NCLEX-RN Exam Preview

The charge nurse has received a change-of-shift report on the following clients in labor. The charge nurse should ask a staff member to first see the client in the 1. First stage of labor who has an oral temperature of 99.7F (37.6 C) 2. First stage of labor whose contractions are occurring every 30 seconds 3. Second stage of labor who has respirations of 26. 4. Second stage of labor whose contractions are lasting for 60 seconds.

2. First stage of labor whose contractions are occurring every 30 seconds Rationale: 1. Elevated temperature is normal during labor. 3. Increased respirations are normal during labor "pant-pant-blow" "hee-hee-hoo" breathing pattern. 4. Contractions shouldn't be longer than 90 seconds, 60 seconds is okay and normal. Second stage: 2-3 minutes apart, 60-90 seconds long, 10cm dilated, strong pain.

The nurse is observing a staff member caring for a client who has chickenpox. Which of the following actions by the staff member would require the nurse to intervene? 1. Placing the client in a private room with monitored negative air pressure. 2. Placing a box of disposable face shields outside the client's room. 3. Placing an alcohol-based hand rub in the client's room for hand hygiene. 4. Placing a surgical mask on the client during transport out of the client's room.

2. Placing a box of disposable face shields outside the client's room. Rationale: Varicella AKA chicken pox is an airborne precaution. Private, negative pressure room, universal precautions (hand sanitizer in room) and placing a surgical mask on client during transport are all correct interventions for varicella.

2. Refuses to go to sleep at night.

A parent is discussing with discussing with the nurse about the behaviors of a 4-year-old child following the death of a grandparent. The nurse should understand that the child may be experiencing dysfunctional grieving if the parent reports that the child: 1. Conducts mock funerals with stuffed animals. 2. Refuses to go to sleep at night. 3. Continues to talk about the grandparents coming to visit. 4. Asks to play with the grandparent while at the cemetery.

1. Client with hepatitis B (HBV) is eating food brought into the facility by a visitor. Rationale: HBV is spread through contact with body fluids including saliva, so it is important to intervene if the patient is eating and possibly sharing food with another person.

The charge nurse is observing the following client situations. It would require intervention if a: 1. Client with hepatitis B (HBV) is eating food brought into the facility by a visitor. 2. Visitor is sitting on the side of the bed of a client with acute pancreatitis. 3. Staff member is entering the room of a client with Haemophilus influenzae meningitis wearing a protective gown and gloves. 4. Family member of a client with mycoplasma pneumonia leaves the door to the client's room open.

3. 56-years-old, has hepatitis C (HCV) and has been afebrile for 24 hours.

The charge nurse must transfer a female client from the medical-surgical unit to the maternity unit to make a bed available. It would be most appropriate for the nurse to transfer the client who is 1. 28-years-old, had a right mastectomy and has a closed-wound drainage system. 2. 49-years-old, has diabetes mellitus (type 2) and has begun receiving insulin. 3. 56-years-old, has hepatitis C (HCV) and has been afebrile for 24 hours. 4. 70-years-old, has a fractures left tibia and had an external fixation device applied 48 hours ago.

1. Breast cancer who had a mastectomy 2 days ago and has had 25mL of drainage from the closed-wound drainage system in the past 12 hours. Rationale: This is very little blood in 12 hours for a surgery that was only 2 days ago. The nurse should assess for obstruction of the drainage system which could be life-threatening if not resolved.

The home-health nurse is assigned to visit the following clients who live within 3 miles (4.8km) of one of another. The nurse should first visit the client with: 1. Breast cancer who had a mastectomy 2 days ago and has had 25mL of drainage from the closed-wound drainage system in the past 12 hours. 2. Lung cancer who received a dose of chemotherapy 2 weeks ago and has a temperature of 101.1 F (38.4 C) 3. Chronic obstructive pulmonary disease (COPD) who is reporting expectorating large amounts of thick, yellow mucus. 4. Diabetes mellitus (type 1) who had a right below-the-knee amputation (BKA) and is reporting having right toe pain.

4. "Instruct your child not to use the same towels as siblings." Rationale: Impetigo is highly contagious through contact. Towels can easily spread the infection. 1. Impetigo is contact precautions; a surgical mask would be for airborne.

The home-health nurse is teaching the parents of a 4-year-old client with impetigo. Which of the following information should the nurse include? 1. "Put a surgical mask on your child when around siblings." 2. "Cleanse the lesions with a povidone-iodine solution daily." 3. "Apply petroleum jelly to the lesions daily." 4. "Instruct your child not to use the same towels as siblings."

4. "Sitting upright seems to reduce the client's noisy breathing more than lying down in the bed." Rationale: It is common for hospice patients to have "death rattle," which are loud, wet respirations. The correct intervention is to reposition them laterally, not upright! Never suction them. Hospice is characterized as making the patient as comfortable as possible so if they have less anxiety with a fan, let them continue using it. Offering foods is okay, but don't force them to eat.

