NCLEX Review 2019

A construction worker comes into the occupational health nurse's clinic reporting chest heaviness. The nurse should assess for what additional signs and symptoms? 1. Headache 2. Dry, flushed skin 3. Lightheadedness 4. Dyspnea 5. Irregular pulse

3., 4. & 5. Correct: The nurse should be thinking myocardial infarction (MI)! All of these are signs of an MI. 1. Incorrect: Headaches do not commonly occur with MI. 2. Incorrect: Skin would be cool and clammy. Identify clues in the stem. Generally the stem is short and contains only the information needed to make the question clear. A clue is the use of a word or phrase that leads you to the correct answer. The clue shows a relationship to word or phrase in the correct answer.​

What action should the nurse take first for the 5 year old client brought to the urgent care clinic with a blistering sunburn? 1. Administer analgesics. 2. Apply cool water soaks. 3. Check immunization status for tetanus. 4. Educate family to avoid greasy lotions or butter on the burn

2. Correct: The priority is to stop the burning process. This can be done by applying cool water to the burned area. 1. Incorrect: Determining pain level and administering pain medication would be the second priority. 3. Incorrect: Before the client is sent home, tetanus immunization status would need to be determined. 4. Incorrect: This would be included in discharge teaching.

A float nurse arrives on the unit to assist in the care of clients for the shift. During report, the charge nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. Based on this information, what should the charge nurse do? 1. Ask the float nurse, "Have you been drinking?" 2. Assign the float nurse to the least acute clients. 3. Notify the nursing supervisor of the observations. 4. Notify the board of nursing (BON) that the float nurse is an alcoholic.

3. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. Confrontation should occur in the presence of a supervisor or other nurse and should include the offer of assistance in seeking treatment. This can prevent harm to client's and save the nurse's career or life. 1. Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. The charge nurse should not lecture, scold or argue with the float nurse. 2. Incorrect: This response overlooks a potentially severe problem. Nurses dependent on drugs or alcohol can harm clients. The nurse should not be assigned to provide care if impairment is suspected. Patient safety must remain the priority. 4. Incorrect: If a report is made to the BON, it should be a factual documentation of specific events and actions, not a statement of impairment. The report should contain consequences. Each state BON differs in that also some have treatment programs they administer themselves.

A newly appointed nurse manager on the unit has a stable staff who have worked together for 5 or more years. The unlicensed assistive personnel (UAPs) are accustomed to informally arranging their lunch time; however, the nurse manager has implemented a plan to assign breaks and lunch. The UAPs are angry and refuse to change to the new system. What should be the nurse manager's first action in this situation? 1. Plan a unit staff meeting to discuss the problem and receive input for resolution. 2. Inform the staff that the plan will be implemented and those not following the plan will be disciplined. 3. Ask the charge nurse to address the problem daily as it occurs. 4. Plan a meeting with all UAPs to discuss the problem and reason for the new assignments.

1. Correct: The key word in the stem is first. So yes, get everyone together and discuss the problem and find areas of compromise where possible. 2. Incorrect: Too authoritative. This is good staff that has worked together on the unit for a long time. We want them to be happy and get the work done. Again, the key word in the stem is first. 3. Incorrect: No, this is a manager's issue resulting from a new system. This may need to be done but is not the first action. 4. Incorrect: Explaining the rationale to one group does not promote teamwork. It is better to plan a unit staff meeting and not a meeting for only the UAPs.

The charge nurse has assigned four clients due for a morning assessment. The nurse knows what client should be assessed first? 1. A client with diabetis admitted for debridement of a foot ulcer. 2. A client with epilepsy reporting an odd smell in the room. 3. A client with exacerbation of COPD reporting dyspnea. 4. An adolescent client post appendectomy reporting pain

2. CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. 1. INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. This client is not the nurse's first priority. 3. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. 4. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. The nurse has another priority.

The nurse is preparing to educate a client about human papillomavirus (HPV). What information should the nurse include? 1. There is no vaccine to prevent HPV. 2. HPV is the cause of most ovarian cancers. 3. The only way to prevent HPV is refraining from any genital contact with another. 4. HPV is cured by removal of genital warts.

3. Correct: This is a true statement. Latex condoms have been associated with lower risk, however, there is still a risk of coming into contact with the virus even when a condom is used correctly. 1. Incorrect: There is a vaccine against the human papillomavirus. 2. Incorrect: HPV is the cause of most cervical cancers. 4. Incorrect: Even after genital warts are removed, HPV remains, and viral shedding will continue

The charge nurse in the pediatric unit is making assignments for the day shift. What clients would be appropriate for an LPN floated from the medical-surgical unit? 1. A 12-year-old with diabetes mellitus. 2. A 6-year-old one day post tonsillectomy. 3. A 3-year-old admitted in sickle cell crisis. 4. A 9-year-old with Hirschsprung's disease. 5. A 2-year-old in a mist tent with epiglottitis.

1 and 4. CORRECT. The LPN scope of practice is task oriented. An LPN floated to a specialty floor, such as pediatrics, should be assigned the most stable, uncomplicated clients, and ideally those that may have a disease process which also occurs on a medical-surgical floor. The 12-year old with diabetes mellitus is a good choice. This client will require accu-checks and SubQ insulin, both of which are within the scope of practice for the LPN. A client with Hirschsprung's disease experiences bowel dysfunction, usually with constipation, pain or anorexia. This client could also be assigned to an LPN who would have experience with bowel issues. 2. INCORRECT. Even though this child is one day post-op, throat surgery would require frequent assessments of the airway and the client's ability to swallow. Additionally, pain medication is usually given I.V. since the child still has difficulty swallowing. LPN's may not give I.V. meds. 3. INCORRECT. Children in sickle cell crisis require on-going assessments of the vascular system as well as the need for supplemental oxygen and pain medication. In addition to the young age of the client, the disease process requires advanced assessments. This client is not appropriate for the LPN. 5. INCORRECT. A two year old with epiglottitis in a mist tent will need airway and respiratory assessments frequently, along with teaching the parents about this illness. This client is not appropriate for the LPN.

A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to do what? 1. Remove air from the pleural space 2. Create access for irrigating the chest cavity 3. Evacuate secretions from the bronchioles and alveoli 4. Drain blood and fluid from the pleural space

1. Correct: A chest tube placed in the upper chest is to remove air from the pleural space. Remember air rises and fluid settles down low. 2. Incorrect: Chest tubes are placed in the pleural space to get rid of air, blood, fluid, or exudate so that the lung can re-expand. The purpose is not to create an access for irrigating the chest cavity. 3. Incorrect: The chest tube is inserted into the pleural space because the lung has collapsed due to air, blood, fluid, or exudate. The chest tube does not go into the lung so secretions can not be removed from the bronchioles and alveoli by way of the chest tube. 4. Incorrect: You have to know the purpose of the upper chest tube. Fluid drains down, so the lower one is for fluid.

Which assigned postpartum client should the nurse identify as being at highest risk for hemorrhage? 1. C-section delivery 2. Vaginal delivery of twins 3. Vaginal delivery of premature baby 4. Precipitous delivery of gravida 5

1. Correct: A client with a surgical wound is at risk for hemorrhage and is at greater risk than birth from a vaginal delivery. The surgical opening of the abdomen and the uterus makes this the highest risk. 2. Incorrect: If the placenta is removed and the fundus massaged properly, risk of hemorrhage decreases. The risk of hemorrhage goes up with multiple births, such as twins, as compared with a single birth, but it is still not as high a risk as a c-section. 3. Incorrect: Premature does not place the client at higher risk of bleeding. The premature newborn is generally smaller with less risk of damage to the uterus and perineum of mom. 4. Incorrect: A precipitous delivery could make you think tear, but the client is Gravida 5. Tearing is less likely after having 5 children.

Which finding in fetal heart rate during a non-stress test would indicate to the nurse that a potential problem for the fetus may exist? 1. Increases 30 beats per minute for 20 seconds with fetal movement. 2. Increases 8 beats per minute for 10 seconds with fetal movement. 3. Remains unchanged with maternal movement. 4. Increases 5 beats per minute for 30 seconds with maternal movement.

2. Correct. A non-reactive test is when the FHR accelerates less than 15 beats per minute above baseline. This may indicate fetal compromise. 1. Incorrect. This would be a reactive test. This is characterized by acceleration of fetal heart rate of more than 15 beats per minute above baseline, lasting for 15 seconds or more. 3. Incorrect. This test does not look at fetal heart rate with maternal movement. 4. Incorrect. This test does not look at fetal heart rate with maternal movement.

The nurse is teaching a community health class for cancer prevention and screening. Which individual does the nurse recognize as having the highest risk for colon cancer? 1. Diagnosed with irritable bowel syndrome 2. Has a family history of colon polyps 3. Diagnosed with cirrhosis of the liver 4. Has a history of colon surgery

2. Correct: A family history of colon polyps and/or colon cancer is the greatest risk factor for development of colon cancer. Other factors include increasing age and a low fiber diet of processed foods. 1. Incorrect: Irritable bowel syndrome is not a risk factor for developing cancer of colon. 3. Incorrect: Cirrhosis of the liver is not a risk for cancer of colon. 4. Incorrect: Having had colon surgery does not increase a person's risk for developing cancer of colon.

The nurse has initiated instruction for an 11 year old child newly diagnosed with diabetes mellitus. The child indicates anxiety about the need for daily insulin injections. What nursing action would best address this issue? 1. Tell the child it only hurts for a moment. 2. Have the parents administer the shots. 3. Show the child how to give self injections. 4. Provide toy syringe for the client to play with.

3. Correct: A school age child needs a sense of achievement and control of the situation. Because diabetes will be a life-long disease, it is important for the child to begin learning about self-care which includes daily insulin injections. Age eleven is not too young to begin administering self injections. 1. Incorrect: This is a false statement, considering the fact that pain perception varies. Minimizing the amount of potential discomfort will instill distrust in the child, decreasing compliance with the health regimen. This is false assurance. 2. Incorrect: While parents may administer injections for much younger children, school aged children are capable of becoming independent with all aspects of diabetes. Additionally, an 11 year old client needs to develop a sense of mastery and achievement to accomplish this stage successfully. 4. Incorrect: The client is too old for pretend play with imitation syringes. That process is more appropriate for a preschool child. It would be beneficial to allow this child to handle regular syringes without a needle initially, and then add all the necessary equipment when the client feels more comfortable handling everything.

The emergency room nurse is assessing a client reporting severe abdominal pain for several hours prior to arrival at the hospital. Assessment findings include slight mottling of the lower extremities and a pulsating mass near the umbilicus. Which actions should the nurse implement immediately? 1. Position client on the left side. 2. Apply warm blankets to legs. 3. Administer I.M. pain medication. 4. Alert the operating room staff. 5. Notify the primary healthcare provider. 6. Palpate mass to determine size.

4. & 5. Correct: The client's symptoms indicate the presence of an aortic abdominal aneurysm that may be dissecting (rupturing) at this time. This is a life-threatening emergency and the client will need urgent surgery to survive. The nurse should immediately notify the healthcare provider and alert the operating room staff of impending surgery. 1. Incorrect: These are the classic symptoms of a dissecting abdominal aneurysm, a life-threatening situation requiring immediate surgery. Positioning the client on either side is contraindicated as that action may cause further internal bleeding, complete rupture of the aneurysm, or death. 2. Incorrect: Mottling of lower extremities accompanied by severe abdominal pain suggests a dissecting abdominal aneurysm. The discoloration of lower extremities indicates compromised circulation secondary to interrupted blood flow because of the aneurysm. This client would not benefit from warm blankets but rather needs immediate surgery to survive. 3. Incorrect: Pain medications in general are not administered until an exact diagnosis is confirmed, since relieving pain would mask those signs or symptoms needed to verify the problem. While the client may be given medications at some point, this is not the life-saving action the nurse must take immediately. 6. Incorrect: The client's symptoms are suggestive of a dissecting abdominal aneurysm, a life-threatening emergency requiring immediate surgical intervention. It is never acceptable for the nurse to palpate an abdominal mass, particularly a pulsating mass, since this would likely cause complete rupture of the blood vessel and immediate death.

