viewed as unsuccessful without accomplishing life's goals, a sense of despair and hopelessness develops.

The nurse evaluates the effectiveness of discharge teaching for a client with type I diabetes mellitus. Which statement by the client would indicate to the nurse that teaching has been effective? 1. "Exercising regularly will decrease my insulin need." 2. "I will need to decrease my insulin dose when I develop an infection." 3. "I need to lose weight since obesity decreases insulin resistance." 4. "Increased stress levels will cause the glucose level in my blood to go down."

1 - exercising regularly will decrease my insulin need Regular exercise decreases the need for insulin. Regular exercise reduces insulin resistance and permits increased glucose uptake by cells. This serves to lower insulin levels and reduce hepatic production of glucose.

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 - fam hx 2 - alcohol consumption 4 - hpv 5 - tobacco use

A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar with this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the nurse expect on assessment? 1. Fever and shivering 2. Agitation 3. Decreased body temperature 4. Constipation 5. Increased heart rate

1 - fever and shivering 2 - agitation 5 - increased heart rate Serotonin syndrome is a group of symptoms that can result from the use of certain serotonin reuptake inhibitors. These symptoms can range from mild to severe and include high body temperature, agitation, increased reflexes, diaphoresis, tremors, dilated pupils and diarrhea. The client is likely to experience shivering with fever. Increased heart rate and blood pressure are also commonly experienced. More severe symptoms, including muscle rigidity and seizures, can occur. If not treated, serotonin syndrome can be fatal.

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 - hand washing needed 2 - do not visit if you have any infection 4 - children under 12 may not visit 5 - flowers are not allowed in the room Protective isolation is needed for this client because of the presence of a low white blood cell count. We are protecting the client 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 and should not be brought into the room.

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 - identify safe zones 2 - how to account for everyone present 3 - warning system activation 5 - regular practice protocols

A nurse is caring for a client admitted with chronic fatigue and weakness. During the physical assessment, the nurse notes jaundiced sclera, abdominal distension, swelling in the legs and ankles, and bruises in various stages of healing throughout the body. What nursing interventions should the nurse initiate? 1. Measure abdomen 2. Monitor intake and output 3. Obtain daily weight 4. Place on fall precautions 5. Provide three meals per day 6. Dangle legs

1 - measure abdomen 2 - monitor Is and Os 3 - obtain daily weight 4 - place on fall precautions the symptoms presented are indicative of liver disease. Measuring abdominal girth will monitor for accumulating ascitic fluid. Clients with liver disease have fluid volume problems, so daily weight and I&O are indicated. This client is at risk for injury related to chronic fatigue and weakness, so fall prevention is indicated. The client may need help eating if fatigue is severe.

To reduce the risk of developing a complication following balloon angioplasty, the nurse should implement which measure? 1. Monitor cardiac rhythm 2. Assess the puncture site every 8 hours 3. Measure urinary output hourly 4. Prevent flexion of the affected leg 5. Avoid lifting buttocks off the bed

1 - monitor cardiac rhythm 3 - measure urinary output hourly 4 - prevent flexion of the affected leg 5 - avoid lifting buttocks off the bed The primary healthcare provider should be notified of any rhythm changes or report chest pain/discomfort. These could be signs of re-occlusion. Decreased urinary output (UOP) could be due to poor renal perfusion, which can result from decreased cardiac output and shock. Frequent VS and UOP measurements are needed. Flexion should be avoided at the catheter access site to allow time for the clot to stabilize and reduce the risk of bleeding and hematoma formation. The client should avoid lifting the buttocks off the bed because this increases pressure at the insertion site which increases the risk of hematoma formation/bleeding.

The nurse is caring for a client who has just arrived at the emergency department with suspected acute myocardial infarction. Which medications should the nurse administer immediately? 1. Oxygen 2. Heparin 3. Morphine 4. Sublingual nitroglycerin 5. Furosemide

1 - oxygen 3 - morphine 4 - sublingual nitroglycerin Initial management should take place immediately. According to the American Heart Association/Heart & Stroke Foundation of Canada and the American College of Cardiology, oxygen, SL nitroglycerin, morphine, and aspirin should be administered immediately. The initial goal of therapy for clients with an acute MI is to restore perfusion to the myocardium as soon as possible. Oxygen is appropriate and advisable when hypoxia is present. Pain from acute MI's may be intense and requires prompt administration of analgesia. Morphine sulfate is the medication of choice (2-4 mg every 5-15 minutes). Reducing the myocardial ischemia also helps reduce pain, so oxygen therapy and nitrates are main components of the therapy. The vasodilation effects of morphine and the nitroglycerin improve coronary blood flow and reduce myocardial ischemia.

The emergency department nurse is assessing a client who presents with severe epigastric pain. The client reports that three rolls of calcium carbonate were consumed in the past eight hours to treat the indigestion. Which blood gas report does the nurse associate with this situation? 1. pH - 7.49, pCO2 - 40, HCO3 - 30 2. pH - 7.32, pCO2 - 48, HCO3 - 20 3. pH - 7.38, pCO2 - 52, HCO3 - 32 4. pH - 7.29, pCO2 - 54, HCO3 - 26

1 - pH - 7.49, pCO2 - 40, HCO3 - 30 These ABGs are indicative of metabolic alkalosis. The pH is high, the pCO2 is within normal limits and the bicarb is high (alkalosis). So, the excess Tums (calcium carbonate) could have caused metabolic alkalosis.

Which prescriptions would the nurse recognize as being appropriate for the client with shingles? 1. Private room 2. Negative pressure airflow 3. Respirator mask 4. Face Shield 5. Positive pressure room

1 - private room 2 - negative pressure airflow 3 - respirator mask According to the current standards of Standard Precautions per the CDC, the client with shingles should be placed on airborne precautions which require the use of a private room with negative pressure airflow and a N-95 respirator mask.

A client diagnosed with glomerulonephritis presents with generalized malaise, weight gain, generalized edema, and flank pain. The primary healthcare provider prescribes antibiotics and strict bedrest. What is the best explanation to give the client regarding the strict bedrest prescription? 1. Promotes diuresis 2. Prevents injury 3. Promotes rest 4. Stimulates RBC production

1 - promotes diuresis Bedrest and the supine position promote diuresis. When the client is supine, there is a gradual shift of fluids away from the legs toward the thorax, abdomen and head. This increased volume causes the right atrium of the heart to stretch and release ANP, which leads to diuresis: renal blood flow increases due to vasodilation, and aldosterone and ADH secretion are inhibited.

What measures should the unit nurse initiate after admitting a client who had a chest tube inserted for pleural effusion of the right lung? 1. Place in semi-Fowler's position. 2. Connect to oxygen saturation monitor. 3. Assess respiratory status every 2 hours. 4. Prevent dependent loops in closed drainage unit tubing. 5. Maintain closed drainage unit at the level of the client's chest.