The hospice nurse has taught an in-home caregiver about comfort care for a client at the end of life. Which of the following statements by the caregiver would require follow-up? 1. "I have been applying petroleum jelly to keep the client's lips moist." 2. "I have been offering healthy foods frequently to keep up the client's strength." 3. "A blowing fan seems to be less anxiety-producing for the client than an oxygen mask." 4. "Sitting upright seems to reduce the client's noisy breathing more than lying down in the bed."

4. Place in the prone position a client who had an above-the-knee amputation (AKA) 1 day ago.

The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. It would be most appropriate for the nurse to assign UAP to: 1. Apply a continuous passive motion (CPM) device to the affected extremity of a client who had a total knee replacement. 2. Change the bed linens for a client who was admitted 1 hour ago following a closed-head injury and is comatose. 3. Reposition a client with hydrocephalus who has a headache and is vomiting. 4. Place in the prone position a client who had an above-the-knee amputation (AKA) 1 day ago.

1. Assisting a client with atrial fibrillation to shower. Rationale: A UAP can perform/assist with hygiene. Only nurses can assess. Transporting a client in respiratory arrest is not safe to delegate to a UAP.

The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks would be appropriate for the nurse to assign to UAP? 1. Assisting a client with atrial fibrillation to shower. 2. Checking the ability of a client to swallow water after a transesophageal echocardiogram (TEE). 3. Observing while a client with dysphagia begins a thickened liquid diet. 4. Transporting a client with respiratory distress to the radiology department for a chest radiograph.

4. Wearing clothing in layers.

The nurse at a health fair is talking with a client who is in perimenopause and is experiencing hot flashes. Which of the following lifestyle modifications would be appropriate for the nurse to recommend? 1. Increasing fluid intake. 2. Exercising daily. 3. Decreasing sodium intake. 4. Wearing clothing in layers.

2. Reports of muscle stiffness. Rationale: Muscle stiffness is one of the extrapyramidal symptoms (EPS). When taking haloperidol and needs immediate intervention.

The nurse has administered haloperidol to a client with schizophrenia who is agitated. Which of the following findings would require immediate follow-up? 1. Continued lack of motivation. 2. Reports of muscle stiffness. 3. Inappropriate emotional expressions. 4. Difficulty focusing due to blurred vision.

4. "Bubonic plague is transmitted from person to person via airborne droplets." Rationale: It is actually spread through flea bites and contact with infected skin. 1. Botulism is transmitted by foods. Ex: Babies getting botulism from honey. 2. Infectious diseases that affect clotting and is spread by blood or body fluids. 3. Anthrax=Contact.

The nurse has attended a staff education program about bioterrorism. Which of the following statements by the nurse would require follow-up? 1. "Botulism is transmitted by ingestion of contaminated canned foods." 2. "Hemorrhagic fever is spread by direct contact with blood or body fluids." 3. "Anthrax is spread through direct contact with the bacteria and its spores." 4. "Bubonic plague is transmitted from person to person via airborne droplets."

2. "Clients may develop stress ulcers and gastrointestinal bleeding." Rationale: Positive pressure ventilation increases the likelihood of developing stress ulcers and bleeding.

The nurse has attended a staff education program about caring for clients who are receiving positive pressure mechanical ventilation. Which of the following statements by the nurse would indicate a correct understanding of the teaching? 1. "Clients should avoid range-of motion (ROM) exercises until weaned from ventilation." 2. "Clients may develop stress ulcers and gastrointestinal bleeding." 3. "Clients will be chemically paralyzed to improve oxygenation." 4. "Clients will experience diuresis and polyuria."

3. Wearing a protective gown when entering the room of a client with Escherichia coli O157.H7 who is incontinent. Rationale: E. coli is contact precautions; wear a gown whenever coming in contact with bodily fluids which is highly likely with an incontinent patient. 1. H.flu is droplet precautions. 2. Strep is droplet, and RSV is contact. 4. They will infect each other, they need private rooms.

The nurse has attended a staff education program about infection control precautions. It would indicate a correct understanding of the teaching if the nurse is observed: 1. Wearing a particulate respirator mask (N95) when entering the room of a client with Haemophilus influenzae pneumonia. 2. Placing a client with streptococcal pneumonia in a room with a client who has respiratory syncytial virus (RSV). 3. Wearing a protective gown when entering the room of a client with Escherichia coli O157.H7 who is incontinent. 4. Placing a client with pediculosis capitis (head lice) in a room with a client who has scabies.

1. "I will use a 3mL syringe to flush the catheter port." Rationale: A 10mL flush is appropriate. Obtaining blood specimens from a VAD: Stop IV infusion for at least a minute. Scrub cap for 10-15 seconds and allow to air dry. Pull back 5mL of discard blood and discard in biohazard container. Scrub cap again. Withdraw blood for specimen. Scrub, flush, and lock. Restart infusion.