A client being treated for major depressive disorder arrives at group therapy for the first time in a week wearing clean clothes after showering. What response by the nurse would be therapeutic? 1. "Why are you all dressed up for group?" 2. "Maybe you could add makeup tomorrow." 3. "You must feel better after finally showering." 4. "You look really nice in that flowered jacket."

4. CORRECT: When a depressed client has a sudden change in behavior or attitude, the nurse must cautiously evaluate any meaning behind such abrupt behavior. The best way to proceed is to engage the client in an interactive conversation by utilizing therapeutic techniques. This nursing comment provides positive affirmation of the client's actions by drawing attention to the choice of clothing. Open-ended statements provide a safe environment for building rapport and client interaction. 1. INCORRECT: Demanding an explanation for behavior is always non-therapeutic. Most often, the client will have no response or even understanding of the behaviors and can become frustrated trying to respond. Additionally, this question could be interpreted as disapproving of the clothing, causing the client to return to previous behaviors. 2. INCORRECT: The nurse is suggesting the client's attempts to improve self are less successful by inferring that makeup should be applied. This comment is not therapeutic, nor does it acknowledge the positive initial actions taken by the client. Rather than encouraging, such a response by the nurse is negative and not constructive. 3. INCORRECT:. While this statement does acknowledge the client has showered, the word "finally" has a negative connotation, suggesting the client has neglected personal care for an unacceptable amount of time. Such a comment by the nurse is non-therapeutic and discourages communication.

What signs/symptoms would the nurse expect to assess in a client diagnosed with exocrine pancreatic cancer? 1. Dark tea colored urine 2. Clay colored stools 3. Jaundice 4. Coffee ground emesis 5. Lower abdominal pain

1., 2., & 3. Correct: Diseases of the head of the pancreas such as pancreatic cancer can lead to darkening of the urine, clay colored stools, and jaundice. All are the result of bile duct blockage. 4. Incorrect: Coffee ground emesis is a symptom of an ulcer that is bleeding. 5. Incorrect: Pain in the upper abdomen that radiates to your back is seen with pancreatic cancer. Lower abdominal pain can be associated with diseases such as diverticulitis.

A client has been admitted voluntarily to the psychiatric unit. During the admitting interview, the client confides to the nurse that they have a lethal plan for committing suicide. At the end of the interview the client asks the nurse, "How long will I have to stay here?" What should the nurse say to this client? 1. "Let's discuss this after the health team has assessed you." 2. "Since you signed papers to be admitted, you cannot leave until the primary healthcare provider discharges you." 3. "A lawyer will have to make that decision." 4. "You can leave when you are no longer suicidal."

1. Correct: A client may sign out of the hospital at any time, unless following a mental status examination the healthcare professional determines that the client may be harmful to self or others and recommends that the admission status be changed from voluntary to involuntary. 2. Incorrect: A client may sign out of the hospital at any time, unless following a mental status examination the healthcare professional determines that the client may be harmful to self or others and recommends that the admission status be changed from voluntary to involuntary. 3. Incorrect: Lawyers do not make that decision. This client was voluntarily admitted, not involuntary. Involuntary admission can be from three different commitment procedures: judicial, administrative and agency determination. Involuntary admission can be further categorized as emergency, observational/temporary or indeterminate/extended. 4. Incorrect: This is not the best response, since the client has told you of a plan. They might decide to tell you they have no plan when in fact they do.

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 to 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. Correct: Audiotapes made in the language of high volume clients who speak a language other than English is helpful to inform clients about admission procedures, room and unit orientation, and pre-surgical procedures. 2. Incorrect: This is not the best option. Some pre-surgical procedures may be difficult to draw or difficult to understand. 3. Incorrect: This is called "Getting by" and may have to be used when the nurse cannot speak the client's language, without interpreters, audiotapes, or written materials available to inform the client in their language. This is not the best option. 4. Incorrect: Disadvantages of using ad hoc interpreters include compromising the client's right to privacy and relying on someone without training as an interpreter. They may leave out important words, add words, or substitute terms that make communication inaccurate 1. Identify key words in the stem that set a priority, such as first, initially, best, priority, safest, most. These words modify what is being asked. This question requires you to put a value on each option and then place them in rank order. If you are having difficulty ranking the options, eliminate the option that you believe is most wrong among the options. 2. If age, sex, nationality are identified in the stem, it is important to the question and will generally direct you to an answer. Remember Erickson's stages of psychosocial development and growth and development.

Which action by the nurse administering intravenous ciprofloxacin would require intervention by the charge nurse? 1. Sets IV pump to administer ciprofloxacin over a period of 30 minutes. 2. Educates client that medication may cause dizziness. 3. Instructs client to notify nurse for any tendon pain. 4. Administers ciprofloxacin through 20 gauge catheter into the cephalic vein.

1. Correct: Cipro IV should be administered to by intravenous infusion over a period of 60 minutes. Slow infusion of a dilute solution into a larger vein will minimize client discomfort and reduce the risk of venous irritation. 2. Incorrect: This action does not require intervention by the charge nurse as dizziness is a side effect of this medication. 3. Incorrect: This is a correct action. Fluoroquinolones, including Cipro IV, are associated with an increased risk of tendinitis and tendon rupture in all ages. This adverse reaction most frequently involves the Achilles tendon, and rupture of the Achilles tendon may require surgical repair. Tendinitis and tendon rupture in the rotator cuff (the shoulder), the hand, the biceps, the thumb, and other tendon sites have also been reported. 4. Incorrect: Slow infusion of a dilute solution into a larger vein will minimize client discomfort and reduce the risk of venous irritation Identify key words in the stem that indicate negative polarity, such as not, except, never, contraindicated, unacceptable, avoid, unrelated, violate, least, further teaching needed. These words indicate negative polarity and the question being asked is looking for what is false.

The nurse is reviewing the immunization record of a 3 month old. Which immunization does the nurse expect the child to have received by this age? 1. First Hepatitis B vaccination. 2. Second diphtheria vaccination. 3. Third Hib vaccination. 4. Influenza vaccination.

1. Correct: In the US the first dose is recommended at birth. In Canada, the first dose is recommended between birth and two months. 2. Incorrect: In both the US and Canada, the first diphtheria vaccination is recommended at 2 months, and the second at 4 months. 3. Incorrect: In both the US and Canada, the first Hib vaccination is recommended at 2 months, the second at 4 months, and the third at 6 months. 4. Incorrect: In both the US and Canada, all healthy children ages 6 months and older should receive a yearly influenza vaccination.

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

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

In caring for a client exposed to radiation, the nurse knows that the type of damage due to radiation exposure depends on which factors? 1. Dose rate. 2. Organs exposed. 3. Type of tumor being treated. 4. Presence of metastatic disease. 5. Type of radiation.

1., 2. & 5. Correct: The extent of damage due to radiation exposure depends on the quantity of radiation delivered to the body, the dose rate, the organs exposed, the type of radiation, the duration of exposure, and the energy transfer from the radioactive wave or particle to the exposed tissue. 3. Incorrect: The type of tumor being treated is important to know, but this will not affect the type of damage the client receives from the radiation. 4. Incorrect: The client may be receiving radiation therapy for palliative treatment. Damage to the client due to the radiation exposure will not increase or decrease due to the metastatic disease.

Which action by a nurse requires intervention by the charge nurse? 1. The two-handed method is used to recap a needle. 2. A needleless system is used to give medication through an intravenous (IV). 3. A blunt cannula is used to withdraw medication from a vial. 4. An engineered sharp injury protective device is used to recap a used needle.

1. Correct: Needles should be recapped using a one hand scoop method to prevent accidental sticks. Two-handed method increases the risk that the nurse's non-dominant hand will be punctured with the needle. Think about it. You do not want the hand holding the cap to get close to the needle. What if you miss the needle and stick your hand. The best solution is to not recap at all. Place the needle in the sharps container at once. But if the sharps container is not close by then the one hand scoop method is appropriate. You are not exposing one hand to the needle. 2. Incorrect: This is a correct method to use. To prevent injury during injection administration or body fluid retrieval, use a one-handed scoop method, needleless system, blunt cannula for medication withdrawal from a vial, or an engineered sharp injury protective device whenever possible. 3. Incorrect: This is a correct method to use. To prevent injury during injection administration or body fluid retrieval, use a one-handed scoop method, needleless system, blunt cannula for medication withdrawal from a vial, or an engineered sharp injury protective device whenever possible. 4. Incorrect: This is a correct method to use. To prevent injury during injection administration or body fluid retrieval, use a one-handed scoop method, needleless system, blunt cannula for medication withdrawal from a vial, or an engineered sharp injury protective device whenever possible.

A client has been prescribed sodium polystyrene sulfonate 30 grams rectally every 6h times 2. Which laboratory value would indicate that the prescribed sodium polystyrene sulfonate has been effective? 1. Potassium 4.8 mEq/L (4.8 mmol/L) 2. Sodium 148 mEq/L (148 mmol/L) 3. Calcium 8.9 mg/dL (2.2207 mmol/L) 4. Magnesium 1.2 mEq (0.6 mmol/L)

1. Correct: Sodium polystyrene sulfonate's action is to reduce the serum potassium level. The normal range for potassium is 3.5 - 5.0 mEq/L (3.5 - 5.0 mmol/L). The potassium level is 4.8 mEq/L (4.8 mmol/L) which is within the normal range. The potassium level would indicate that the prescribed sodium polystyrene has been effective. 2. Incorrect: A side effect of sodium polystyrene sulfonate is sodium retention. The normal range for sodium is 135 - 145 mEq/L (135-145 mmol/L). The client's sodium level of 148 mEq/L (148 mmol/L) indicates sodium retention. This is not the desired outcome of sodium polystyrene sulfonate. 3. Incorrect: The normal range of calcium is 9.0-10.5 mg/dL (2.25 - 2.62 mmol/L). The calcium level of 8.9 mg/dL (2.2207 mmol/L) indicates hypocalcemia. This is a side effect of sodium polystyrene sulfonate. 4. Incorrect: The magnesium level of Magnesium 1.2 mEq (0.6 mmol/L) indicates hypomagnesemia. This is a side effect of sodium polystyrene sulfonate. The normal range of magnesium is 1.3-2.1 mEq/L (0.65-1.05 mmol/L)

The nurse assesses bruises on a child's face, the hands, and the feet. When questioned, the parents state their child is so clumsy. What action by the nurse demonstrates client advocacy? 1. The nurse reports the incident to the Child Protective Services. 2. The nurse notifies the parent's clergy. 3. The nurse reports the assessment to the primary healthcare provider. 4. The nurse speaks to the parents privately about any concerns

1. Correct: The action is appropriate. The nurse is serving as an advocate for the child who cannot advocate for self. Early identification of possible child treatment by the nurse is crucial. A pattern or combination of indicators should arouse suspicion and cells for further investigation. Incompatibility between the reported cause the injuries noted is the most important criterion to base decision to report suspected abuse. All states as well as the provinces in North America have laws that require child maltreatment or suspected child abuse to be reported. Therefore, the nurse has an obligation to report any suspicions of child maltreatment. An advocate pleads the cause of another person. In this case, the nurse pleads the cause of the child to help protect the child's human rights. 2. Incorrect: The nurse should not contact the parent's clergy without their permission. This would be a violation of HIPAA. 3. Incorrect: The nurse is acting in the caregiver role. Although client finding will be documented and reported to the primary healthcare provider, client advocacy would involve proper reporting to the appropriate child protection agency and authorities. 4. Incorrect: If abuse is occurring, the parents will usually deny it. If a child is old enough to talk, the history of the injuries may be reported if the child id separated from the parents for this discussion.