1 - semi-fowlers position 2 - connect to O2 sat monitor 3 - assess resp status every 2 hours 4 - prevent dependent loops in closed drainage system tubing A pleural effusion is a collection of fluid in the pleural space that moves to the bottom of the chest cavity when upright. The semi-Fowler's position allows the client to be in an upright position to promote drainage and facilitate ease of respirations by promoting lung expansion. Since lung expansion is compromised with a pleural effusion, the oxygen level should be assessed using an oxygen saturation monitor. The client's respiratory status should be assessed at least every 2 hours: respiratory rate, work of breathing, breath sounds, pulse oximetry. The development of kinks, loops, or pressure on the drainage tubing can produce back pressure, which may force fluid back into the pleural space or interfere with the drainage.

During an assessment interview with a client, what alternative healing modalities should the nurse inquire about 1. "Tell me about your use of teas, herbs, and vitamins." 2. "What traditional or folk remedies are used in your family?" 3. "Do you meditate, pray, or use relaxation techniques for healing purposes?" 4. "What prescription medications are you taking?" 5. "What alternative therapies have you used?"

1 - teas, herbs, vitamins 2 - traditional or fold remedies used 3 - meditate, pray, or relaxation techniques used 5 - alternative therapies used

What should the nurse tell the parents of a newborn about a Guthrie test? 1. The purpose of this test is to determine the presence of phenylalanine in the blood. 2. A positive test indicates a metabolic disorder. 3. To conduct this test, a sample of blood is taken from the baby's heel. 4. An increase in protein intake can interfere with the test. 5. This test will be done when your baby is 6 weeks old.

1 - the purpose is to determine the presence of phenyalanine in the blood 2 - a pos test indicates a metabolic disorder 3 - to conduct this test, a sample of blood is taken from the heel A positive test indicates decreased metabolism of phenylalanine, leading to phenylketonuria. The normal level of phenylalanine in newborns is 0.5to 1 mg/dl. The Guthrie test detects levels greater than 4 mg/dl. Only fresh heel blood, not cord blood, can be used for the test. The main objective for diagnosing and treating this disorder is to prevent cognitive impairment.

What information should a nurse include when educating a client regarding buccal administration of a medication? 1. This route allows the medication to get into the blood stream faster than the oral route. 2. Stinging may occur after placing the medication in the cheek. 3. If swallowed, the medication may be inactivated by gastric secretions. 4. The buccal dose of medication will need to be increased from the oral dose. 5. Remove the tablet from buccal area after 15 seconds

1 - this route allows the med to get into the blood stream faster than the oral route 2 - stinging may occur in the cheek 3 - if swallowed, gastric secretions may inactivate the med Buccal administration involves the medication being placed between the gums and cheek, where it dissolves and becomes absorbed into the bloodstream. The cheek area has many capillaries that allow the medication to be absorbed quickly without having to pass through the digestive system. The degree of stinging experienced depends on the medication being administered. Some effects of certain medications can be lessened by digestive processes.

Which statement made by a client post-thyroidectomy would require further investigation by the nurse? 1. "I have a tingling feeling of my fingers." 2. "It hurts when I move my head." 3. "I feel pressure in my arm when you take my blood pressure." 4. "My legs are weak."

1 - tingling in fingers after this procedure the nurse should worry about the possibility of some of the parathyroids being accidentally removed with resulting hypoparathyroidism. Hypoparathyroidism results in hypocalcemia. Signs and symptoms include tingling, burning, or numbness of lips, fingers, and toes. The muscles may become tight and rigid, and seizures can result.

A client suffers from migraine headaches. What assessment finding would the nurse expect to find during a migraine attack? 1. Unilateral, pulsating pain quality. 2. Bilateral, pressing/tightening pain quality. 3. Ipsilateral nasal congestion and rhinorrhea. 4. Headache occurs after recovering from a headache treated with narcotics.

1 - unilateral, pulsating pain quality Migraine headaches have a pulsating pain quality, unilateral location, moderate or severe pain intensity, aggravated by or causing avoidance of routine physical activity (walking, climbing stairs). During headache at least one of the following accompanies the headache: nausea and/or vomiting; photophobia and phonophobia.

A client, who only speaks Spanish, is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure? 1. Use an audiotape made in Spanish to inform the client of the pre-surgical procedure. 2. Draw pictures of what the client can expect prior to surgery. 3. Facial expressions and gestures can be used to let the client know what to expect. 4. Enlist the help of a Spanish speaking family friend to tell the client what to expect prior to surgery.

1 - use a spanish audiotape explaining the procedure

An adult client has just returned to the nursing care unit following a gastroscopy. Which intervention should the nurse include on the plan of care? 1. Vital sign checks every 15 min x 4 2. Supine position for 6 hours 3. NPO until return of gag reflex 4. Irrigate NG tube every 2 hours 5. Raise four siderails

1 - vital signs checks every 15 min for 4 hours 3 - NPO until return of gag reflex

A school nurse is teaching a group of preteens with acne how to care for the skin. What points should the nurse include? 1. Wash face with soap and warm water. 2. Avoid using oily creams. 3. Do not use cosmetics that block sebaceous gland ducts. 4. Do not squeeze lesions. 5. Clean face vigorously with a terrycloth.

1 - wash face with soap and warm water 2 - avoid using oily creams 3 - don't use cosmetics that block sebaceous gland ducts 4 - do not squeeze lesions

The family member of a schizophrenic client asks the nurse why the client is receiving chlorpromazine and benztropine. 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. Benztropine 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 benztropine. 4. Chlorpromazine is used for psychosis and benztropine is used for preventing agranulocytosis.

2 - benzotropine is given to treat side effects of chlorpromazine Benztropine is used to treat parkinsonism of various causes and drug-induced extrapyramidal reactions seen with chlorpromazine, which is an antipsychotic agent. Extrapyramidal symptoms are neurologic disturbances in the area of the brain that controls motor coordination. This disruption can cause symptoms that mimic Parkinson's disease, including stiffness, rigidity, tremor, drooling and the classic "mask like" facial expression. These symptoms can be treated and are reversible using such medications as benztropine.

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

2 - contact with siblings 3 - day care attendance 4 - season of the year Contact with siblings, day care attendance, and season of the year all increase a child's risk of developing otitis media. Otitis media usually follows or accompanies an upper respiratory infection or the common cold. The exposure to upper respiratory infections is increased when other siblings are in the home and when the child attends daycare. More upper respiratory infections occur during times when the climate changes and during the winter month

Which signs and symptoms would the nurse expect to see in a client who has taken prednisone for two months? 1. Weight loss 2. Decreased wound healing 3. Hypertension 4. Decreased facial hair 5. Moon face

2 - decreased wound healing 3 - hypertension 5 - moon face decreased wound healing is a side effect with prolonged steroid use due to the immunosuppressive effects. All steroid medications, such as prednisone, can lead to sodium retention which then leads to dose related fluid retention. Hypertension is seen due to this fluid and sodium retention. Cushingoid appearance (moon face) is a side effect that is created from the abnormal redistribution of fat from prolonged steroid use.

A client diagnosed with major depression has been taking a selective serotonin reuptake inhibitor for the past 6 weeks. When visiting the mental health center, the nurse discusses the medication and response with the client. The nurse's assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation? 1. Are you having trouble sleeping at night? 2. Do you have periods of muscle jerking? 3. Are you having any sexual dysfunction? 4. Is your mood improving?