The nurse has attended a staff education program about obtaining blood specimens from a central venous access device (VAD). Which of the following statements by the nurse would require follow-up? 1. "I will use a 3mL syringe to flush the catheter port." 2. "The injection cap should be cleansed with antiseptic and allowed to air-dry." 3. "I will aspirate 5mL of blood and discard the syringe in the biohazard container before obtaining the specimen." 4. "The infusion should be turned off for at least 1 minute before the specimen is aspirated."

3. Spastic paralysis below the level of injury.

The nurse has attended a staff education program about spinal shock following acute spinal cord injury. Follow-up is required if the nurse states that manifestations of spinal shock include. 1. Bowel dysfunction. 2. Bladder dysfunction. 3. Spastic paralysis below the level of injury. 4. Loss of sensation below the level of injury.

4. With heart failure who has a productive cough and is restless. Rationale: A productive cough (pink, frothy sputum) is indicative of pulmonary edema which is life threatening. Treatment would be to improve cardiac output by placing client in High-Fowler's, giving them O2, receiving mechanical ventilation, and medications.

The nurse has become aware of the following client situations. The nurse should first assess the client: 1. Who had a right pneumonectomy 24 hours ago and is in the High-Fowler's position while lying on the right side. 2. With chronic obstructive pulmonary disease (COPD) who is using pursed-lip breathing and reporting hemoptysis. 3. Who had a wedge resection of the left lung 24 hours ago and is sitting in the High-Fowler's position. 4. With heart failure who has a productive cough and is restless.

2. Who had a total knee replacement 24 hours ago, is restless, and has a petechial rash on the chest. Rationale: A petechial rash is indicative of DIC or a fat embolus.

The nurse has become aware of the following client situations. The nurse should first assess the client: 1. Who had a total abdominal hysterectomy (TAH) 1 day ago and is unable to void 7 hours after the indwelling urethral catheter was removed. 2. Who had a total knee replacement 24 hours ago, is restless, and has a petechial rash on the chest. 3. With bacterial pneumonia who has bronchial breath sounds auscultated between the scapulae and a temperature of 103.3 F (39.6 C). 4. With hepatic cirrhosis who has an elevated aspartate aminotransferase (AST) level and respirations of 24.

1. Heart failure who has a productive cough and is anxious. Rationale: The productive cough (Pink, frothy sputum) indicates pulmonary edema. The patient's anxiety may be caused by decreased perfusion.

The nurse has been made aware of the following client situations. The nurse should first assess the client with 1. Heart failure who has a productive cough and is anxious. 2. Regional enteritis (Crohn's Disease) who is reporting cramping abdominal pain and diarrhea. 3. Idiopathic thrombocytopenic purpura (ITP) who has petechiae on the trunk and is reporting heavy menses. 4. Chronic obstructive pulmonary disease (COPD) who has dyspnea with exertion and is using accessory muscles to breathe.

3. Who had a total abdominal hysterectomy (TAH) 12 hours ago and has saturated 1 perineal pad in the past 5 hours.

The nurse has been made aware of the following client situations. The nurse should first assess the client: 1. With chronic obstructive pulmonary disease (COPD) who is using pursed-lip breathing after ambulating in the hallway. 2. With pericarditis who has a systolic blood pressure that is 20 mmHg higher during expiration than during inspiration. 3. Who had a total abdominal hysterectomy (TAH) 12 hours ago and has saturated 1 perineal pad in the past 5 hours. 4. Who has Guillain-Barre syndrome and has had an increase in the vital capacity over the past 4 hours.

4. A spinal cord injury at T2 two weeks ago and is currently diaphoretic and nauseated. Rationale: 1. This needs to be addressed, but not immediately. 2. This patient is at risk for infection and urinary retention, but not immediately life-threatening. 3. Numb feet is concerning, but could be a normal part of the recovery process. Not immediately life-threatening.

The nurse has been made aware that the following 4 clients require assistance. The nurse should first assist the client who had: 1. An abdominal hysterectomy 5 hours ago and is reporting severe incisional pain. 2. A transurethral resection of the prostate (TURP) yesterday and whose catheter has become disconnected. 3. A lumbar laminectomy 2 days ago and is reporting that the feet are still numb. 4. A spinal cord injury at T2 two weeks ago and is currently diaphoretic and nauseated.

3. "Clients have a right to provide feedback about services without fear of punishment." Rationale: 4. This is incorrect because the staff member wasn't even setting a proper limit. They should be taught that they cannot limit clients feedback about the unit.

The nurse has observed a staff member tell a client with bipolar disorder that there will be consequences for making negative comments about conditions in the facility. When the nurse meets privately with the staff member, which of the following statements would be most appropriate for the nurse to make to the staff member? 1. "Threatening a client can result in the immediate dismissal of a staff member." 2. "Staff members who have difficulty with control issues often seek power over clients." 3. "Clients have a right to provide feedback about services without fear of punishment." 4. "Staff should set limits with clients in a nonjudgmental manner."

3. 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of apple juice, and 3 servings of infant cereal. Answer: Cow's milk should be introduced at 12 months old. It doesn't provide the necessary nutrients, and the baby can develop iron deficiency.