The community health nurse is planning to teach nutritional education to a group of adults attending a health fair. What tips about health eating should the nurse include? 1. Pay attention to fullness cues during meals. 2. Make one fourth of the plate fruits and vegetables. 3. Drink sweet tea rather than soft drinks with meals. 4. Eat foods low in dietary fiber. 5. Consume less than 30% of calories from saturated fatty acids. 6. Use a smaller plate for meals.

1., & 6. Correct: Pay attention to hunger and fullness cues before, during, and after meals. Use them to recognize when to eat and when you have had enough. Portion out foods before eating. A smaller plate will make the amount of food look larger. 2. Incorrect: Make half the plate fruits and vegetables. 3. Incorrect: Cut calories by drinking water or unsweetened beverages rather than drinks with sugar, such as soft drinks and sweet tea. 4. Incorrect: Diets should be high in fiber coming from fruits, vegetables, and whole grains. 5. Incorrect: Individuals should consume less than 10% of calories from saturated fatty acids (approximately 20 grams of saturated fat per day in a 2000 calorie diet) With Select All That Apply questions, look at each option as a true/false statement. Match what is being asked in the stem with the options. If the stem is asking for a true response, then the true options should be selected.

Which interventions should a nurse discuss with a client for primary prevention of skin cancer from exposure to ultraviolet light? 1. Use sunscreen when outdoors. 2. Stay in the shade when outdoors. 3. Wear wide brimmed hats when outdoors. 4. Examine skin every 3 months for changes. 5. Have an annual skin assessment by a dermatologist.

1., 2. & 3. Correct: According to the Task Force on Community Preventive Services, using sunscreen, staying in shaded areas, and wearing wide brimmed hats are effective interventions to prevent skin cancer. 4. Incorrect: Examine your whole body monthly for possible changes that may be precancerous or cancerous lesions. This would be considered secondary prevention. 5. Incorrect: Assessment by a dermatologist is not a primary prevention strategy. Early diagnosis is considered secondary prevention.

A client who has diabetes calls the nurse hot-line reporting shakiness, nervousness, and palpitations. Which questions would yield information that would help the nurse decide that this is a hypoglycemic episode? 1. What have you eaten today and at what times? 2. Are you using insulin as a treatment of diabetes, and if so, what kind? 3. Do you feel hungry? 4. Do you have access to a glucose monitor to check your current glucose level? 5. Does your skin feel hot and dry?

1., 2., 3. & 4. Correct. This question will give the nurse information about how much time has elapsed since the last meal and will indicate the amount of protein and carbohydrates consumed at the last meal. Even a minor delay in meal times may result in hypoglycemia. Insulin type will give the nurse information about duration of action and peak time. Hunger is a symptom of hypoglycemia.If the client has a glucose monitor, an accurate reading would give the nurse valuable information about how much food the client should consume now. 5. Incorrect. Hot and dry skin is not an indicator of hypoglycemia and would not help the nurse determine if the client is experiencing a hypoglycemic episode. Cool, clammy skin is a symptom of hypoglycemia.

Which independent nursing actions should the nurse initiate for a client admitted with heart failure? 1. Monitor for distended neck veins 2. Measure abdominal girth 3. Evaluate urine output from diuretic therapy 4. Educate client regarding signs and symptoms of heart failure 5. Administer medications as prescribed

1., 2., 3., & 4. Correct: An independent nursing intervention is one that an RN can prescribe, perform, or delegate based on their skills/knowledge. A collaborative intervention is one that is carried out in collaboration with other health team members (physical therapist, healthcare provider). Dependent nursing intervention is one prescribed by a healthcare provider but carried out by the nurse. These actions do not require an order by a healthcare provider nor collaboration with another. They are independent nursing functions. 5. Incorrect: Administering prescribed medications is a dependent nursing intervention and cannot be initiated without an order being in place. This is the only option that is dependent on the primary healthcare provider's actions first before the nurse can initiate it.

Which interventions would the nurse initiate to lessen acid reflux in a client diagnosed with gastric esophageal reflux disease (GERD)? 1. Provide small, frequent meals. 2. Avoid carbonated beverages. 3. Administer omeprazole as prescribed. 4. Assist with smoking cessation. 5. Place in right lateral position after eating.

1., 2., 3., & 4. Correct: Gastroesophageal reflux disease is a disorder that results from stomach acid moving backward from the stomach into the esophagus. GERD usually happens because the lower esophageal sphincter (LES) — the muscular valve where the esophagus joins the stomach — opens at the wrong time or does not close properly. All of these actions are correct to help alleviate GERD. 5. Incorrect: It is best for the client to sit upright for 3 hours after a meal and to not eat 2 to 3 hours before going to bed.

The client diagnosed with active tuberculosis has been prescribed isoniazid 300 mg by mouth every day. What should the nurse teach this client? 1. "Notify your healthcare provider if your urine turns dark." 2. "Your healthcare provider has prescribed B6 along with the isoniazid to prevent neuritis." 3. "You should avoid eating aged cheeses and smoked fish." 4. "Eat foods such as tuna twice a week." 5. "Rise slowly from lying to sitting, or sitting to standing."

1., 2., 3., & 5 Correct: Signs of hepatotoxicity from this medication include dark urine, jaundice, and clay-colored stool. Isoniazide- induced pyridoxine (Vitamin B6) depletion causes neurotoxic effects. Vitamin B6 supplementation of 10-50 mg usually accompanies isoniazid use. Aged cheeses and smoked fish are high in tyramine which may cause palpitations, flushing, and blood pressure elevation while taking isoniazid. Avoid these foods during treatment. Isoniazid should be taken on an empty stomach, one hour before or two hours after food. Some clients experience orthostatic hypotension while taking isoniazid, so caution against rapid positional changes. 4. Incorrect: Histamine containing foods such as tuna and yeast extracts may cause exaggerated drug response (H/A, hypotension, palpitations sweating, itching, flushing, diarrhea).

The nurse is caring for a client who has hypercholesterolemia. When evaluating the effects of atorvastatin, the nurse should monitor the results of which laboratory tests? 1. AST 2. Alkaline phophatase 3. Complete blood count 4. Serum cholesterol levels 5. Serum triglyceride levels

1., 2., 4. & 5. Correct: AST is a liver function test. Liver function tests including AST should be monitored before, at 12 weeks after initiation of therapy or after dose elevation, and then every 6 months. If AST levels increase to 3 times normal, atorvastatin should be reduced or discontinued. Atorvastatin may increase alkaline phosphatase and bilirubin levels. Atorvastatin is a lipid-lowering agent/HMG-CoA reductase inhibitor. The expected outcome of treatment with atorvastatin is lower serum cholesterol and triglycerides. 3. Incorrect: The CBC results would not be used to evaluate the effectiveness of treatment with atorvastatin. The CBC is used to evaluate your overall health and can be used to measure components and features of your blood such as RBC'c, WBC's, Hgb, Hct and platelets.

A nurse is caring for a client diagnosed with the ebola virus who is experiencing vomiting and diarrhea. What personal protective equipment should be worn by the nurse while providing care to this client? 1. Single use impermeable gown 2. Powered Air Purifying Respirator (PAPR) or N95 respirator 3. One pair of sterile gloves 4. Single use boot covers 5. Single use apron

1., 2., 4., & 5. Correct: The nurse should wear a single use (disposable) impermeable gown OR a single use impermeable coverall. Either a PAPR or a disposable, NIOSH-certified N95 respirator should be worn to reduce the risk of contamination in the case of an emergency situation where a potentially aerosol-generating procedure would be performed. The PAPR reduces the risk of self-contamination while providing client care, but the N95 respirator is less bulky. If the N95 respirator is selected for use, nurses should be extremely careful to make sure that they do not accidentally touch their faces under the face shield during client care. Disposable boot covers should be worn and should extend to at least mid-calf. Some agencies may add the single use shoe covers over the boot covers to reduce the risk of contaminating the underlying shoes. If clients with Ebola are vomiting or have diarrhea, a single use (disposable) apron should be worn over the gown to cover the torso to mid-calf. This will provide additional protection to reduce the risk of contaminating the gown (or coveralls) by the infectious body fluids and also provides a way to rapidly remove a soiled outer layer if contamination occurs on the apron. 3. Incorrect: Sterile gloves are not required, but two pairs, instead of one pair, of gloves should be worn so that a contaminated outer glove can be safely removed when providing client care or safely removed without self-contamination when removing the PPE. These gloves should at the very least have extended cuffs.

Which manifestations, if noted in a pregnant client, would the nurse need to report to the primary healthcare provider? 1. Calf muscle irritability 2. Facial edema 3. Pressure on the bladder 4. Blurry vision 5. Hemoglobin of 11 mg/dL 6. Epigastric pain

1., 2., 4., & 6. Correct: These are danger signs/symptoms of pregnancy and need further investigation by the primary HCP. These signs could indicate preeclampsia, fluid and electrolyte disturbances, and other high risk complications during pregnancy. 3. Incorrect: As the baby gets bigger, it pushes on the bladder, causing pressure, so this is an expected symptom in pregnancy. 5. Incorrect: This is normal for the pregnant client and within the normal range for the female client.

A client who is at high risk for developing a stroke has been advised to follow a Mediterranean type diet by the primary healthcare provider. Which food choices, if selected by the client, would indicate to the nurse that the client understands this diet. 1. Grilled eggplant 2. Purple grape juice 3. Bacon 4. Cashews 5. Skim milk 6. Salmon

1., 2., 4., 5., & 6. Correct: It is reasonable to counsel clients to follow a Mediterranean-type diet over a low-fat diet. The Mediterranean type diet emphasizes vegetables, fruits, and whole grains and includes low fat dairy products, poultry, fish, legumes, and nuts. It limits intake of sweets and red meats. 3. Incorrect: Substitute fish and poultry for red meat. When eaten, make sure it's lean and keep portions small (about the size of a deck of cards). Also avoid sausage, bacon and other high-fat meats.

Following vaginal birth, a neonate has a large area of diffuse swelling over the left occiput that crosses the sagittal suture line. When discussing this finding with the neonate's parents, which statements by a nurse are accurate? 1. "No treatment will be required to resolve swelling." 2. "Due to the swelling, bleeding may occur under the scalp." 3. "The swelling overlies the periosteum that covers the skull bone." 4. "Pressure on the fetal head before delivery caused the swelling." 5. "Your infant has a collection of blood under the skull bone."