2 - do you have periods of muscle jerking Myoclonus, high body temperature, shaking, chills, and mental confusion are some of the symptoms of serotonin syndrome. This client may be having symptoms of this adverse reaction which, if severe, can be fatal.

A client diagnosed with major depression is admitted to the psychiatric unit for electroconvulsive therapy (ECT). The client asks the nurse, "How many of these treatments do you think I will need?" What is the nurse's best response? 1. That is a question you need to discuss with your primary healthcare provider. 2. Everyone responds differently, but on average clients need 6-12 treatments. 3. You will need to take a treatment every month for at least a year. 4. Let's just take one treatment at a time, shall we?

2 - everyone responds differently, but usually between 6-12 sessions Most clients require an average of 6 to 12 treatments, but some may require up to 20 treatments. These treatments are generally given two to three times per week for three to four weeks. The number of treatments required depends on the severity of the symptoms and how quickly the client improves.

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. Three year old admitted with febrile seizures. 4. Two year old who has a fractured tibia.

2 - four year old with nephrotic syndrome This child is not infectious and could be placed in the room with the child who has glomerulonephritis. Since the children are close in age, they will adapt well together.

The nurse is teaching the Type II diabetic about monitoring average blood glucose levels over time. The nurse evaluates teaching has been effective when the client verbalizes the need to return to the clinic for which test? 1. Glucose tolerance test 2. Glycosylated hemoglobin 3. Glucose-6-phosphate dehydrogenase 4. Fasting blood glucose

2 - glycosylated hemoglobin Glycosylated hemoglobin (also known as hemoglobin A1C) tests the average blood glucose over 90 days, or 2-3 month time period. Specifically, this test measures the percentage of hemoglobin that is coated with blood sugar (glycated).

The nurse in the emergency department suspects that a client's lesion is caused by anthrax. What assessment question is most important? 1. Have you traveled out of the United States recently? 2. Have you recently worked with any farm animals or any animal-skin products? 3. Have you experienced any gastrointestinal upset recently? 4. Have you eaten any home-canned foods recently?

2 - have you recently worked with any farm animals or an animal skin products? Cutaneous anthrax may be contracted by working with contaminated animal-skin products. Anthrax is found in nature and commonly infects wild and domestic hoofed animals.

A child is being admitted with possible rheumatic fever. What assessment data would be most important for the nurse to obtain from the parent? 1. 102° F (38.89° C) temperature that started 2 days previously. 2. History of pharyngitis approximately 4 weeks ago. 3. Vomiting for 3 days. 4. A cough that started about 1 week earlier.

2 - history of pharyngitis approximately 4 weeks ago Rheumatic fever is often the result of untreated or improperly treated group A β-hemolytic streptococcal infections (GABHS), such as pharyngitis. Therefore, the history of pharyngitis or upper respiratory infection is a key assessment finding for establishing a diagnosis of rheumatic fever. Subsequent development of rheumatic fever usually occurs 2 to 6 weeks following the GABHS, so the assessment should include a remote history of pharyngitis.

What interventions should the nurse initiate to keep the airway free of secretions in a client with pneumonia? 1. Evaluate results of ABG's and report abnormal findings. 2. Increase oral intake to at least 2000 mL/day. 3. Administer a cough suppressant medication. 4. Educate client on incentive spirometry. 5. Perform percussion to affected area.

2 - increase oral intake to at least 2000 ml/day 4 - educate on incentive spirometry 5 - perform percussion to affected area Liquefy secretions by increasing oral intake to at least eight, 8 ounce glasses of liquid/day unless fluid restrictions are required. Incentive spirometry helps keep alveoli open and prevents further pneumonia and atelectasis. Prescribed percussion can assist with loosening secretions for expectoration.

The client at the mental health center has voiced suicidal thoughts and has access to firearms at home. Which action by the nurse is priority? 1. Empathize with the client and listen to feelings. 2. Inform the family and ask them to remove the guns. 3. Chart the thinking pattern and make a follow up appointment. 4. Ask the client to return to the clinic tomorrow for further evaluation.

2 - inform the family and ask them to remove the guns The family should be notified. Suicidal thinking is one condition that necessitates breach of confidentiality. The client has identified a plan and has access to firearms; therefore, the family should remove them from the house. Client safety is a priority. This client will likely be directly admitted to the hospital.

A newly admitted client with schizophrenia has an unkempt appearance and needs to attend to personal hygiene. Which statement by the nurse is most therapeutic? 1. A shower will make you feel better. 2. It is time to take a shower. 3. Have you thought about taking a shower? 4. I need you to take a shower.

2 - its time to take a shower Schizophrenia is a thought disorder. Many clients with schizophrenia are concrete thinkers and have difficulty making decisions. The nurse needs to be direct, clear and concise in communicating with the client. This is a direct, clear and concise statement that guides the client to perform the needed activity.

Which statements should a nurse make when educating a client about advance directives?' 1. Used as guidelines for client treatment should the client's family deem them necessary. 2. Legally binding document. 3. Should be documented in the client's medical record as to whether or not the client has an advance directive. 4. Specifies a client's wishes for healthcare treatment should the client become incapacitated. 5. Allows the client's spouse to make end-of-life decisions.

2 - legally binding document 3 - should be documented in the clients medical record as to whether or not the client has an advance directive 4 - specifies a clients wishes for healthcare treatment should the client become incapacitated

The school nurse has identified a large outbreak of viral conjunctivitis among one middle school class and plans to educate these students on this illness. Which data should the nurse be sure to include? 1. Use personal handkerchief to wipe the eye of discharge. 2. Light cold compresses over the eyes several times a day will ease discomfort. 3. Do not share towels or linens. 4. Discard all makeup and use new makeup after infection resolves. 5. Wash hands frequently with soap and water.

2 - light cold compress for discomfort 3 - do not share towels 4 - discard old makeup after infection 5 - wash hands frequently All of these measures will promote comfort and decrease risk of transmitting infection. Clients should also avoid touching the eyes and shaking hands/touching other. Cool compresses provide symptomatic relief. Use a new tissue every time you wipe the discharge from the eye. You can dampen the tissue with clean water to clean the

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

2 - look up how to perform the procedure in the policy and procedure manual The best action for the nurse to take is to look up how the procedure is done in the agency by looking it up in the policy and procedure manual. The nurse could then discuss the procedure with an experienced nurse and ask the nurse to observe the new nurse while inserting the feeding tube

Which assessment finding would indicate to a nurse that a client receiving chemotherapy may have difficulty maintaining proper nutrition? 1. Fatigue 2. Mucositis 3. Neutropenia 4. Diarrhea

2 - mucositis Ulcerations in the oral cavity can make it difficult to chew food or be intolerant to certain foods due to discomfort and pain. Intake may be inadequate as a result of this.