The nurse has taken a nutritional history from parents of clients. It would be a priority for the nurse to follow up with the 1. 5-month-old client whose only source of nutrition is 5 formula feedings daily. 2. 7-month-old client who eats several crackers as finger food. 3. 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of apple juice, and 3 servings of infant cereal. 4. 1-year-old client whose typical food intake includes 4 breast-feedings and 3 servings of cooked vegetables, pears, or sliced cheese.

1. "The viral load test is used to determine my response to the treatment regimen I am receiving for HIV." Rationale: Repeat viral load tests performed every 4-6 weeks until viral load falls below the assays limit of detection. The decrease the viral load the better. On the other hand with CD4 cells the increase, the better. CD4 under 200 or/and AIDS defining illness (Candidiasis, pneumonia) is AIDS.

The nurse has taught a client who has a positive laboratory test result for human immunodeficiency virus (HIV) infection. The client is scheduled for a viral load test. Which of the following statements by the client would indicate a correct understanding of the teaching? 1. "The viral load test is used to determine my response to the treatment regimen I am receiving for HIV." 2. "The viral load test can rapidly detect HIV-specific antibodies in the blood." 3. "I will be able to decrease the dosage of my prescribed medications if my viral load is low." 4. "I am unlikely to develop acquired immune deficiency syndrome (AIDS) if my viral load is high."

1. "I will eat steamed, fresh broccoli with herbs and spices for an evening meal." Rationale: Veggies are low sodium, and herbs and spices are great substitutes for salt.

The nurse has taught a client who has been ordered a low-sodium diet about appropriate food choices. Which of the following statements by the client would indicate a correct understanding of the teaching? 1. "I will eat steamed, fresh broccoli with herbs and spices for an evening meal." 2. "I will add cottage cheese and other dairy products to my daily diet." 3. "I am glad I can still enjoy eating cereals, such as bran flakes with raisins." 4. "I am glad I can eat lean meats daily because I eat ham sandwiches for an afternoon meal."

1. "I will take alendronate a half hour before I eat breakfast." 4. "I will need to remain in an upright position for 30 minutes after I take alendronate." 5. "I should notify my primary health care provider if I experience difficulty swallowing while taking alendronate. Rationale: 2. Weight-bearing exercises are actually recommended for clients taking alendronate as they help to maintain bone density. 3. Nausea and vomiting are common side effects of alendronate, but do not necessarily require discontinuation of the medication. The client should discuss any side effects with their healthcare provider.

The nurse has taught a client who is receiving alendronate. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply. 1. "I will take alendronate a half hour before I eat breakfast." 2. "I should avoid weight-bearing exercises while taking alendronate." 3. "I should discontinue alendronate if I experience nausea or vomiting." 4. "I will need to remain in an upright position for 30 minutes after I take alendronate." 5. "I should notify my primary health care provider if I experience difficulty swallowing while taking alendronate.

3. "I should elevate the head of the bed on 6 inch (15cm) blocks."

The nurse has taught a client with a hiatal hernia about interventions for the condition. Which of the following statements by the client would indicate a correct understanding of the teaching? 1. "I will consume 3 regular-sized meals daily." 2. "Wearing an abdominal binder can help relieve symptoms." 3. "I should elevate the head of the bed on 6 inch (15cm) blocks." 4. "Eating foods with a high fat content will increase gastric emptying."

1. "I will increase my oral fluid intake to 2 to 3 L daily while taking the medication." Rationale: Getting dehydrated can increase risk for lithium toxicity. 2. Takes about 1-3 weeks to work. 3. Do not go on a low sodium diet because it can decrease lithium elimination and cause lithium toxicity. 4. Sweating too much can cause you to lose too much sodium.

The nurse has taught a client with bipolar I disorder who is experiencing a manic episode and is receiving lithium. Which of the following statements by the client would indicate a correct understanding of the teaching? 1. "I will increase my oral fluid intake to 2 to 3 L daily while taking the medication." 2. "I will experience an improvement in my condition 5 weeks after starting the medication." 3. "I should decrease my intake of dietary sodium after starting the medication." 4. "I should limit time spent in a sauna to 1 hour weekly while taking the medication."

1. "I will check my shoes for foreign objects prior to putting them on." 4. "I should avoid crossing my legs to prevent decreased circulation to my feet." 5. "I should wear new shoes for a few hours for several days until they fit well." Rationale: 1. Diabetics are at risk for feet injuries. 2. Do NOT use files on feet, they can injure themselves. 3. Do NOT apply lotion between toes because it can cause maceration and skin breakdown. Dry carefully between toes. 4. This is correct because diabetics have poor perfusion and peripheral neuropathy. 5. Diabetics should always wear good fitting shoes and never walk barefoot.

The nurse has taught a client with diabetes mellitus (type 2) about foot care. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply. 1. "I will check my shoes for foreign objects prior to putting them on." 2. "I should use a large, coarse file to remove dry skin from a bunion." 3. "I will apply a petroleum-based ointment between my toes after bathing." 4. "I should avoid crossing my legs to prevent decreased circulation to my feet." 5. "I should wear new shoes for a few hours for several days until they fit well."