1., 3. & 4. Correct: Swelling over the left occiput that crosses the sagittal suture (caput succedaneum) requires no treatment, is swelling that overlies the periosteum, and is caused by pressure on the fetal head before delivery. 2. Incorrect: Caput succedaneum is a collection of serosanguineous fluid, not blood. Cephalohematoma refers to bleeding under the scalp. 5. Incorrect: Caput succedaneum is a collection of serosanguineous fluid, not blood

A client admitted to ICU has a prescription for an arterial line insertion to the right radial artery. What assessment findings by the nurse would be of concern? 1. Right sided mastectomy 2. Inability to abduct fingers of right hand 3. Negative Allen's test 4. Radial pulse 3+/4+ 5. Presence of A-V shunt to right forearm

1., 3. & 5. Correct: Right sided mastectomy would be a contraindication. A negative Allen's test means that the ulnar artery is not patent enough to supply blood to the hand. An A-V shunt would be a contraindication. 2. Incorrect: This assesses peripheral nerve function which is used for musculoskeletal assessment. The nurse needs to check the circulatory system. 4. Incorrect: Normal finding. This would not cause the nurse to be concerned.

What should the nurse check when assessing a client's balance? 1. Walking on tiptoes 2. Babinski reflex 3. Romberg test 4. Muscle strength of legs 5. Dorsalis pedis pulses

1., 3., & 4. Correct: Asking the client to walk on the tips of the toes assesses foot strength and balance. Muscle strength is needed to maintain balance and a Romberg's test asks the client to stand erect with arms at their side and feet together. The nurse notes any sway or unsteadiness. Then the client does the same thing with their eyes closed for 20 seconds again noting imbalance and sway. A positive Romberg is seen with swaying and moving feet apart to prevent a fall. It indicates a problem with balance. 2. Incorrect: Babinski sign is an important neurologic examination based upon what the big toe does when the sole of the foot is stimulated. If the big toe goes up, that may mean trouble with the central nervous system. This is not part of assessment for balance 5. Incorrect: Assessing the dorsalis pedis pulse is done as part of a circulatory check not while assessing balance.

The nurse is caring for a client diagnosed with dementia. Which task can the nurse assign to the unlicensed assistive personnel (UAP)? 1. Assist the client with toileting. 2. Inform family that the client needs a Computed Tomography (CT) scan. 3. Accompany the client while walking in the hall. 4. Reorient the client frequently. 5. Apply restraint belt for client safety.

1., 3., & 4. Correct: The UAP can provide assistance with routine activities of daily living, which includes toileting. The UAP can also walk with a client in the hallway. There is no mention that the client is having difficulty with ambulation, so there is no reason why the UAP cannot walk with the client. Orienting the client frequently can be done by all staff encountering the client. 2. Incorrect: Informing the client or family of procedures is not within the scope of practice for the UAP. 5. Incorrect: Restraints need to be put on properly, insuring that they are not applied too tightly. This is not within the scope of practice for the UAP.

What medications should the nurse anticipate the primary healthcare provider prescribing for the client with portal hypertension and bleeding esophageal varices associated with advanced cirrhosis? 1. Oxygen 2. Clopidogrel 3. Propranolol 4. Vitamin K 5. Lactulose

1., 3., 4., & 5. Correct: We know that they need oxygen because they may have been bleeding. Propranolol acts to reduce portal venous pressure and reduce esophageal varices bleeding. Vitamin K is a clotting factor and helps to correct clotting abnormalities because of the damaged liver. Lactulose decreases what? Ammonia, which is elevated with cirrhosis. 2. Incorrect: You don't want to give them a platelet aggregation inhibitor. They are already bleeding.

What nursing interventions should the nurse include when planning care for a client admitted with Guillain-Barre' Syndrome? 1. Monitor for contractures. 2. Place prone for 30 minutes, 4 times per day. 3. Provide therapeutic massage for pain relief. 4. Teach range of motion exercises. 5. Provide high protein meals 3 times a day. 6. Refer to physical therapist

1., 3., 4., & 6. Correct: This client will have progressive weakness and paralysis. Contractures and pressure ulcers need to be prevented through ROM exercises and frequent turning. Muscle spasms and pain can be relieved by therapeutic massage, imagery, diversion, and pain medication. 2. Incorrect: The client will need to be repositioned every 2 hours to prevent pressure sores and pneumonia and atelectasis. Elevate the head of the bed to help with lung expansion. Prone will interfere with lung expansion ability. 5. Incorrect: Encourage small, but frequent meals that are both well-balanced and nourishing

The nurse is teaching a client who is at risk for developing a stroke. What primary prevention strategies should the nurse include? 1. Promote a diet rich in fruits and vegetables. 2. Provide instruction on benefits of carotid endarterectomy. 3. Limit sodium intake to 2 grams/day. 4. Engage in low intensity exercise once a week. 5. Avoid tobacco products. 6. Decrease alcohol consumption to two drinks per day.

1., 3., 5., & 6. Correct: These strategies are considered primary prevention strategies that can decrease the risk of developing a stroke. 2. Incorrect: This would be considered secondary prevention: early diagnosis and treatment to prevent stroke. 4. Incorrect: The client needs 3-4 sessions per week of moderate-vigorous intensity aerobic physical exercise to reduce stroke risk factors. Session should last an average of 40 minutes. Moderate intensity exercise is typically defined as sufficient to break a sweat or noticeably raise heart rate (e.g. walking briskly, using an exercise bicycle). Vigorous intensity exercise includes activities such as jogging.

A home care nurse is making an initial visit to an elderly client recently discharged following hip surgery. When evaluating the home environment, what environmental hazard is most concerning to the nurse? 1. Lamp plugged into extension cord. 2. Throw rugs on kitchen tile floor. 3. Gas fireplace in the living room. 4. Non-working wall socket in hall.

2. CORRECT: It is quite common to find throw rugs, or "scatter rugs" in homes to protect carpets and absorb moisture or dirt. However, throw rugs are a common hazard, posing the potential for tripping or catching on wheels. In this situation, a tile floor is generally smooth, making it even more likely to slip on the rugs. 1. INCORRECT: An extension cord, by itself, is not a problem. If the cord was placed under carpeting, it could be a fire hazard. Also, if the cord was too short and hung suspended in air the client could trip. However, just using an extension cord does not present a problem. 3. INCORRECT: Many homes use a gas fireplace which is actually safer than wood burning. The presence of a gas fireplace does not create an immediate danger. 4. INCORRECT: A non-working wall socket does not present any danger to the client. If the socket were sparking, there would be cause for concern. But there are many reasons for a socket not to work, and without any information, the nurse cannot consider this a danger.

A client receiving chemotherapy for lung cancer reports increased fatigue. The family confirms client is sleeping most of the day and night. What priority action would the nurse take? 1. Discuss the risks of immobility with client and family. 2. Check current lab values of hematocrit and hemoglobin. 3. Suggest family seek counseling for the client's depression. 4. Request a referral from the healthcare provider for physical therapy.

2. CORRECT: The side effects of chemotherapy can impact all body systems, including the blood and circulatory system. The nursing process requires the nurse to first assess and gather data before proceeding with a plan. Though fatigue in cancer clients can have many causes, the nurse should check current laboratory results for decreased RBCs, hematocrit or hemoglobin caused by chemotherapy. Decreased levels of these elements are a side effect of chemotherapy and could definitely contribute to fatigue or exhaustion. 1. INCORRECT: While the nurse may want to discuss many topics with client or family, effects of immobility does not address the present issue of exhaustion or fatigue. The nursing process always begins with collection of data. 3. INCORRECT: Individuals respond to a terminal disease in different ways but certainly depression is common. Though a possible symptom of depression can be constantly sleeping, the nurse has not collected evidence to support that assumption. Potential physical causes for behavioral changes must be eliminated first. 4. INCORRECT: This action is premature since the nurse has not completed an assessment or collected data. While physical therapy may help to strengthen the client, an exact cause for the fatigue must first be established.

A client who is gravida 2 para 1 is visiting the obstetric clinic for a checkup. The first delivery was a cesarean for failure to progress, and the client indicates a desire for a vaginal delivery this time. The nurse knows the most important factor in determining the possibility of a vaginal birth after cesarean (VBAC) is what? 1. The length and difficulty of the previous labor. 2. The type of incision used for the cesarean. 3. The position of the fetus before delivery. 4. Total number of pregnancies desired.

2. Correct: A VBAC is often requested by a client for a number of reasons. There is less pain after delivery with a shorter recovery period and less chance of infection. A VBAC can also potentially increase the number of pregnancies possible, since cesarean sections dramatically limit the number of children. The main factor that determines whether the client could safely have a VBAC is the type of uterine incision made for the previous C-section. Those who have had a low, transverse incision are candidates for trial of labor after cesarean (TOLAC). 1. Incorrect: Obviously, in this situation, the client had experienced failure to progress in the previous pregnancy, necessitating the need for a C-section. The length and difficulty of the previously attempted birth would have affected the decision to have the first C-section, but would not impact the current choice to attempt a VBAC. 3. Incorrect: The position of the fetus prior to delivery does not have a significant bearing on the decision to have a VBAC. Clients who intend to try a vaginal birth are very closely monitored prior to labor. If the obstetrician determines by ultrasound that the fetus is incorrectly positioned, there is the possibility of "turning" the fetus prior to the onset of labor. Only in extreme circumstances would the fetal position prevent vaginal birth. 4. Incorrect: The factor that is most important in determining the chance for a VBAC is not the number of pregnancies desired, but rather the position of the uterine incision made with the last C-section. The ability to actually have a successful VBAC may affect the total number of children desired.

A client with hemophilia has been scheduled for extraction of wisdom teeth. The nurse anticipates that the client will receive what priority intervention before this procedure? 1. Prophylactic antibiotics 2. A unit of cryoprecipitate 3. Packed red blood cells 4. Fresh frozen plasma

2. Correct: Hemophilia is a heredity disease characterized by a deficiency of specific clotting factors, including Factor VIII, Factor XIII, and fibrinogen. Clients with hemophilia are given cryoprecipitate prophylactically prior to invasive procedures to replace these deficient factors and prevent hemorrhaging. 1. Incorrect: The priority concern is the potential for bleeding during the procedure. Although infection is always a concern and antibiotics may be considered, it is not the main issue for this client. 3. Incorrect: Packed red blood cells (PRBC's) mean the liquid portion of the blood has been removed so only the cells are infused. PRBC 's are generally administered in the face of severe hemorrhaging or very low hemoglobin and hematocrit. Bleeding is the main concern for this client, but packed red blood cells would not be the correct intervention prior to the procedure. 4. Incorrect: Although hemophilia affects the blood's coagulation ability, fresh frozen plasma (FFP) is not the correct intervention. FFP is generally used in situations such as massive hemorrhaging, severe anemia, cardiac bypass, or DIC. Another prophylactic intervention would be considered priority for the hemophilia client.

The nurse is caring for a client taking lithium. Which comment by the client indicates lack of understanding of the therapeutic regimen? 1. "I must keep my sodium intake steady over time. " 2. "If I miss a dose of lithium, I should make it up with the next dose." 3. "I must check with my primary healthcare provider before changing my diet for weight loss." 4. "I must keep my exercise routine the same or discuss with my primary healthcare provider. "

2. Correct: If a client misses a dose of lithium, the client should take the next dose as prescribed without doubling it. If the client adds the missed dose, toxicity may occur. If sodium intake is reduced or the body is depleted of its normal sodium (due to sweating, fever, diuresis), lithium is reabsorbed by the kidneys, increasing the possibility of toxicity. 1. Incorrect: This comment indicates understanding. The client should keep sodium levels the same over time as lithium and sodium are both excreted by the kidney. 3. Incorrect: This comment indicates understanding. Food intake should remain constant. Therapeutic levels should be monitored closely while the client is losing weight. Sodium reduction can lead to lithium reabsorption in the body causing toxicity. 4. Incorrect: This comment indicates that the client does understand the treatment regimen. Any changes that would change the concentration of the drug in the bloodstream should be discussed with the primary healthcare provider. Activities that cause excess sodium loss, such as heavy exertion, exercise in hot weather, or saunas should be avoided.