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 - my eyes may be different colors, so I will use the drops in both eyes 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. Prostaglandins cause increased permeability in the sclera to aqueous fluid. So, as the prostaglandin agonist increases this activity, the outflow of aqueous fluid increases and the ocular pressure decreases. Administering the drops in the unaffected eye may result in a subnormal intraocular pressure.

Which statement, made by a client scheduled for a total laryngectomy, indicates to the nurse a need for further preoperative teaching? 1. After the surgery, I will breathe only through a hole in my neck. 2. My wife will have to get a hearing aid because I will not be able to talk above a whisper. 3. I must have smoke detectors installed at home since I may not be able to smell after surgery. 4. After surgery, I will have a tube going through my nose to my stomach for feeding.

2 - my wife will have to get a hearing aid because I will not be able to talk above a whisper With a total laryngectomy, the vocal cords are removed. The entrance to the trachea is closed, so no air moves upward into the throat or mouth areas. The client will not be able to speak or whisper. The client's wife does not need a hearing aid, so further teaching is necessary.

A nurse, assigned to take care of a client who is HIV positive, refuses the assignment, stating fear of personal injury. What action should the charge nurse take first? 1. Re-assign the client to a nurse who does not mind caring for HIV positive clients. 2. Inform the nurse that refusing client care is not acceptable nursing practice. 3. Have the nurse document rationale and support for refusing the client assignment. 4. Transfer the nurse to a unit where there are no HIV positive clients.

2 - not acceptable nursing practice This action by the charge nurse demonstrates an understanding of the code of ethics for nurses. Any nurse who feels compelled to refuse to provide care for a particular type of client faces an ethical dilemma. The reasons given for refusal range from a conflict of personal values to fear of personal risk of injury. Such instances have increased since the advent of acquired immunodeficiency syndrome (AIDS) as a major health problem. The ethical obligation to care for all clients is clearly identified in the first statement of the Code of Ethics for Nurses. To avoid facing these moral and ethical situations, a nurse can follow certain strategies. For example, when applying for a job, one should ask questions regarding the client population. If one is uncomfortable with a particular situation, then not accepting the position would be an option. Denial of care, or providing substandard nursing care to some members of our society, is not acceptable nursing practice. As a professional, the nurse should provide the same level of care to every client, regardless of diagnosis, skin color, ethnicity or economic status.

A nurse is caring for a client who delivered a baby vaginally two hours ago. What signs and symptoms of postpartum hemorrhage should the nurse report to the primary healthcare provider? 1. Two blood clots the size of a dime. 2. Perineal pad saturation in 10 minutes. 3. Constant trickling of bright red blood from vagina. 4. Oliguria 5. Firm fundus

2 - perineal pad saturation in 10 min 3 - constant trickling of bright red blood from vagina 4 - oliguria Lochia should not exceed an amount that is needed to partially saturate four to eight peripads daily, which is considered a moderate amount. Perineal pad saturation in 15 minutes or less is considered excessive and is reason for immediate concern. Saturation of a peripad in one hour is considered heavy. Also, trickling of bright red blood from the vagina can indicate hemorrhage and is often a result of cervical or vaginal lacerations. Bright red blood indicates active bleeding. Oliguria is a sign of fluid volume deficit. As blood volume goes down, renal perfusion decreases and urinary output (UOP) decreases. The kidneys are also attempting to hold on to what little fluid volume is left.

A client, hospitalized with possible acute pancreatitis secondary to chronic cholecystitis, has severe abdominal pain and nausea. The client is kept NPO, an NG tube is inserted, and IV fluids are being administered. What is the rationale for the client being NPO with an NG tube to low suction? 1. Relieve nausea 2. Reduce pancreatic secretions 3. Control fluid and electrolyte imbalance 4. Remove the precipitating irritants

2 - reduce pancreatic secretions In clients with pancreatitis, the pancreatic enzymes cannot exit the pancreas. These enzymes, when activated, begin to digest the pancreas itself. The enzymes become activated in the pancreas when fluid or food accumulates in the stomach. The goal in treating this client is to stop the activation of the pancreatic enzymes. Treatment is focused on keeping the stomach empty and dry. This allows the pancreas time to rest and heal. Note: Autodigestion (pancreas digesting itself) is painful for the client and can lead to other problems such as bleeding.

A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book, the nurse crushes the tablet and mixes it into 3 ounces of applesauce. The new nurse proceeds to the client's room. What priority action should the supervising nurse take? 1. Tell the new nurse to recheck the drug reference book before administering the medication. 2. Suggest that the new nurse reconsider the client's developmental needs. 3. Check the prescription order and the client dose. 4. Observe the new nurse administer the medication.

2 - suggest the nurse reconsider the clients developmental needs Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old.

A client's last two central venous pressure (CVP) readings were 13 cm of water. The nurse would expect the client to manifest which associated signs and symptoms 1. Dry oral mucus membranes 2. Tachypnea 3. Orthostatic hypotension 4. Rales in the posterior chest 5. Jugular vein distention 6. Weight gain

2 - tachypnea 4 - rales in the posterior chest 5 - jugular vein distention 6 - weight gain The normal range for CVP is 2-8 cmH​2O or 2-6 mmHg. Therefore, the readings of 13 cmH​2O are high and may be the result of fluid volume excess. The signs and symptoms of FVE include: tachynea, rales, and jugular vein distention from the increased volume and preload. Acute weight gain is one of the best indicators of FVE due to circulatory overload.

The nurse is caring for a client admitted to the skilled nursing unit approximately 3 months ago. Since admission, the client has lost 8 pounds. There have been no documented changes in the client's physical health. Which strategy may help to improve caloric intake for this client? 1. Encourage the client to eat meals in the room. 2. Take the client to the dining room for all meals. 3. Provide a high protein supplement 30 minutes before meals. 4. Ask the unlicensed assistive personnel to feed the client at each meal.

2 - take the client to the dining room for all meals The client may be lonely and miss the interaction with others, but reluctant to go to the dining room. Eating with others may help to improve appetite and intake of food. The nurse can actively seek out the client and take this client to the dining room. Simply encouraging the client to go to the dining room may not be sufficient to get the client to go.

The nurse wants to provide anticipatory guidance for a group of young parents who have children between the ages of 18 months to 3 years. What points about the next year should the nurse be sure to provide these parents? 1. Be strict and rigid with toilet training, rather than being accepting and letting the child lead the training. 2. Tell the parents about the importance of letting the child do tasks alone. 3. Provide finger foods for the child to eat. 4. Your child will want you to provide emotional support when needed. 5. Assist your child with all tasks to promote independence.

2 - tell parents about the importance of letting child do tasks alone 3 - provide finger foods for the child to eat 4 - your child will want you to provide emotional support when needed

The nurse is caring for a client in the emergency department after a violent altercation with her husband. She describes increasingly violent episodes over the past 10 years. She says, "This is the last time he will hit me." Which response by the nurse demonstrates understanding of the violence cycle? 1. When you leave, you don't have to worry anymore. 2. You are at greatest risk when you leave. 3. That is the best decision you can make. 4. I am glad that you won't be hurt ever again.