4. "I should expect the blurred vision to resolve after I have received medications for several weeks." Rationale: MS causes nerve damage & can result in optic neuritis (Vision loss, blurry vision). In most cases it resolves itself in 4-12 weeks, but medications (steroids can speed up the process & resolve it quicker. 1. MS patients should not exert themselves too much at one time. Space out activities & allow time for rest. 2. Urinary retention is primarily treated by medication (bethanochol), and exercises can aid with it but are not the primary treatment. 3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves are already messed up and extra heat can stress the body into overdrive.

The nurse has taught a client with multiple sclerosis (MS). Which of the following statements by the client would indicate a correct understanding of the teaching? 1. "I will complete all of my household chores in the morning when I am well rested." 2. "I have learned how to massage my bladder to help empty my bladder completely." 3. "I will take a hot bath in the evening to help me relax if I have had a stressful day at work." 4. "I should expect the blurred vision to resolve after I have received medications for several weeks."

1. "I will begin to take dancing lessons." Rationale: 1. Dancing is a weight-bearing exercise that can help strengthen bones and reduce the risk of osteoporosis.

The nurse has taught about preventing osteoporosis to a 45-year-old client who has had a hysterectomy and bilateral salpingo-oophorectomy. Which of the following statements by the client would indicate correct understanding of the teaching? 1. "I will begin to take dancing lessons." 2. "I will get more rest at night." 3. "I will take a multivitamin supplement daily." 4. "I will add more fiber to my diet."

2. "I will place a picture on the bathroom door to indicate which room in our home is the bathroom." Rationale: 4. This is dangerous, they can get lost.

The nurse has taught the adult child caregiver of a client with moderate Alzheimer's disease (AD) about home care. Which of the following statements by the adult child would indicate a correct understanding of the teaching? 1. "I will only allow my parent to smoke while my parent is outdoors." 2. "I will place a picture on the bathroom door to indicate which room in our home is the bathroom." 3. "I will encourage family members to visit in large groups to keep my parents interested in the conversation." 4. "I will encourage my parent to take walks in the park when the weather permits to get the exercise needed."

3. "Participate in daily aerobic exercises for 60 minutes."

The nurse in a community-based setting is teaching clients over 65 years of age about health promotion activities. Which of the following information should the nurse include? 1. "Purchase all of your prescribed medications at the same pharmacy." 2. "Schedule an appointment for a vision screening every 3 years." 3. "Participate in daily aerobic exercises for 60 minutes." 4. "Increase your intake of fat-soluble vitamins."

Highlight: "Loss of appetite" "Abdominal pain rated 7/10 on the Numerical Rating Scale for 1 week." "Client states, "The abdominal pain started after my 7-year-old child accidentally kicked me in the stomach." "Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. Rationale: Loss of appetite may indicate an underlying medical condition or infection. The intensity of abdominal pain requires evaluation to determine the cause. Trauma to the abdomen can cause internal injuries that need to be assessed to ensure no significant damage or complications.

The nurse in the emergency department (ED) is caring for a 41-year-old male client. Highlight the findings below that would require follow-up. (See Picture)

Answer: Bowel obstruction: Appetite, Bowel Pattern, Gastrointestinal Symptoms. Appendicitis: Pain level. Ruptured Spleen: Pain level.

The nurse in the emergency department is caring for a 41-year-old male client. Nurse's Notes: 11:00: Client reports nausea, loss of appetite, vomiting, fever, and constipation for the past 2 weeks and abdominal pain rated 7/10 on the Numerical Rating Scale for 1 week. Client states "The abdominal pain started after my 7-year-old child accidentally kicked me in the stomach." Client plays soccer with the child once a week. Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No significant past medical or surgical history. Body mass index (BMI) 32. Drinks alcohol only during social occasions, usually 3 beverages. Smokes cigarettes during social occasions. For each assessment finding below, click to specify if the finding is consistent with the disease process of bowel obstruction, appendicitis, or ruptured spleen. Each finding may support more than 1 disease process.

Answer: •Anemia •Peritonitis •Septic Shock

The nurse in the emergency department is caring for a 41-year-old male client. Nurse's Notes: 11:00: Client reports nausea, loss of appetite, vomiting, fever, and constipation for the past 2 weeks and abdominal pain rated 7/10 on the Numerical Rating Scale for 1 week. Client states "The abdominal pain started after my 7-year-old child accidentally kicked me in the stomach." Client plays soccer with the child once a week. Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No significant past medical or surgical history. Body mass index (BMI) 32. Drinks alcohol only during social occasions, usually 3 beverages. Smokes cigarettes during social occasions. Select the 3 complications the client is at risk for developing. •Anemia •Peritonitis •Septic Shock •Hypovolemia •Dysrhythmias •Cardiac Arrest