What is the primary electrolyte that the nurse should be aware to monitor for in a client who is receiving an insulin infusion? 1. Sodium 2. Potassium 3. Calcium 4. Phosphorus

2. Correct: Insulin causes movement of potassium into the cells, which can lead to a severe reduction in serum potassium if not regulated appropriately. A severe decrease in serum potassium could be fatal. 1. Incorrect: Although insulin has been shown to increase sodium reabsorption in the kidneys, the change is not as rapid and not as life threatening as the change in potassium can be. 3. Incorrect: A significant change in the calcium level is not anticipated with the insulin infusion. 4. Incorrect: A significant change in the phosphorous level is not anticipated with the insulin infusion.

The nursing staff have not been able to control the outbursts of a violent adult client. The primary healthcare provider prescribes physical restraints to be applied for the next 8 hours. What is the nurse's best action? 1. Apply the restraints for the 8 hours, with a trial release every 2 hours. 2. Explain to the primary healthcare provider that the prescription will have to be reissued in 4 hours. 3. Refuse to place the client in restraints unless the primary healthcare provider gets a permit signed from the family. 4. Apply the restraints, and observe the client hourly.

2. Correct: Orders for restraints or seclusion must be reissued by a primary healthcare provider every 4 hours for adults age 18 and older, every 2 hours for children and adolescents ages 9-17, and every hour for children less than 9 years. 1. Incorrect: Orders for restraints or seclusion must be reissued by a primary healthcare provider every 4 hours for adults age 18 and older, every 2 hours for children and adolescents ages 9-17, and every hour for children less than 9 years. 3. Incorrect: A permit is not needed if the client is a risk to self or others. The primary healthcare provider must write a prescription for restraints. 4. Incorrect: Clients in restraints or seclusion must be observed and assessed every 10-15 minutes with regard to circulation, respiration, nutrition, hydration, and elimination.

When caring for a client on extended bedrest, which intervention should the nurse implement to decrease the risk of contractures? 1. Use a large pillow to support the head and shoulders. 2. Properly reposition every 2 hours. 3. Use a knee gatch to place knees at a 30 degree angle. 4. Place a trochanter roll along the inner aspect of each thigh.

2. Correct: Properly repositioning every 2 hours is the best way to prevent contracture. 1. Incorrect: A small rather than large pillow should be used to prevent neck flexion contracture. A small pillow should be used under their head and shoulders. 3. Incorrect: Avoid the use of knee gatch and pillows under the knees for extended times to avoid knee contractures. Knee gatch can be used but the position will need to be changed every 2 hours. 4. Incorrect: A trochanter roll is used on the outside of the thigh to prevent external rotation of the hips. This technique will not prevent contractures.

The parents of a child admitted with rheumatic fever (RF) ask why the child has been placed on bedrest. The nurse explains that bedrest serves what primary purpose for the client? 1. Prevents permanent joint damage. 2. Decreases workload on the heart. 3. Helps regulate body temperature. 4. Reduces joint pain and body aches

2. Correct: Rheumatic fever is a secondary, infectious process that occurs several weeks after an unresolved streptococcal infection, such as strep throat. The Group A beta-hemolytic strep can cause inflammation in the myocardium or epicardium, ultimately affecting the valves of the heart, particularly the mitral valve. The resulting thickening and fibrosis leads to cardiac stenosis which could lead to heart failure. During this illness, decreasing the workload on the heart is vital to help prevent cardiac complications. 1. Incorrect: Rheumatic fever causes increased body temperature, muscle aches and swollen painful joints, particularly knees, ankles and wrists. Although clients may need ibuprophen for pain and swelling, there is no permanent damage to the joints. Bedrest serves another purpose for this client. 3. Incorrect: It is true that these clients can run a high fever at times and even develop a red rash over the torso. However, the purpose of bedrest is not related to controlling body temperature. 4. Incorrect: It may seem logical that bedrest would decrease joint pain and body aches, but this is not the primary purpose for bedrest

A client has been trying to implement a low fat diet for prevention of heart disease and enhancement of weight loss. He further reports that his wife shows her love by preparing rich foods and pastries. Which action should the nurse make? 1. Suggest that the client prepare all meals at home. 2. Schedule a meeting with husband and wife to discuss diet and health. 3. Suggest that the client limit intake to one serving of each food at meals. 4. Ask the client to give his wife a cookbook with low fat recipes

2. Correct: The meeting with the wife and husband together may help to gain the support of the wife. She may not realize that meal preparation is actually serving as a barrier to successful change. Also, the importance of the opinions and behaviors of the wife are important to the client as he tries to engage in long-term behavioral change. 1. Incorrect: This intervention may actually increase barriers to change because the wife's feeling and support are necessary to maintain long-term change. 3. Incorrect: While this practice may reduce the intake of fat, the issue of spousal support should be addressed. 4. Incorrect: Open discussion with the wife about the need for low-fat meals is essential. Identify specific determiners in options. These convey a thought or concept that has no exceptions. Words such as just, always, never, all, every, none, and only are absolute and place limits on the statement that generally is considered correct. Statements including these words generally make the statement false as the statement is general and broad and does not allow for exceptions. Option 1 states "the client prepare ALL meals". This does not allow for exceptions, so it is not correct. When two possible options contain the same directive word, in this case "suggest", the test taker can either rule out these two as incorrect, or prioritize between the two responses. In this case neither answer is appropriate. Eating one serving of rich foods and pastries daily will not help the client achieve the set goal. Whenever a client problem is identified, nursing interventions must address the specific problem. How does giving the wife a cookbook on low fat food help the problem? It doesn't since the wife shows "her love" by cooking the foods she does. The problem is that since the wife does the cooking, a meeting with the couple regarding diet and health would be a way to educate both of them and get buy-in from the wife.

The client with ulcerative colitis calls the clinic and reports increasing abdominal pain and increased frequency of loose stools. The client asks the nurse to clarify foods that can be eaten with ulcerative colitis. What foods should the nurse suggest? 1. Dried beans 2. Fish 3. Apples 4. Yogurt 5. Scrambled eggs

2., & 5. Correct: Fish and scrambled eggs are both high in protein and low in fiber. Foods high in fiber are irritating to the GI tract and should be avoided. A food diary is needed to determine triggers for flare-ups. 1. Incorrect: Fiber in the beans will increase motility. 3. Incorrect: Fiber in apple will increase motility. 4. Incorrect: Dairy products should be avoided in times of flare-ups as dairy is often a cause of flare ups.

The parents of a 2 year old child, diagnosed with autism spectrum disorder (ASD), ask the nurse what led the primary healthcare provider to diagnose this disorder for their child. What behaviors will the nurse indicate as signs of ASD? 1. Delusions 2. Twisting 3. Preoccupation with objects 4. Delayed speech 5. Changes are easily tolerated.

2., 3. & 4. Correct: All are behaviors seen in children with ASD. Additionally, they often do not form interpersonal relationships with others or play well with others. They are usually not socially responsive with eye contact and facial expressions. The language characteristics may be delayed, totally absent, echolalia, unusual vocalizations, immature grammatical structures or idiosyncratic words. Their motor behaviors may include poor coordination, tiptoe walking, peculiar hand movements such as flapping and clapping and stereotypical body movements of rocking, dipping, swaying or spinning. 1. Incorrect: Delusions and hallucinations are not characteristic of ASD. These are seen more in the adult. 5. Incorrect: Changes are met with resistance with ASD. Changes in daily routines or in the child's environment can cause catastrophic reactions. With Select All That Apply questions, look at each option as a true/false statement. Match what is being asked in the stem with the options. If the stem is asking for a true response, then the true options should be selected. The nurse must know the signs and symptoms of ASD to be able to answer each option as a true/false statement.

What assessment findings would the nurse expect when evaluating whether treatment has been effective for a client hospitalized with systolic heart failure? 1. 3+ pedal edema 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 4. Purse-lip breathing 5. Pale nail beds 6. Urine output at 50 mL/hr

2., 3. & 6. Correct: Normal CVP is 2-6 mm Hg. This CVP is within normal range so treatment is effective. Weight loss indicates that fluid is being removed and a urine output of 50mL/hour indicates that renal perfusion is adequate. All three assessents indicate improvement. 1. Incorrect: 3+ pedal edema would indicate that the client is not better. 4. Incorrect: Purse-lip breathing is seen when client is still short of breath. 5. Incorrect: Pale conjuctiva, nail beds, buccal mucosa are signs of impaired gas exchange.

Which assignment by the charge nurse would be most appropriate for a general pediatric nurse being reassigned to the hematology/oncology pediatric unit? 1. Child dying with leukemia who has been on the hematology/oncology unit for two weeks. 2. Teenager with sickle cell disease in for pain management. 3. Child admitted following a bicycle accident that has idiopathic thrombocytopenic purpura (ITP). 4. New admit scheduled for bone marrow transplant. 5. Child diagnosed with leukemia admitted for stomatitis.

2., 3., & 5. Correct: The nurse should be given an assignment similar to the type of clients and skill level the nurse is accustomed to on the general pediatric unit. Therefore, the choices should be these three clients. Even though one of the clients has leukemia, the child is being treated for stomatitis, not the leukemia. Sickle cell clients are frequently cared for on general pediatric units. The reassigned nurse has the knowledge and skills needed to meet the clients needs for pain management and treatment for the sickle cell disease. The general pediatric nurse should be competent in caring for children with low platelet counts, so the child with ITP could be assigned to this nurse. The nurse would be familiar with bleeding precautions, monitoring for bleeding, and associated care. 1. Incorrect: This client is dying with leukemia and needs consistency in the staff assigned to care for them. Although the general pediatric nurse could competently care for a dying child, the focus should be on the client. This child needs and deserves consistent care and care by those that are familiar to this child. 4. Incorrect: A child who is to receive a bone marrow transplant would not be the best assignment, since the nurse must have special preparation and an understanding of the protocol with a bone marrow transplant client. This is not something that a general pediatric nurse would typically do. Therefore, this client would need to be cared for by the nurses on the hematology/oncology unit who has this special training and/or knowledge. Identify client-centered options. The focus of the nurse should be the client. Items that test your ability to be client-centered tend to explore client feelings, identify client preferences, empower the client, provide the client choices, or in some way put emphasis on the client. The client is the priority. The key to this question is the fact that, although the nurse is an experienced general pediatric nurse, the nurse is not experienced in hematology/oncology nursing. The client who could receive a treatment on a general pediatric unit should be assigned to the nurse.

What teaching points would the nurse include when educating a client how to prevent a venous stasis ulcer? 1. Dangle legs for 30 minutes, three times a day. 2. Perform leg exercises regularly. 3. Wear graduated compression stockings. 4. Avoid crossing the legs. 5. Minimize stationary standing.

2., 3., 4., & 5. Correct: Regular leg exercises improve calf muscle function. Wearing graduated compression stockings will help prevent dilation of lower extremity veins, pain, and a heavy sensation in the legs. Crossing of the legs causes venous obstruction that can lead to stasis. Minimize stationary standing as much as possible to decrease pooling of blood in the lower extremities. 1. Incorrect: Elevating legs above the heart for 30 minutes, three times a day will minimize edema and reduce intra-abdominal pressure.