2 - you are at greatest risk when you leave

A nurse from an adult unit was reassigned to the pediatric unit. Which client would be least appropriate to assign to this nurse? 1. Ten year old with 2nd and 3rd degree burns. 2. Five year old that was in a MVA and has a femur fracture. 3. Six year old admitted for evaluation of possible sexual abuse by a parent 4. Two month old with bronchopulmonary dysplasia being admitted for reflux.

3 - 6 year old admitted for evaluation of possible sexual abuse by a parent The least appropriate client to assign the nurse from the adult unit would be the suspected sexual abuse. Caring for an abused child requires skill that must be developed from understanding the dynamics of abuse as well as working with a certain developmental level.

An angry client visits the primary healthcare provider's office and requests a copy of their medical records. The client is angry after being placed on hold several times for over 10 minutes when requesting an appointment. What should the nurse tell this client? 1. All client appointment calls are transferred to the scheduling clerk. 2. The client will have to speak to the primary healthcare provider. 3. A copy of the record may be obtained within 24 hours of the request. 4. Medical records must stay within the facility unless requested by another primary healthcare provider.

3 - a copy of the record may be obtained within 24 hours of the request

The triage nurse in the emergency department (ED) assesses 4 clients. Which client is in need of emergent care? 1. A 52 year old who has a partially amputated finger. 2. A 9 month old with temperature of 103°F (39.4°C). 3. A two year old with excessive drooling and a weak cough. 4. A 28 year old experiencing a migraine headache for three days.

3 - a two year old with excessive drooling and weak cough The two year old is exhibiting signs of respiratory difficulty with excessive drooling and a weak cough. Partial airway obstruction is likely and maybe the result of acute epiglottitis in which rapid progression to severe respiratory distress can occur . Airway takes priority over the other clients.

A client has been admitted for exacerbation of ulcerative colitis with severe dehydration. What is the best indicator that this client has an actual fluid deficit? 1. Stool count of 10 episodes of diarrhea in 24 hours. 2. Weight increase of 2 kg and a 24 hour output of 1000 mL. 3. Admission weight of 74.3 kg and 2 days later a weight of 72 kg. 4. Daily intake of 2400 mL and an output of 1600 mL, plus diarrheal stools.

3 - admission weight of 74.3 kg and 2 days later a weight of 72 kg Any acute weight gain or loss is fluid. Weight is the best measurement for fluid loss or gain. Acute weight losses correspond to fluid volume deficits. This client has lost 2.3 kg over a 2 day period, indicating a fluid volume deficit (FVD).

The nurse is preparing a client for a renal biopsy. Which is most important for the nurse to assess prior to this procedure? 1. BUN and creatinine 2. NPO status and signature on consent 3. Bleeding time and coagulation studies 4. Serum potassium and urine sodium

3 - bleeding time and coagulation studies Before you insert a needle into an organ for a biopsy, it would be best to know the client's bleeding time because there is a risk of bleeding when the biopsy is performed.

Which assessment finding by a nurse would best indicate a positive Mantoux tuberculin skin test in a client? 1. Formation of a vesicle that is 4 mm in diameter 2. A sharply demarcated region of erythema of 10 mm 3. A central area of induration of 15 mm surrounded by erythema 4. A circle of blanched skin surrounding the injection site

3 - central area of induration of 15 mm surrounded by erythema The basis of reading the skin test is the presence or absence of induration, which is a hard, dense, raised formation. This is the area that is measured. Sometimes the site has erythema, a reddening of the skin that can also have swelling. The erythema should NOT be measured. Reactions to the skin test will vary. Measure only the induration. An induration of 15 mm or more is positive in persons with no known risk factors of TB. Reactions larger than 15 mm are unlikely to be due to previous BCG vaccination or exposure to environmental mycobacteria.

On the third postoperative day, a client develops a fever of 103.3ºF (39.6ºC) shivering and nausea. The primary healthcare provider writes these prescriptions. Which should the nurse do first? 1. Apply cooling blanket for fever. 2. Give ceftriaxone 1 gram IVPB stat. 3. Draw blood cultures. 4. Give promazine 50 mg po PRN for nausea.

3 - draw blood cultures Blood cultures MUST be drawn immediately to identify the causative bacteria. Once the organism is identified, the primary healthcare provider will order organism specific antibiotics. Always draw blood cultures before administering the antibiotic. If antibiotics are given before the blood cultures are drawn, the culture will be inaccurate, and the client cannot be treated appropriately.

The nurse is teaching a client about foods containing tyramine which should be avoided while taking a monoamine oxidase inhibitor (MAOI). Which meal selection, if chosen by the client, indicates successful teaching? 1. Smoked turkey and dressing, sweet peas and carrots and milk. 2. Baked chicken over pasta with parmesan sauce, baked potato and tea. 3. Fried catfish, French fries, coleslaw and apple juice. 4. Liver smothered in gravy and onions, rice, squash and water.

3 - fried catfish, french fries, coleslaw, apple juice Tyramine is an amino acid that helps in the regulation of blood pressure. MAOIs block the enzyme monoamine oxidase which is responsible for breaking down excess tyramine in the body. Eating foods high in tyramine while on MAOIs can result in dangerously high levels of tyramine in the body. This can lead to a serious rise in blood pressure, creating an emergency situation. Tyramine is found in protein-containing foods and the levels increase as these foods age. Food such as strong or aged cheese, cured meats, smoked or process meats, liver (especially aged liver), pickled or fermented foods, sauces, soybeans, dried or overripe fruits, meat tenderizers, brewer's yeast, alcoholic beverages and caffeine- such as in tea, cokes and coffee are considered to be high in tyramine and should be avoided in clients taking MAOIs.

The charge nurse is observing the work of an unlicensed assistive personnel (UAP). Which observation will require the nurse to intervene? 1. Placing soiled linen in a hazardous waste linen bag outside of the client's room. 2. Closing the door when exiting the room of a client diagnosed with tuberculosis (TB). 3. Going between client rooms wearing the same pair of gloves to collect I&O reports. 4. Cleaning a blood pressure cuff with a disinfectant.

3 - going between client rooms wearing the same pair of gloves to collect I and O reports gloves should be removed and hands washed before leaving each client's room. Gloves quickly become contaminated and then become a potential vehicle for the transfer of organisms between clients.

The nurse is caring for a client who was admitted to the hospital following a severe motor vehicle crash (MVC) in which the client was trapped in the car for several hours. The client is being closely monitored for the development of renal failure. Which assessment finding would warrant immediate reporting? 1. Creatinine 1.1 mg/dl (97.24 mmol/L) 2. Urinary output of 150 mL per hour. 3. Gradual increase of BUN levels. 4. Calcium levels of 9.0 mg/dL (2.25 mmol/L)

3 - gradual increase of BUN levels Gradual accumulation of nitrogenous wastes results in elevated BUN and serum creatinine. This is an indication of impaired renal function.

A 70 year old client was admitted to the vascular surgery unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's BP is 198/94. What would be the best action for the charge nurse to delegate at this time? 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm in 15 minutes. 3. Have the LPN/LVN administer the 0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for pain.