Answer: Answers: Indicated: •Clear liquid diet •Soapsuds enema •Abdominal girth measurements •Abdominal Computed Tomography (CT) scan NOT indicated: •Heating pad to abdomen

The nurse in the emergency department is caring for a 41-year-old male client. Nurse's Notes: 11:00: Client reports nausea, loss of appetite, vomiting, fever, and constipation for the past 2 weeks and abdominal pain rated 7/10 on the Numerical Rating Scale for 1 week. Client states "The abdominal pain started after my 7-year-old child accidentally kicked me in the stomach." Client plays soccer with the child once a week. Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No significant past medical or surgical history. Body mass index (BMI) 32. Drinks alcohol only during social occasions, usually 3 beverages. Smokes cigarettes during social occasions. The nurse has reviewed the Nurses' Notes from 11:30. For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client.

1. Bipolar 1 disorder is experiencing a manic episode, is moving the legs, and is looking around the room restlessly. Rationale: These actions indicate that they could become a danger to others or themselves and should be removed from the situation.

The nurse in the inpatient psychiatric unit is leading a support group for clients. It would be a priority for the nurse to intervene if the client with: 1. Bipolar 1 disorder is experiencing a manic episode, is moving the legs, and is looking around the room restlessly. 2. Borderline personality disorder is saying that another group member is too disturbed to be attending the session. 3. Major depressive disorder is sitting quietly with the eyes downcast. 4. Schizophrenia is rocking in place and copying the gestures of another client in the group.

2. Private room with monitored negative air pressure. Rationale: Measles is airborne (MTV) and requires a private room with negative air pressure.

The nurse in the pediatric unit is preparing to admit a client with rubeola (measles). The nurse should assign the client to a: 1. Private room at the end of the hallway. 2. Private room with monitored negative air pressure. 3. Room with a client who has chickenpox. 4. Room with a client who has atopic dermatitis (eczema).

4. Request assistance from several nearby staff members with controlling the client's behavior.

The nurse in the psychiatrist unit is administering medications when a client with a borderline personality disorder approaches and asks to talk. The nurse suggests having a talk in 1 hour. The client shouts, "I'll wait. but you will be sorry!" and then picks up a pitcher of water and throws it onto the floor. Which of the following actions should the nurse take? 1. Offer to listen to the client while continuing to administer the medications. 2. Suggest that the client take a PRN prescribed medication for agitation. 3. Ask another nurse to finish administering the medications, and talk with the client. 4. Request assistance from several nearby staff members with controlling the client's behavior.

1. Closed reduction of a fractured tibia with cast applications 1 hour ago and is reporting that the casted leg feels hot. Rationale: Pain, tightness, or a hot feeling can indicate that the cast is on too tight. 2. It is normal to feel nauseous after coming off of anesthesia. 3. Knee pain is expected after knee surgery. 4. Right shoulder pain is common in laparoscopic cholecystectomy due to gas left in the abdomen after the procedure. This will resolve on its own.

The nurse in the same-day surgical center has received a change-of-shift report on the following clients. The nurse should first see the client who had: 1. Closed reduction of a fractured tibia with cast applications 1 hour ago and is reporting that the casted leg feels hot. 2. Extraction of a cataract lens 2 hours ago and is reporting nausea. 3. An arthroscopy of the right knee 3 hours ago and is reporting knee pain rated as 4 on a scale of 0 (no pain) to 10 (severe pain). 4. A laparoscopic cholecystectomy 4 hours ago and is reporting right shoulder pain.

2. 1+ pedal pulse of the affected extremity

The nurse is assessing a client who had cardiac catheterization 2 hours ago. Which of the following findings would require immediate follow-up? 1. Blood pressure, 104/70 mmHg 2. 1+ pedal pulse of the affected extremity 3. Heart rate, 98 4. Urine output of 100mL for the past 2 hours

4. Spontaneous bruising. Rationale: The liver has a role in synthesizing coagulating factors. Damage to the liver impairs coagulation. 1. Steatorrhea indicates a pancreatic problem.

The nurse is assessing a client with cirrhosis. Which of the following findings would be consistent with a diagnosis of cirrhosis? 1. Steatorrhea. 2. Deep vein thrombosis (DVT). 3. High fever. 4. Spontaneous bruising.

1. Dyspareunia. Rationale: This means pain with intercourse.

The nurse is assessing a client with suspected endometriosis. Which of the following findings would support a diagnosis of endometriosis? 1. Dyspareunia. 2. Hot flashes. 3. Weight gain. 4. Amenorrhea.

1. Elevated serum uric acid. 2. A swollen, red joint. 3. Reports of moderate fatigue. 5. Pain associated with movement of the affected extremity. Rationale: 4. Distal joints would be warm to touch. 6. Low fat milks can decrease occurrence of gout attacks.

The nurse is assessing a client with suspected gout. Which of the following findings would support a diagnosis of gout? Select all that apply. 1. Elevated serum uric acid. 2. A swollen, red joint. 3. Reports of moderate fatigue. 4. Distal extremities cool to touch. 5. Pain associated with movement of the affected extremity. 6. Intolerance of dairy products.