What electrolyte imbalance should the nurse monitor for when caring for a client diagnosed with chronic alcoholism? 1. Hypochloremia 2. Hypokalemia 3. Hypophosphatemia 4. Hypomagnesemia 5. Hypocalcemia

2., 3., 4., & 5. Correct: The number one way of getting rid of potassium is through the kidneys. What does alcohol make you do? Diuresis. Acute hypophosphatemia is seen in up to 50% of patients over the first 2-3 days after they are hospitalized for alcohol overuse. Hypophosphatemia is manifested as rhabdomyolysis (muscle breakdown) and weakness of the skeletal muscles. Magnesium deficiency occurs due to that increase in diuresis as well. Hypomagnesemia is often accompanied by hypocalcemia, or lowered calcium levels, which may be aggravated by a deficiency of vitamin D. 1. Incorrect: Hypochloremia is usually caused by excess use of loop diuretics, nasogastric suction, vomiting or diarrhea due to small bowel abnormalities, and loss of fluids through the skin occurring because of trauma such as burns.

What signs/symptoms would the nurse expect to assess in a client diagnosed with pernicious anemia? 1. Pain 2. Smooth, red tongue 3. Burning feeling in feet 4. Lightheadedness 5. Dyspnea on exertion

2., 3., 4., & 5. Pernicious anemia symptoms could include a smooth tongue that is red in color rather than a healthy pink. And neurological problems such as a burning feeling in the feet, slow reflexes, and disorientation. Light headedness, dyspnea on exertion, fatigue, and breathlessness are anemia symptoms that clients often report. 1. Incorrect. Pain is a symptom seen in sickle cell anemia.

What assessments would be appropriate for the school nurse to perform related to school safety practices and emergency preparedness? 1. Teach about gun control laws. 2. Observe for gaps or changes in levels of sidewalks. 3. Identify which students have special healthcare needs. 4. Locate all entrances and exits to buildings. 5. Identify threats and hazards in the school and surrounding community. 6. Perform a check of all fire extinguishers.

2., 3., 4., 5., & 6. Correct: One of the first things that a school nurse should do is to assess where an accident might happen. Observing for gaps or changes in the level of sidewalks is an example of this assessment. The school nurse should assess for special healthcare needs in the event that the school enters a time of extended lockdown. Some students would require attention during the time of lockdown, such as diabetics who could not wait to receive insulin or have food available. All entrances to the schools must be identified to know where a potential entry for intruder might could occur. Some access points may need to be changed to reduce risk to students. Becoming familiar with all exits is crucial to planning timely and safe evacuation of students if needed. The school nurse can draw upon a wealth of information that exists regarding threats or events that have occurred in the past at the school or in the local community in order to plan for possible future events. Fire extinguishers should be checked on a regular schedule for assessment of access, date of expiration, and functionality. 1. Incorrect: Teaching about laws on gun control is not an assessment, but rather an intervention that can be done. Teaching is not the initial step of the nursing process. Assessment comes first.

The nurse is caring for a client who has aphasia. What interventions should the nurse include in the plan of care to improve communication with this client? 1. Increase speaking volume and tone. 2. Present one thought at a time. 3. Use and encourage use of gestures. 4. Do not push communication if client is tired. 5. Give client time to generate a response. 6. Ask questions that can be answered with "Yes" or "No".

2., 3., 4., 5., & 6. Correct: These interventions will help to improve communication. Don't overwhelm the client with multiple thoughts or pushing communication on a tired or anxious client. Gestures such as pointing to something or asking the client to point to what they want will help to increase communication. Using a communication board for the client to point to commonly needed things is helpful. Give extra time to comprehend and respond to communication. Keep questions easy to answer and communication simple. 1. Incorrect: Don't yell at the client. The problem is not inability to hear. Asphasia is loss of ability to understand or express speech caused by brain injury.

An elderly client diagnosed with Stage 4 cancer is anxiously awaiting the primary healthcare provider to discuss possible care options. What is the appropriate way for the nurse to assist the client? 1. Assure the client that the healthcare provider will present all the best options. 2. Assist client to make list of questions to ask prior to the discussion. 3. Offer to remain with the client during healthcare provider's visit. 4. Suggest the presence of a family member could be helpful to client. 5. Provide written information to client about cancer treatments.

2., 3., and 4. CORRECT: Consider this client has been diagnosed with Stage 4 cancer. The thought of cancer can quickly overwhelm a client, making it difficult to hear and focus on information. It will be very helpful for the nurse to assist the client to create a list of questions which may otherwise be forgotten when the primary healthcare provider arrives. It will also be useful to have the nurse present during the discussion since the client may need some clarification after the fact. Though there is no indication the client has family, it would be beneficial if the client would allow family to be present during the discussion. The emotional support is often extremely positive to help the client cope with the information. 1. INCORRECT: This false reassurance does not provide any details that may be helpful for client. Also, the nurse is assuming the healthcare provider is aware of all possible cancer treatments that exist. 5. INCORRECT: While some clients benefit from written information, handing brochures to an anxious client is not one of the most appropriate ways to assist the client. The nurse is not focusing directly on the client's emotional needs at this point.

The nursing supervisor is reviewing several instances in which restraints have been used. The nurse is aware the only acceptable use of restraints is what? 1. An elderly male had a chest restraint applied after crawling over bed rails several times. 2. An Alzheimer client's room door is closed to prevent wandering during shift change. 3. A confused client with a closed head injury had hand mitts applied after pulling out IV 4. A dementia client with sundowners is placed in Geri-chair with lap belt at nurse's station.

3. CORRECT: Restraints are considered a last resort when caring for a client, whether soft cloth or chemical restraints. The most acceptable use is to prevent a client from harming self or others. In this instance, a confused client has previously pulled out a prescribed IV. Therefore, the use of hand mitts is the most appropriate, least-restrictive method to prevent the client from further self-harm. 1. INCORRECT: There are several problems here. The client had side rails up, which are considered a form of restraint and in many facilities are no longer permitted. By applying a chest restraint, the client has been restrained twice. Just because a client is elderly does not mean restraints are needed. This restraint is not acceptable. The nurse should provide regular toileting periods and determine why this client is climbing out of bed. 2. INCORRECT: Closing a client into a room is overly restrictive and unsafe. This Alzheimer's client needs to be observed and closing the room door prevents visual access. Additionally, closing the door may violate fire safety codes in certain facilities. At shift change, when staff is occupied with report, special arrangements should be made so that the client can be observed and not restrained. 4. INCORRECT: Depending on the facility, placing a client upright at night, using a Geri-chair and a lap belt is overly restrictive. A client with dementia is challenging, particularly in the presence of sundowner syndrome. However, keeping a client upright all night, belted into a chair for the purpose of observation, is neither safe nor healthy for the client. Stay away from restraints, wheelchairs, and invasive drugs as long as possible when choosing an answer. The NCLEX lady does not like nurses who tie people down or nurses who run to the medication cart for every little thing.

A client asks, "I would like to view my medical records." Which response made by the nurse is most appropriate? 1. You will first need to contact your primary healthcare provider. 2. You may view your electronic health records on a weekly basis. 3. You have the right to view the medical records that pertain to your care. 4. You want to view your medical records?

3. Correct: According to the Client's Bill of Rights, the client has the right to view medical records pertaining to the client's care and to have those records explained if necessary. 1. Incorrect: The client may contact medical records and does not need to first contact the primary healthcare provider. 2. Incorrect: The electronic health record can be made available to the client when requested. 4. Incorrect: This is an open ended question, but the client may view this as challenging their desire to view the medical records.

A client has been admitted with advanced cirrhosis. The nurse's assessment verifies an increase weight of 6 lbs. (2.71 kg) since yesterday's weight and an abdominal girth increase of 5 inches (12.7 cm). What is the priority assessment? 1. Urinary Output 2. Daily weight 3. Blood pressure 4. LOC

3. Correct: Blood Pressure. We said that all of this ascites is coming from the vascular space and it's getting worse, So what could happen to my blood pressure? It will drop! 1. Incorrect: SURE, you are going to watch the urinary output and the daily weight. LOC is very important as well and one of the first assessments we make, BUT if I can only do one of these assessments, I better take the BP because that is the one that says SHOCK 2. Incorrect: SURE, you are going to watch the urinary output and the daily weight. LOC is very important as well and one of the first assessments we make, BUT if I can only do one of these assessments, I better take the BP because that is the one that says SHOCK 4. Incorrect: SURE, you are going to watch the urinary output and the daily weight. LOC is very important as well and one of the first assessments we make, BUT if I can only do one of these assessments, I better take the BP because that is the one that says SHOCK

Which statement by the spouse of a client diagnosed with Alzheimer's indicates to the nurse that the spouse is dealing appropriately with stressors? 1. "I am in charge of every aspect of the care provided." 2. "I do not expect our children who live out of town to help." 3. "I keep a list of small tasks ready for people who ask me if they can help." 4. "I only go to my primary healthcare provider when I am sick."

3. Correct: Encourage caregivers to say "yes" when someone offers assistance. It's smart to have a list ready of small tasks that others could easily take care of, such as picking up groceries or driving the person to an appointment. 1. Incorrect: The caregiver should be willing to surrender some control. Delegating is one thing. Trying to control every aspect of care is another. People will be less likely to help if the caregiver micromanages, or insists on doing things their way. 2. Incorrect: The caregiver should spread the responsibility. Get family members involved as much as possible. Even someone who lives far away can help. Encourage the caregiver to divide up caregiving tasks. One person can take care of medical responsibilities, another with finances and bills, and another with groceries and errands. 4. Incorrect: Encourage the caregiver to stay healthy by keeping on top of primary healthcare provider visits. They should not skip annual routine, checkups, or medical appointments. Identify the central person in the question. Usually the nurse is required to respond to the needs of the client. Some questions focus on the needs of others, such as a child, parent, spouse, or roommate. To select the correct answer, you must identify the central person in the stem. Identify specific determiners in options. These convey a thought or concept that has no exceptions. Words such as just, always, never, all, every, none, and only are absolute and place limits on the statement that generally is considered correct. Statements including these words generally make the statement false as the statement is general and broad and does not allow for exceptions

The emergency department nurse is assuming care of a client with full thickness burns to both legs. Which primary healthcare provider prescription should be implemented first? 1. Administer IV morphine 2. Insert oropharyngeal airway 3. Start two large bore IVs 4. Apply silver sulfadiazine to burn area

3. Correct: Full thickness burns of both legs would result in a severe fluid volume deficit. A priority treatment for burns include fluid replacement; therefore, insertion of 2 large bore IVs is a priority. 1. Incorrect: Pain is important but not priority over fluid volume status. Remember, pain never killed anybody. 2. Incorrect: This client does not have airway involvement. These burns are on the legs; there is no indication in the stem that the airway is involved. 4. Incorrect: Application of silver sulfadiazine does not take priority over fluid replacement.

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

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

What intervention should the nurse take when providing oral care for the unconscious client? 1. Brush teeth with a stiff toothbrush. 2. Use thumb and index finger to hold the client's mouth open while brushing teeth. 3. Position the client on their side. 4. Rinse by injecting water into the center of client's mouth.

3. Correct: Placing client on side helps fluid run out of the mouth. 1. Incorrect: A soft bristled brush should be used. 2. Incorrect: Fingers should not be placed in client's mouth. 4. Incorrect: Should be injected into the sides of the client's mouth.