3 - have the LPN give the 0900 dose of furosemide and enalapril now The nurse should recognize the need for measures to reduce the blood pressure. Administering the client's blood pressure medicine is aimed at correcting the problem. It is appropriate to administer the medications at this time in relation to the time that the next dose is due.

An elderly male, diagnosed with chronic renal failure and depression, lives alone. Which question should the home health nurse ask first when assessing this client? 1. Have you had suicidal thoughts in the past? 2. How are you feeling today? 3. Have you had thoughts of harming yourself? 4. Do you have guns in your home?

3 - have you had thoughts of harming yourself Suicide assessment should begin with direct questions about the presence of suicidal thinking. The nurse should recognize that elderly men are at higher risk for committing suicide, especially those with a history of depression, chronic illness and isolation.

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. 4. Tympany noted on percussion.

3 - high pitched bowl sounds High-pitched bowel sounds are indicative of an early bowel obstruction and hypoactive bowel sounds develop as obstruction worsens. The additional signs presented are also clues of a possible obstruction.

A low income family with children lives in an old, run-down apartment building situated close to a salvage yard in a poor neighborhood. Which area of assessment would be most important for the home health nurse? 1. Immunization status 2. School-related problems 3. Lead poisoning 4. Signs of child abuse

3 - lead poisoning Lead may be found in the soil around rusted cars and can cause lead exposure. Old paint contains lead. Chips of paint may be consumed by young teething children. Old, run-down apartments may also have pipes which contain lead. Exposure to and consuming even small amounts of lead can be harmful. No safe lead level in children has been identified, and lead can affect nearly every system in the body. Mental and physical development can be negatively impacted by lead in the body.

The nurse is assisting an unlicensed assistive personnel (UAP) move an obese and dependent client toward the top of the bed. Which action is most important to prevent shearing forces on the skin? 1. Each person puts hands under the client and slides client toward the top of the bed. 2. Apply powder to the sheet before pulling client toward the top of the bed. 3. Place turn sheet under the client and use it to slide the client toward the top of bed. 4. Seek assistance of another person before pulling up in bed.

3 - place turn sheet under the client and use it to slide the client toward the top of bed Placing a turn sheet under the client before moving will prevent friction and shearing forces which may lead to an abrasion or skin tear. Pressure ulcers are more likely to develop in tissues where shear force injury has occurred.

The nurse is performing morning care on a client on the medical unit. What should the nurse do after changing a client's bed linen? 1. Hold the linen close to the body while transporting it to the dirty utility room. 2. Wear a gown and gloves to transport the linen to the biohazard container. 3. Place the linen into a leak proof container sitting outside the room. 4. Place the linen in a pillow case and set it on the floor until client care is completed.

3 - put the linen into a leak proof container outside the room

A client, admitted in Sickle Cell Crisis, is started on oxygen at 2L/NC and given a narcotic analgesic for pain control. What additional prescription is a priority for the nurse to initiate? 1. A high protein, low fat diet 2. Administration of a thrombolytic, such as streptokinase 3. Implementation of bleeding precautions 4. Administration of IV fluids for hydration

4 - administration of IV fluids for hydration Increasing hydration status via the administration of IV fluids is indicated in sickle cell crisis to increase that volume in the vascular space and subsequently decrease the vaso-occlusion from the sickling effects of the RBCs. The increased volume separates the sickled cells to reduce the clumping together of the cells.

A client was admitted to the medical unit with pneumonia 2 days ago. There is a history of drinking 5-6 martinis every night for the past 2 years. Today, the nurse notes that the client is disoriented to time and place and is seeing imaginary spiders on the ceiling. The nurse cannot understand what the client is saying. What is this client most likely experiencing? 1. Wernicke's Encephalopathy 2. Korsakoff's Psychosis 3. Alcohol Withdrawal 4. Alcohol Withdrawal Delirium

4 - alcohol withdrawal delirium Alcohol Withdrawal Delirium usually occurs on the second or third day following cessation of or reduction in prolonged, heavy alcohol use. Symptoms are the same as for delirium: Difficulty sustaining and shifting attention. Extremely distractible; disorganized thinking; rambling, irrelevant, pressured, and incoherent speech; impaired reasoning ability; disoriented to time and place; impairment of recent memory; delusions and hallucinations.

What medication should the nurse anticipate giving to a client in preterm labor to stimulate maturation of the baby's lungs? 1. Magnesium sulfate 2. Terbutaline 3. Methotrexate 4. Betamethasone

4 - betamethasone Betamethasone is used to stimulate maturation of the baby's lungs in case preterm birth occurs. This medication is given to help prevent respiratory distress syndrome (RDS) by improving storage and secretion of surfactant that helps to keep the alveoli from collapsing.

A female client taking captopril for hypertension tells the clinic nurse that she is planning to get pregnant. What recommendation should the nurse make? 1. "Captopril can be taken safely during pregnancy, but we will need to decrease your dose so you do not become hypotensive." 2. "We will need to increase your dose of captopril once you become pregnant." 3. "In order to prevent neural tube defects, start taking folic acid." 4. "Captopril can cause serious harm to an unborn baby, so you must prevent pregnancy while taking this medication. "

4 - can cause serious harm to an unborn baby, must prevent pregnancy while on captopril

A client has sustained a major head injury as a result of a motor vehicle accident. The emergency department nurse is assessing the client's neurological status every 15 minutes. Which sign would the nurse recognize as an early indicator of an increased intracranial pressure (ICP)? 1. Dilated and unresponsive pupils 2. Cheyne-Stokes respirations 3. Cushing's triad 4. Change in level of consciousness (LOC)

4 - change in LOC

A client in a psychiatric unit sings over and over, "It is hot, I am a hot tot in a lot, I sit all day on a cot drinking a pop." How should the nurse document this form of thought? 1. Neologisms 2. Dissociation 3. Fugue 4. Clang Association

4 - clang association Dissociation is the splitting off of clusters of mental contents from conscious awareness. It is a mental process that leads to a lack of connection in the client's thoughts, memory and sense of identity. In its mild form, it is similar to day dreaming. In a more severe form, it can be manifested as multiple personalities. Fugue is sudden, unexpected travel away from home or customary place of daily activities, with inability to recall some or all of one's past. The person is unaware that anything has been forgotten. Following recovery, there is no memory of the time during the fugue.

A client experiencing chest pain is prescribed an intravenous infusion of nitroglycerin. After the infusion is initiated, the occurrence of which symptom would prompt the nurse to discontinue the nitroglycerin? 1. Frontal headache 2. Orthostatic hypotension 3. Decrease in intensity of chest pain 4. Cool, clammy skin

4 - cool clammy skin This assessment finding of cool, clammy skin is an indication of decreased cardiac output that could be the result of too much vasodilatation. Cardiac output could continue to decrease if the nitroglycerin is not discontinued.