3. Cervical lymphadenopathy.

The nurse is assessing a client with suspected mononucleosis. Which of the following findings would support a diagnosis of mononucleosis? 1. Polyarthralgia. 2. Costovertebral pain. 3. Cervical lymphadenopathy. 4. Left lower quadrant (LLQ) tenderness.

3. Chancre lesions.

The nurse is assessing a male client who has suspected syphilis. Which of the following findings would support a diagnosis of syphilis? 1. Urethritis. 2. Conjunctivitis. 3. Chancre lesions. 4. Penile discharge.

1. Dizziness and confusion. Rationale: 3. Vesicular breath sounds are normal breath sounds.

The nurse is assessing a newly admitted client who sustained partial-thickness (second-degree) burns to the anterior thorax in a house fire. Which of the following findings would require immediate follow-up? 1. Dizziness and confusion. 2. Hypoactive bowel sounds and nausea. 3. Vesicular breath sounds throughout the lung fields. 4. Pain rated 5 on a scale of 0 (no pain) to 10 (severe pain)

1. Uneven stairs. 2. Throw rugs. 4. Dim lighting. Rationale: Hemiparesis and confusion are intrinsic factors. Intrinsic: A characteristic that is inherent to the individual and can not be influenced by behavioral changes.

The nurse is assessing an older adult client who is scheduled for discharge and is at risk for falls. Which of the following are extrinsic risk factors for falling? Select all that apply. 1. Uneven stairs. 2. Throw rugs. 3. Hemiparesis. 4. Dim lighting. 5. Confusion.

4. "I have let down my family because I will not be able to financially support them any longer."

The nurse is assessing the coping strategies of a client who had a myocardial infarction (MI) 3 days ago. Which of the following statements by the client would indicate ineffective coping? 1. "I know that stopping smoking will be difficult." 2. "I plan to attend a cardiac rehabilitation support group." 3. "I have trouble believing this has really happened to me." 4. "I have let down my family because I will not be able to financially support them any longer."

2. The client is sleeping but is easily aroused.

The nurse is caring for a 3-year-old client with a cerebral concussion who is being observed overnight in the pediatric unit. Which of the following observations would be most significant for the nurse to report to the oncoming shift? 1. The client has a blood pressure of 94/58 mmHg and an apical pulse of 90. 2. The client is sleeping but is easily aroused. 3. The client's pupils are equal and reactive to light. 4. The client has an axillary temperature of 99.0 F (37.2 C) and respirations of 24.

2. Wear a protective gown when changing the client's bed linens. 4. Place a box of clean gloves outside the client's door. Rationale: Impetigo is a highly infectious skin disease spread by direct contact. Contact Precautions include: Gown and gloves. Private closed door and surgical masks are appropriate for airborne and not necessary for contact.

The nurse is caring for a 3-year-old client with impetigo. Which of the following infection control precautions should the nurse implement? Select all that apply. 1. Wear a surgical mask when bathing the client. 2. Wear a protective gown when changing the client's bed linens. 3. Keep the door to the client's room closed. 4. Place a box of clean gloves outside the client's door. 5. Place a surgical mask on the client during transport to other departments.

3. Assist the client into a knee-chest position.

The nurse is caring for a client in the first stage of labor and observes that a segment of the umbilical cord is visible in the vaginal opening after rupture of the client's amniotic membranes. Which of the following actions should the nurse take? 1. Instruct the client to lie on her left side. 2. Attempt to place the umbilical cord back into the uterus. 3. Assist the client into a knee-chest position. 4. Administer an intravenous tocolytic agent.

2. Placing her left palm against a wall and "climbing" the wall with the left fingers.

The nurse is caring for a client who had a left modified radical mastectomy. The client received discharge instructions for performing range-of-motion (ROM) exercises on her left arm. Which of the following, if reported by the client on her return visit to the clinic, would indicate to the nurse that the instructions have been followed correctly? 1. Regular squeezing of a tennis ball in her left hand. 2. Placing her left palm against a wall and "climbing" the wall with the left fingers. 3. Carrying light hand weights while walking 1 mile every other day. 4. Performing isometric exercises with both arms extended.

1. Tracheal deviation.

The nurse is caring for a client who has a chest tube attached to a closed-chest drainage system. It would be a priority for the nurse to monitor the client for: 1. Tracheal deviation. 2. Pain at the insertion site. 3. Subcutaneous emphysema. 4. Redness or swelling at the insertion site.

4. Assess the client.

The nurse is caring for a client who has a prescription for an intravenous infusion of 0.45% sodium chloride (half-strength saline). The nurse notes the client is receiving 5% dextrose in water. Which of the following actions should the nurse take first? 1. Change the intravenous fluid to the prescribed fluid. 2. Notify the primary health care provider. 3. Complete an incident report. 4. Assess the client.