The home health nurse is caring for an elderly client who lives with an adult child. The client's child is divorced, works full-time, and is responsible for caring for two young children. Recently, the client has become incontinent of urine. Which stressor on the caregiver may increase the risk for abuse of this elderly client? 1. Care of young children 2. Being divorced 3. Recent increased care demands 4. Loneliness of the adult child

3. Correct: Recently increased care demands place a greater strain on the time and money required to provide care. The changing level of demands may increase the risk of abuse. 1. Incorrect: The adult child has been successfully managing the children and the elderly client up to this point. The physiological changes of incontinence for the client and increased care required for this is the most significant risk factor that could cause abuse. 2. Incorrect: The divorce is not a recently added stressor so is not a current change or stressor that would trigger the risk for abuse. 4. Incorrect: There is no mention of loneliness as a possible stressor in this scenario. This would be reading into the question and assuming incorrect data.

A client is admitted for management of chronic obstructive pulmonary disease (COPD). What assessment finding would be of concern to the nurse? 1. Pursed lip breathing 2. Productive cough with thick white sputum 3. Ankles with 2+ pitting edema 4. Barrel chest

3. Correct: Swelling in the legs or feet is a serious symptom and should be of concern to the nurse. To make up for the damage to the lungs, the heart must pump harder to get enough oxygen to the rest of the body. Further investigation is needed. 1. Incorrect: Pursed lip breathing helps keep the alveoli open to allow for better oxygen and carbon dioxide exchange. Clients with COPD are taught how to breathe through pursed lips. 2. Incorrect: A chronic, persistent cough is often the first symptom to develop, and may be present every day as the disease progresses. The cough may or may not be productive. If it is productive, white means free of infection, so that is a good thing. 4. Incorrect: As COPD progresses, the antero-posterior diameter of the chest increases. This increase is called a barrel chest and is not of concern to the nurse. The nurse must be aware of the signs and symptoms of COPD and what would indicate a problem. If the test taker does not know the correct answer, think about which body system the question is asking about may help rule out or rule in some of the options.

The nurse manager is presenting a seminar on HIPAA regulations to a group of newly hired graduates. When discussing the most common cause of violating client privacy, the nurse knows teaching was successful when the graduates select what situation? 1. Failure to cover client fully during a bed bath. 2. Leaving chart open in full view when at the desk. 3. Discussing client with staff not providing direct care. 4. Healthcare provider not pulling curtain to talk to client.

3. Correct: The most common violation of HIPAA privacy regulations occurs when healthcare workers discuss a client with those not directly involved in the care of the client, including other staff members. Those working in a facility are not entitled to have access to client health data unless providing direct care to that client. 1. Incorrect: Exposing more of the client than necessary during a bed bath is definitely considered a violation of privacy. However, the graduates are to select the most common situation, and bed bath issues are less common. 2. Incorrect: Leaving a client's chart open in full view of staff and visitors does violate a client's privacy. But, such a problem is not as common as another situation. 4. Incorrect: The problem of overhearing conversations may occur in facilities where multiple clients share the same room or in an emergency room where only a curtain exists between clients. Pulling the curtain does not guarantee that voices will not carry, though most primary healthcare providers try keep voice levels at a minimum.

Following a lumbar puncture, the client reports a headache on a pain scale of 8 out of 10. What priority action should the nurse perform? 1. Instruct the client to drink at least 8 ounces of water. 2. Close room blinds to darken the environment. 3. Assist the client into a supine position in bed. 4. Notify primary healthcare provider of client's complaints

3. Correct: The most frequent cause of headache following a lumbar puncture is loss of, or leaking, of cerebrospinal fluid from the puncture site. Positioning a client is an important nursing responsibility, particularly in this situation since the supine position could help to stop any leaking. Following this, the nurse will pursue additional actions as ordered by the primary healthcare provider, which may include increasing fluids or even a blood patch. 1. Incorrect: Although increasing fluids may help clients under specific circumstances, it is not the priority action in this situation. Additionally, the primary healthcare provider may order IV fluids rather than PO fluids. 2. Incorrect: A darkened room can be beneficial for clients with severe migraine headaches, but would not be useful to this client. Headaches following a lumbar puncture are caused by the loss of cerebrospinal fluid and would not respond to a quiet, dark environment. 4. Incorrect: Although the primary healthcare provider should indeed be notified of this situation, the nurse's priority action should first focus on stabilizing the client by addressing the cause of this problem and positioning the client.

A nurse educator is teaching first responders about disaster management, and provided the following scenario: A small community has experienced a severe tornado that hit a shopping mall and caused extreme damage and suspected mass casualties and injuries. First responders arrive on the scene. The nurse educator recognizes education has been successful when the first responders identify which action as priority? 1. Triage victims and tag according to injury. 2. Assess the immediate area for electrical wires on the ground. 3. Activate the community emergency response team. 4. Begin attending to injuries as they are encountered.

3. Correct: With mass casualties, community response teams are needed, and activating them is the first priority. 1. Incorrect: This would be the third step. 2. Incorrect: This would be the second step so that further injuries are not encountered. 4. Incorrect: Triage must occur before treatment of anyone so that an accurate assessment of level of injuries can be made. With mass casualties, a color tag system is usually implemented. Again, activate the community emergency response team first.

A hospital has incorporated new equipment on all units without nursing or staff input. Frustrated staff members approach the nurse manager, requesting a resolution of the situation. What response by the nurse manager would be most appropriate? 1. "You are over-reacting to this new equipment." 2. "Perhaps you just need some further training." 3. "Unexpected changes can be difficult to accept." 4. "If we work together, everything will get better."

3. Correct:The nurse manager should utilize therapeutic techniques with staff as well as clients. The introduction of new equipment, particularly with no staff input, can cause frustration, job dissatisfaction, or even anger. Open-ended statements and questions allow staff to verbalize emotions in a situation which has led to feelings of powerlessness. This approach by the nurse manager will help staff adapt more successfully to this situation. 1. Incorrect: This closed, antagonistic remark is accusatory and provides no opportunity for staff interaction. The nurse manager has responded by placing blame on the staff instead of encouraging the expression of feelings and frustrations. 2. Incorrect: Such a comment focuses on training or lack of staff knowledge regarding the new equipment. This is a closed-ended comment which focuses on the issue of staff learning rather than lack of input for the equipment. 4. Incorrect: Though the comment may seem encouraging, the nurse manager is ignoring the staff's feelings and implying everything will be okay. This belittles staff emotions and is closed-ended, eliminating the opportunity to work through feelings.

The nurse is planning care for a client with bipolar disorder in the manic phase. Which interventions are appropriate for this client? 1. Engage in a knitting class 2. Encourage client to play basketball 3. Provide frequent snacks 4. Sit with client in the activity room 5. Provide a structured schedule 6. Decrease stimulation

3., 5., & 6. Correct: They need frequent snacks because they are so active........... they need the extra calories. Y'all know that a structured schedule makes people feel secure, especially the manic client. Decreasing stimulation helps to calm the manic client. 1. Incorrect: Knitting could be dangerous, it could be a hazard! 2. Incorrect: Remember the manic client does not do well in groups. They cause too much disruption and ruin it for everyone else! 4. Incorrect: Manic clients need brief contact with staff because too much intense conversation will stimulate the client. Time in the activity room will stimulate the client.

Labetalol has been prescribed for a client in the emergency room. Prior to administering this medication, what assessment should the nurse perform? 1. Listen to the client's breath sounds. 2. Check the client's temperature. 3. Monitor for peripheral edema. 4. Auscultate the apical pulse rate.

4 Correct: The therapeutic effect of labetalol, which is a beta blocker, is to lower the blood pressure and decrease the heart rate. Apical pulse should be assessed for 1 full minute. If pulse is less than 60 the medication is held and the healthcare provider should be notified. 1. Incorrect: Indirectly a beta blocker could affect breath sounds but assessing breath sounds is not as important as taking the client's apical pulse. Beta blocks should be used cautiously in clients with a history of COPD or asthma these could cause airways to constrict. 2. Incorrect: Labetalol does not affect the client's temperature. This is not a side effect of labetalol. 3. Incorrect: Indirectly a beta blocker could affect the amount of peripheral edema, however, assessing for peripheral edema is not as important as taking the client's apical pulse.

The nurse is teaching a community education class on alternative therapies. Which alternative therapy that uses substances found in nature should the nurse include? 1. Energy therapies. 2. Mind-body interventions. 3. Body-based methods. 4. Biologically-based therapies.

4. Correct: Biologically-based therapies use substances found in nature such as herbs, foods, and vitamins. 1. Incorrect: Energy therapies use energy fields. Substances found in nature are biologically-based therapies. 2. Incorrect: Mind-body interventions use the mind to help affect the function of the body. Substances found in nature are biologically-based therapies. 3. Incorrect: Body-based methods use movement of the body. Substances found in nature are biologically-based therapies The test taker would need basic knowledge about biologically-based therapies to answer this question easily, but some clues may be found in the stem.

Which risk factor should the nurse include when planning to educate a group of women about breast cancer? 1. Menopause before the age of 50 2. Drinking one glass of wine daily 3. Multiparity 4. Early menarche

4. Correct: Early menarche before age 12 is a known risk factor for breast cancer. The increased risk of breast cancer linked to a younger age at first period is likely due, at least in part, to the amount of estrogen a woman is exposed to in her life. A higher lifetime exposure to estrogen is linked to an increase in breast cancer risk. The earlier a woman starts having periods, the longer her breast tissue is exposed to estrogens released during the menstrual cycle and the greater her lifetime exposure to estrogen. 1. Incorrect: Studies show women who go through menopause after age 50 have increased risk of breast cancer. The risk for breast cancer increases as time period between menarche and menopause increases. 2. Incorrect: Small increase in risk with moderate alcohol consumption, not one glass of wine daily. Drinking low to moderate amounts of alcohol, however, may lower the risks of heart disease, high blood pressure and death. But, drinking more than one drink per day (for women) and more than two drinks per day (for men) has no health benefits and many serious health risks, including breast cancer. Alcohol can change the way a woman's body metabolizes estrogen (how estrogen works in the body). This can cause blood estrogen levels to rise. Estrogen levels are higher in women who drink alcohol than in non-drinkers. These higher estrogen levels may in turn, increase the risk of breast cancer. 3. Incorrect: Nulliparity (no pregnancies) is a known risk factor for breast cancer. Factors that increase the number of menstrual cycles also increase the risk of breast cancer, probably due to increased endogenous estrogen exposure.

What electrolyte imbalance should the nurse monitor for in a client diagnosed with hyperosmolar hyperglycemic state (HHS)? 1. Hypocalcemia 2. Hypermagnesemia 3. Hyperkalemia 4. Hyponatremia

4. Correct: Hyperglycemia can cause dilutional hyponatremia, so Normal Saline is administered to replace both fluid and sodium lost through increased urinary output. 1. Incorrect: Calcium is not affected in the client who is in HHS. 2. Incorrect: HHS does not specifically cause hypermagnesemia. We do know that magnesium is lost through the kidneys, so hypomagnesemia is possible with uncontrolled diabetes. 3. Incorrect: Serum potassium levels are usually normal when the client arrives with HHS. The potassium will drop as the large volume of NS is administered with IV insulin. Then we worry about hypokalemia.

The nurse is caring for a client diagnosed with schizophrenia who is admitted to the hospital for possible bowel obstruction. The client has a nasogastric tube (NG) and reports pain 8/10. What is the priority nursing action? 1. Decrease the stimuli and observe frequently. 2. Administer the prn sedative. 3. Call the primary healthcare provider immediately. 4. Administer the prn pain medication.