The nurse is preparing to administer nadolol to a hospitalized client. Which client data would indicate to the nurse that the medication should be held and the primary healthcare provider notified? 1. Blood pressure 102/68 2. Glucose 118 3. UOP 440 mL over previous 8 hour shift. 4. Heart rate 56/min

4 - heart rate 56/min This is a beta blocker. It slows the heart rate. If a client's heart rate is less than 60 beats per minute, notify the primary healthcare provider and ask if the client should receive this medication. Administering a beta blocker to a client who has a heart rate less than 60 could possibly cause the client to develop symptomatic bradycardia and hypotension.

During a conversation with a client on a psychiatric unit the client tells the nurse, "Everyone here hates me." Which response by the nurse is best? 1. No, they do not hate you. 2. What did you do to make others not like you? 3. Just don't pay attention to what others think of you. 4. I can't speak for the other people, but I don't hate you.

4 - i can't speak for the others, but I don't hate you Here the nurse is speaking only for the nurse. The nurse cannot legitimately speak for anyone else. The nurse must model the process of not speaking for anyone else. The response also lets the client know that the nurse cares about the way the client feels.

A client with cancer of the larynx undergoes radiation therapy for 5 weeks prior to a neck dissection and tumor excision. The client asks the nurse how long the post surgical recovery time will be. How should the nurse reply? 1. "I really don't know. It is different for everyone, but speak to your surgeon." 2. "Your medical insurance will cover the whole length of your stay, so don't worry." 3. "You shouldn't worry about how long you are going to stay. You should focus on getting better." 4. "It may be a little longer than average. The radiation you received sometimes delays tissue healing."

4 - may take a little longer to heal because radiation delays tissue healing Radiation can cause tissue trauma and changes that can delay wound healing.

Which snack selection by a client receiving chemotherapy would indicate to the nurse that teaching has been successful? 1. Fresh salad with cucumbers, carrots, and tomatoes. 2. Orange slices with yogurt. 3. Strawberries with whipped cream. 4. Milk shake with a packet of instant breakfast added.

4 - milk shake with instant breakfast added Clients with cancer often experience a combination of increased energy expenditure but the nutritional intake is decreased and inadequate to meet the caloric and protein needs. The decreased intake may be, in part, due to the side effects of the chemo. Cold drinks, like shakes, can be soothing, especially if the client has no desire to eat solid foods or is experiencing mouth pain. Shakes will also offer more calories for the client and more protein if a packet of instant breakfast or protein powder is added. Cold, high protein foods are generally tolerated better and have less offensive odors than hot foods.

A client had an abnormal maternal serum alfa fetoprotein (MSAFP) at 18 weeks gestation. She is now 22 weeks gestation, and an amniocentesis has just been completed for genetic analysis. Which nursing action has priority? 1. Monitor the needle entry site for signs of infection. 2. Encourage the client to express her feelings. 3. Assess the maternal blood pressure for hypertension. 4. Monitor fetal heart tones and uterine activity.

4 - monitor fetal heart tones and uterine activity There is a risk for pregnancy loss after amniocentesis. The priority nursing intervention is to monitor for fetal heart tones and uterine contractions.

The occupational health nurse is caring for an employee after a chemical explosion at the local tire factory. The client reports a foreign body in the right eye. The right eye is watery, and the client reports photophobia. Which nursing action takes priority? 1. Evert eyelid and examine for foreign body. 2. Measure visual acuity. 3. Notify the receiving hospital immediately for transfer of the client. 4. Place an eye shield over eye.

4 - place an eye shield over the eye If a foreign body is the result of explosion or blunt or sharp trauma, the eye should be protected from further damage by placing an eye shield over the eye (or if a shield is not available, a paper cup to prevent rubbing of the eye). Then make arrangements to transport the client for emergency care by an ophthalmologist. If movement of the unaffected eye creates movement in the affected eye, it may be necessary to cover the unaffected eye also to prevent further injury to the eye from movement.

The nursing supervisor notified the charge nurse on a pediatric unit that a child with a history of developmental delays is being admitted with shingles. The nurses on the floor have the following assignments. It would be inappropriate for the charge nurse to assign the new admit to which nurse? 1. A nurse caring for clients with nephritis, irritable bowel syndrome, and appendectomy. 2. A new nurse just out of orientation caring for clients diagnosed with RSV, asthma, and anorexia nervosa. 3. A nurse caring for clients diagnosed with spina bifida, Hirschsprung's Disease, and irritable bowel syndrome. 4. A pregnant nurse caring for clients with cystic fibrosis, myelomeningocele, and rheumatoid arthritis.

4 - pregnant nurse caring for clients with cystic fibrosis, myelomeningocele and RA The information does not let you know if any of the nurses have had chickenpox or not. If a nurse has not had chickenpox, then they should not care for the client with shingles. The varicella zoster virus is responsible for chickenpox and shingles. The virus is lying dormant in the nerve ganglia and under certain conditions erupts (for example: stress). With the information you have, it would be best not to assign the new admit to the nurse who is pregnant. The other set of nurses and clients have no identified contraindications to taking care of the client with shingles.

When preparing a client for surgery, the nurse realizes the operative permit has not been signed. The client tells the nurse he understands the procedure, but received his preoperative medication approximately 10 minutes ago. What would be the appropriate action by the nurse? 1. Have the client sign the permit, as he verbalizes understanding. 2. Witness the form after having the client sign it. 3. Have his wife sign the form as she witnessed his statement that he understands. 4. Call the surgical area and explain that the surgery will have to be cancelled.

4 - surgery has to be cancelled The client must sign the operative permit or any other legal document prior to taking preoperative drugs that can affect judgement and decision making capacity

A client diagnosed with a duodenal ulcer is prescribed lansoprazole and sucralfate. What should the nurse teach the client about how to take these medications? 1. Take together immediately before meals. 2. Take together immediately after meals. 3. Take the sucralfate first, wait at least 30 minutes, then take the lansoprazole. 4. Take the lansoprazole first, wait at least 30 minutes, then take the sucralfate.

4 - take the lansoprazole first, wait at least 30 min, then take the sulcrafate When prescribed any medication along with sucralfate, the client should avoid taking the medication at the same time with sucralfate. Sucralfate can make it harder for the body to absorb lansoprazole because it forms a "coating" or "barrier" on the stomach lining. Therefore, the client should wait at least 30 minutes after taking the lansoprazole before taking sucralfate.

The charge nurse is making assignments for one RN and one LPN/VN on a pediatric unit. Which clients would be most appropriate for the charge nurse to assign to the RN? 1. 2 year old with asthma receiving IV medication. 2. 6 year old with new onset seizures. 3. 12 year old with colitis receiving TPN. 4. 2 month old with urinary tract infection. 5. 10 year old paraplegic needing assistance with bowel training.

1 - 2 yo with asthma receiving IV meds 2 - 6 yo with new onset seizures 3 - 12 yo with colitis receiving TPN

Which client will the charge nurse intervene on behalf when making rounds? 1. The client turned to left side 1 ½ hour ago. 2. Client who has been sitting in a chair for 2 ½ hours. 3. Client who is day one postop from hip replacement with abduction pillow in place. 4. The client who is in buck's traction with foot boots.

2 - client who has been in a chair for 2.5 hours Limit sitting in a chair to less than 2 hours. Prolonged sitting or lying in one position predisposes the client to skin breakdown and other hazards of immobility.