4. Correct: Small bowel obstruction has a clinical manifestation of crampy pain that is wave like and colicky due to persistent peristalsis above and below the blockage. Nursing care of the patient includes pain management. 1. Incorrect: Decreasing the stimuli and observing are not appropriate. The pain needs to be assessed and treated. 2. Incorrect: Not necessary, it will sedate them, but not help the pain. Sedation is not a necessary intervention for pain. A medication to relieve pain is needed. 3. Incorrect: The nurse can administer pain medication as ordered. There is no need to contact the healthcare provider.

During evening rounds on a medical unit, a client is discovered in cardiac arrest. After activating the code button, the nurse initiates chest compressions. A second nurse enters the room to assist. What priority task could be delegated to the second nurse? 1. Retrieve the crash cart. 2. Document the code events. 3. Notify the primary healthcare provider 4. Begin oxygenating the client

4. Correct: The chest compressions, airway, and breathing (CAB) sequence is always of primary concern. The first nurse correctly activated a code and then began chest compressions. The second nurse will assist by oxygenating the client, using a bag valve mask. 1. Incorrect: Although it will be necessary to bring the crash cart into the room, the initial priority should focus on the client's needs. In the case of a client in cardiac arrest, the first personnel to respond must focus on CPR protocols, including compressions and oxygenation. Other personnel can bring the crash cart into the room. 2. Incorrect: Documenting all the events that occur during a code is vital for both legal and quality assurance purposes; however, the initial priority must focus on stabilizing the client. 3. Incorrect: The Healthcare Provider does need to be notified, but it is not an immediate priority for either nurse. Ancillary personnel, such as the unit secretary, can complete this task. Professional personnel must focus on the client's immediate needs at this critical point.

Which prevention strategy should the nurse consider when developing a health promotion plan for new parents concerning sudden infant death syndrome (SIDS)? 1. Place the infant in the prone position when placing the infant in the bed. 2. The child should sleep in a separate room from the parents. 3. The child should not have a pacifier in place when sleeping. 4. The child should be placed in the supine position when sleeping.

4. Correct: The child should be placed in the supine position when being put to bed for naps or for the night. This position has helped to reduce the incidence of SIDS by as much as 50% since the 1990s. 1. Incorrect: The child should not be placed in the prone position when being put to bed for sleep. If the child is awake and supervised, the prone position encourages muscular development. 2. Incorrect: The American Academy of Pediatrics recommends that the infant sleep in the same room with the parents, but not in the same bed. 3. Incorrect: The American Academy of Pediatrics recommends that a pacifier be used for the first 6 months because of the benefit in regard to pain management and prevention of sudden infant death syndrome, but recommends the child be weaned from the pacifier during the second 6 months of life.

A client has been unable to eat due to protracted vomiting. Which alterations in the arterial blood gases would the nurse expect to find? 1. pH: 7.40, PaCO2: 44, HCO3: 23 2. pH: 7.33, PaCO2: 35, HCO3: 18 3. pH: 7.28, PaCO2: 48, HCO3: 29 4. pH: 7.46, PaCO2: 35, HCO3: 28

4. Correct: The stomach as a lot of acid in it. So, if the client is vomiting a lot, then the client is losing acid. This will make the client alkalotic inside. Is this going to be a lung problem? No. So we are looking for ABGs that indicate that this client is in metabolic alkalosis. A pH of 7.46 is higher than the normal pH value of 7.45, which indicates alkalosis. The PaCO2 is 35, which is on the low end of normal (34-45). The HCO3 is 28, which is higher than the normal HCO3 of 26, which indicates alkalosis. So the Bicarb (Kidney chemical) matches the pH. Metabolic alkalosis. 1. Incorrect: These are normal ABGs. pH: 7.40 (normal), PaCO2: 44 (normal), HCO3: 23 (normal) 2. Incorrect: This is metabolic acidosis. pH: 7.33 (acid), PaCO2: 35 (normal), HCO3: 18 (acid) 3. Incorrect: This is partially compensated respiratory acidosis. pH: 7.28 (acid), PaCO2: 48 (acid), HCO3: 29 (alkaline)

An elderly client with a recent diagnosis of atrial fibrillation (AF) caused by valvular heart disease, tells the nurse, "My daughter has AF and she only has to take one dabigatran pill a day. I have to take warfarin daily and have my blood checked every month. Why do I have to do all of this?" What education would the nurse provide to the client? 1. Your daughter's atrial fibrillation must not be caused by a heart valve problem so she can take a medication that does not require routine clotting studies. 2. Each primary healthcare provider may treat this dysrhythmia differently based on what the provider is used to prescribing. 3. When your daughter gets older, her primary healthcare provider will switch her to warfarin for the treatment of atrial fibrillation. 4. Your atrial fibrillation is caused by a heart valve problem which is treated best by warfarin, but clotting studies have to be done routinely.

4. Correct: This client has at least three risk factors, warranting more aggressive treatment. Typically warfarin is given to treat AF in the elderly with compounding risk factors. 1. Incorrect: Risk factors are the deciding factors for treatment. 2. Incorrect: Typical regimens are based on risk factors. 3. Incorrect: The primary healthcare provider will assess the daughter when older and based on the assessment and risk factors determine if treatment should be changed.

A client is being cared for in the intensive care unit following a traumatic amputation of the left lower arm. As the nurse enters the room for a routine check, the client begins to cry and states "This is so overwhelming." What statement by the nurse would be most appropriate at this time? 1. "You have been through a lot, but look on the bright side; you are doing better now." 2. "Try to be optimistic. You are going to be fitted for a prosthesis once you are healed." 3. "I understand that you are upset, but crying is not going to help your situation." 4. "This must be very difficult for you. What seems to be the hardest part for you now?"

4. Correct: This client has experienced a very significant personal loss and can go through the grieving process, similar to those who experience the death of a loved one. The nurse should be very sensitive to the feelings of loss being felt by this client due to the loss of a body part. This client is reporting feeling overwhelmed. The best way for the nurse to respond to this client's feelings would be to first acknowledge that the situation must be very difficult for the client. The nurse can further explore this by asking what seems to be the hardest part for the client currently. This will guide the nurse with how to best assist the client at the current time and meet the most immediate emotional needs of this client. By addressing what is most overwhelming at the present time, the nurse can more effectively assist the client in gradually working through the grief process and dealing with the loss. 1. Incorrect: The nurse's comment starts out with an acceptable comment of acknowledging that the client has been through a lot but then immediately negates the client's feelings of being overwhelmed by telling the client to look on the bright side and that the client is doing better now. This statement discounts the client's feelings of loss and being overwhelmed with all that it entails. 2. Incorrect: This comment by the nurse that tells the client to be optimistic because a prosthesis will be fitted does not address the client's current feelings. This is a total disregard to the overwhelming feelings of loss that the client is experiencing. As the client works through the feelings of loss over time, the nurse can help provide a sense of hope and optimism about the use of a prosthesis, but the client's current feelings should be addressed first. 3. Incorrect: Again, the nurse's comment about recognizing that the client is upset could be appropriate, but the comment following this about crying not helping the situation could cause the client to feel belittled and may actually cause the client to become bitter or reluctant to share true feelings with the nurse. The nurse should support the client and explore how to best help the client work through these feelings of extreme loss.

A fully alert and competent client is in end-stage cardiac disease. The client says, "I'm ready to die," and refuses to take nourishment. The family urges the client to allow the nurse to insert a feeding tube. What action should the nurse take? 1. Tell the family that the feeding tube will be inserted after the client becomes unresponsive. 2. Ask the primary healthcare provider to have the dietician talk with the client about food preferences. 3. Notify the case manager to arrange a meeting with the client's family . 4. Provide additional information as requested by the client concerning nourishment.

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

After making rounds on clients, a primary healthcare provider hands the nurse a client record and gives the following verbal order: Administer cisplatin 1 mg IV over 6 hours. What should be the first action by the nurse following this verbal prescription? 1. Call the pharmacy to prepare the drug. 2. Repeat the prescription back to the primary healthcare provider. 3. Ask the primary healthcare provider to spell the drug name for clarification. 4. Inform the healthcare provider that this medication requires a written prescription.

4. Correct: This drug is a high alert drug that should be given careful consideration. Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety. 1. Incorrect: The pharmacy should not be called to prepare this drug as it is unsafe to follow a verbal prescription for an antineoplastic. Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety. 2. Incorrect: The first action by the nurse should be to inform the primary healthcare provider that a verbal prescription is not adequate for this particular category of drug. Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety. 3. Incorrect: Use the testing strategy of finding similar options to eliminate incorrect answers. Options 1, 2 and 3 insinuate the nurse is going to proceed with the prescription, which is an unsafe practice for antineoplastics. Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety.

A client presents in the emergency department extremely anxious and reporting acute onset of chest pain when taking a deep breath and shortness of breath. Initial assessment by the nurse reveals tachycardia, hemoptysis, and a pulse oximeter reading of 90%. What intervention should the nurse initiate first? 1. Administer oxygen. 2. Obtain a blood pressure reading. 3. Connect to cardiac monitor. 4. Raise head of bed to 90 degrees.

4. Correct: This is your priority. This position will facilitate maximum lung expansion. It will also decrease venous return to the right side of the heart so that pressure decreases in the pulmonary vascular system. 1. Incorrect: Oxygen is needed, but the first thing the nurse should do is raise the head of the bed, so the client can breathe easier. Then get the oxygen set up. 2. Incorrect: Obtaining a blood pressure reading at this point is delaying treatment. The problem is a breathing problem. Do something to fix the breathing problem first. Then, you can continue your assessment by checking circulation status. 3. Incorrect: Connecting the client to a cardiac monitor is an appropriate intervention, but facilitating breathing takes priority and should be done first.

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

4. Correct:The greatest concern at this time is the safety of the clients to whom the intoxicated nurse is providing care. The nurses Code of Ethics dictates safe, effective care for the public with protection from incompetent or unethical practice. The chain of command for this floor nurse is to report directly to the unit nurse manager. 1. Incorrect: When dealing with ethical or legal issues, the chain of command starts with the nurse manager of the unit in question. Asking another staff nurse for a personal opinion would not provide any pertinent data and instead amounts to gossip. 2. Incorrect: In order to avoid undue conflict, the nurse needs to immediately alert the unit nurse manager and not the facility supervisor. The nurse manager must then manage any conflict that may result and bears the responsibility to control possible disruption resulting from re-assigning the impaired nurse's clients. 3. Incorrect: Direct confrontation of the allegedly impaired nurse would most likely result in denial or defensive behaviors which could place the clients at further risk. The chain of command for this staff nurse starts with the unit nurse manager who would be more qualified to deal with conflict resolution in this matter. This is a management question. The test taker must know the chain of command and when to report behavior. The test taker should select doing something positive, instead of taking no action.

What foods should the nurse inform the client to avoid for three days prior to a guaiac test? 1. Chicken 2. Carrots 3. Apple 4. Raw broccoli 5. Steak 6. Turnip greens

4., 5., & 6. Correct: Foods that affect this test include raw broccoli, red meats such as steak, turnip greens, cantaloupe, radish, and horseradish. All of these could cause a false positive reading for the guaiac test. 1. Incorrect: Red meats such as steak should be avoided, but chicken is okay. 2. Incorrect: Carrots are not prohibited and will not affect the results of the test. 3. Incorrect: The client can eat apples with no effect on the test results.