A client has been taught guided imagery as a method to relieve pain. How should the nurse first assess for pain relief after completion of guided imagery by the client? 1. Assess vital signs 2. Use of pain intensity scale 3. Ask client to describe the pain 4. Observe ability to perform activities of daily living

2 - use of pain intensity scale The use of pain intensity scales is an easy and reliable method of determining the client's pain intensity.

During the insertion of a urinary catheter, the tip of the catheter touches the client's thigh. What action should the nurse take? 1. Wipe the tip of the catheter with alcohol. 2. Call for another urinary catheter and a pair of sterile gloves. 3. Insert the catheter and obtain a prescription for antibiotics. 4. Leave the room to obtain another sterile urinary catheter kit.

2 - call for another kit and gloves Indwelling catheter insertion is a sterile procedure. If contamination occurs, do not turn back on sterile field. Get on the call light to request another urinary catheter and sterile gloves to continue the procedure. Continuing the procedure with contaminated equipment would jeopardize the client's safety The catheter is contaminated, but the sterile field is still okay. It is more cost efficient to have someone bring the nurse another catheter and pair of sterile gloves rather than getting an entire sterile kit.

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

2 - assess bladder and bowel for distention 3 - examine skin for pressure areas 4 - eliminate drafts 5 - remove triggering stimulus 6 - administer hydralazine if BP does not return to normal The client is experiencing autonomic dysreflexia, which is a potentially dangerous syndrome that can develop in clients with spinal cord injuries. The cause of autonomic dysreflexia with these associated symptoms is a strong sensory or noxious stimulus. The most common stimulus is bowel, bladder distention, or irritation. Any painful, irritating or strong stimulus including environmental temperature changes, drafts, etc. can trigger autonomic dysreflexia. It is considered a medical emergency and must be promptly treated.

A group of women ask a community health nurse how to prevent stress incontinence. What points should the nurse teach these women? 1. Limit alkaline foods. 2. Avoid caffeine. 3. Maintain a healthy weight. 4. Eat less fiber. 5. Perform high-impact exercise.

2 - avoid caffeine 3 - maintain a healthy weight Fluids containing caffeine, carbonation, alcohol or artificial sweeteners act as irritants to the bladder wall and should be avoided. Acidic foods, such as citrus fruits, are also irritants. Obesity can cause increased pressure on the bladder, leading to incontinence.

The RN is caring for a client diagnosed with an abdominal aortic aneurysm. Which prescription can the RN delegate to the LPN? 1. Obtain vital signs every 15 minutes. 2. Insert a urinary catheter for hourly urinary outputs. 3. Place a PICC line for fluid management. 4. Provide morphine 1 mg per PCA pump at a 10 minute lockout.

2 - insert a urinary catheter for hourly urine outputs

A nurse educator is explaining the Health Insurance Portability and Accountability Act (HIPAA) of 1996 to a group of nursing students. What points about HIPAA should the nurse educator include? 1. Primary healthcare providers employed at the facility where a client receives treatment can legally access any client's health information at any time. 2. Health related information revealed by a client to healthcare personnel must be kept confidential. 3. The client has the right to access personal healthcare records and to obtain copies of those records. 4. A client's information can be revealed only with the client's permission, or when the primary healthcare provider or facility is required by law to do so. 5. Unlicensed assistive personnel employed where a client receives treatment can legally access any client's health information at any time.

2. Health related information revealed by a client to healthcare personnel must be kept confidential. 3. The client has the right to access personal healthcare records and to obtain copies of those records. 4. A client's information can be revealed only with the client's permission, or when the primary healthcare provider or facility is required by law to do so.

The nurse is working in a long term care facility. What actions by the nurse are appropriate when taking a telephone prescription from a primary healthcare provider? 1. Document the prescription prior to the end of the shift. 2. Explain to the pimary healthcare provider that nurses cannot take telephone prescriptions. 3. Repeat the prescription back to the primary healthcare provider prior to hanging up. 4. Transcribe the prescription in the client's record. 5. Ask the primary healthcare provider to wait and write the prescription during rounds.

3 - repeat the prescription back to the doctor 4 - put the prescription in the medical record Whenever a verbal or telephone prescription is given, the nurse is to transcribe the prescription, and then read it back to the prescribing primary healthcare provider at the time the prescription is given for validation of accuracy of the prescription received. Otherwise an error may occur.

What assignment would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Teaching the client perineal care. 2. Changing a colostomy bag on a client. 3. Serving the diet tray for a diabetic client. 4. Taking the initial vital signs on a client who is to receive blood.

3 - serving the diet tray to the diabetic client This does not require experience for a particular skill nor does it require higher level skills that would require a licensed person to perform.

Which client admitted to the emergency department should the nurse assess first following shift report on assigned clients? 1. Client reporting inability to void and a distended bladder on palpation. 2. Client diagnosed with a confirmed closed fracture of the tibia. 3. Client who has a suspected corneal laceration. 4. Client with abdominal discomfort and a rigid abdomen on palpation.

4 - Client with abdominal discomfort and a rigid abdomen on palpitation A rigid abdomen may indicate bleeding or other causes of peritonitis which takes priority over the other three, more stable clients. This could lead to shock in this client. Conditions requiring immediate treatment include cardiac arrest, anaphylaxis, multiple trauma, shock, poisoning, active labor, drug overdose, severe head trauma, and severe respiratory distress.

A nurse is at highest risk for blood-borne exposure during which situation? 1. When removing a needle from the syringe. 2. While placing a suture needle into the self-locking foreceps. 3. Prior to inserting the intravenous (IV) line, the client moves causing a needle stick to the nurse. 4. A clean needle sticks the nurse through blood-soiled gloves.

4 - a clean needle sticks the nurse through the blood soiled gloves

How would the nurse determine the correct size oropharyngeal airway for a client? 1. Select the same size as the little finger of the victim. 2. Measure from the tip of the lips to the epiglottis. 3. Determine the length from the earlobe to the xiphoid process. 4. Measure from the earlobe to the corner of the mouth.

4 - measure from the earlobe to the corner of the mouth An airway of proper size will extend from the corner of the client's mouth to the tip of the earlobe on the same side of the client's face.

The nurse is giving discharge instructions to an Asian client following a colonoscopy. During the instructions, the client stares directly at the floor, despite being able to speak English. Based on the client's body language, how would the nurse classify this behavior? 1. Embarrassment. 2. Attentiveness. 3. Disinterest. 4. Confusion.

Asian societies have a deep respect for others and making eye contact with the nurse would be considered rude and offensive.

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. Bulb suction excessive mucus. Assess newborn's heart rate. Place identification bands on newborn and mom. Administer sterile ophthalmic ointment containing 0.5% erythromycin.

The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat through a non-tunneled central venous catheter lumen with no other medication or fluid infusing. In what order should the nurse administer this prescription?

Cleanse access port Connect 10 mL normal saline to access port Gently aspirate for blood Flush saline using push-pause method Administer phenytoin Flush with normal saline, then with heparin