2. The foot is 2 inch (5cm) away from the foot plate. Rationale: The foot should be touching the foot plate.

The nurse is caring for a client who is in Buck traction. Which of the following would require immediate intervention? 1. A pillow is placed under the knee. 2. The foot is 2 inch (5cm) away from the foot plate. 3. The weights attached to the puller are 6 inch (15cm) from the floor. 4. A pillow is placed under the lower leg with the heel off the bed.

1. Stop the transfusion. 2. Check the client's vital signs. 3. Notify the client's primary health care provider. 4. Return the blood and infusion tubing to the blood bank. Rationale: Back pain and chills are symptoms of hemolytic transfusion reaction (wrong blood type). Must stop infusion, check vital signs, and notify the provider. 5. NS is used to keep the line open, not dextrose in water.

The nurse is caring for a client who is receiving a blood transfusion and states, "I feel chilled and am having back pain." Which of the following actions should the nurse take? Select all that apply. 1. Stop the transfusion. 2. Check the client's vital signs. 3. Notify the client's primary health care provider. 4. Return the blood and infusion tubing to the blood bank. 5. Infuse 5% dextrose in water through the intravenous catheter. 6. Administer a dose of an antiemetic prescribed PRN to the client.

3. Fever. Rationale: Phenothiazine side effects include ABCDEFG- anti-cholinergic (dry mouth), blurry vision, constipation, drowsiness, EPS, photosensitivity, and agranulocytosis. Fever would be a complication of agranulocytosis and requires the nurse to report.

The nurse is caring for a client who is receiving a high dose of a phenothiazine. When evaluating the client for a life-threatening syndrome related to the medication, it would be a priority for the nurse to report: 1. Dry mouth. 2. Orthostatic hypotension. 3. Fever. 4. Photophobia.

4. Hematoma. Rationale: A hematoma is a collection of blood outside of a blood vessel, usually caused by trauma or injury. It can cause pain and swelling, and can also affect the rate of infusion by compressing the vein.

The nurse is caring for a client who is receiving an intravenous infusion VIA a peripheral venous access device (VAD). The client reports sharp pain at the VAD site. The nurse notes the intravenous fluid in infusing more slowly than prescribed. The nurse should recognize that the client is most likely experiencing: 1. Venous spasm. 2. Nerve damage. 3. Septicemia. 4. Hematoma.

2. Prepare for transcutaneous pacing. & 5. Assess the client for angina. Rationale: 1. Beta Blockers would further decrease HR. 2. External pacing stimulates the ventricles to pump at a set rate. 3. Valsalva maneuver would further decrease HR. 4. Chest compressions are for cardiac arrest. 5. Angina (Chest pain) can be caused by both tachycardia (most common) and bradycardia (rare but can happen). Therefore, assessment of angina is appropriate.

The nurse is caring for a client who reports feeling faint and is experiencing the cardiac rhythm shown in the electrocardiogram (ECG) strip below. Which of the following actions would be appropriate for the nurse to take? Select all that apply. 1. Administer the client's prescribed beta blocker. 2. Prepare for transcutaneous pacing. 3. Instruct the client to perform the Valsalva maneuver. 4. Begin chest compressions. 5. Assess the client for angina.

2. Putting a surgical mask on the client during transport to the radiology department. Rationale: 1. The door should be closed. 4. TB is airborne precautions, not droplet.

The nurse is caring for a client with active pulmonary tuberculosis (TB). Which of the following should the nurse include in the client's plan of care? 1. Placing the client in a private room with the door open. 2. Putting a surgical mask on the client during transport to the radiology department. 3. Instructing the primary caregivers to wear surgical masks when caring for the client. 4. Instituting the standards for droplet precautions while caring for the client.

4. Early Mobilization

The nurse is caring for an older adult client in the postoperative period. The nurse should know that this client, compared with younger clients in the postoperative period, will have an increased need for: 1. Oral hygiene 2. Analgesics 3. High-calorie foods 4. Early Mobilization

1. Rheumatoid arthritis (RA) who has a 2-month-old infant.

The nurse is caring for the following clients. The nurse should recommend a referral to an occupational therapist for the client with: 1. Rheumatoid arthritis (RA) who has a 2-month-old infant. 2. An intertrochanteric hip fracture who works as a surgeon. 3. Mononucleosis who is a college student. 4. Tendonitis who is a professional tennis player.

2. Maintaining the urine collection bag in a dependent position. Rationale: The drainage bag should always be below the level of the bladder to prevent back flow.

The nurse is developing a plan of care for a client with a spinal cord injury at C5 who has an indwelling urethral catheter. Which of the following would be a priority for the nurse to include in the plan of care? 1. Encouraging the client to drink 6 to 8 glasses of fluid per day. 2. Maintaining the urine collection bag in a dependent position. 3. Teaching the client about foods high in fiber. 4. Assessing the color of the urine output.

3. Placing tissues and a trash receptacle within the client's reach. Rationale: It is important to not leave tissues laying around and to put them in a leak proof bag in the trash.

The nurse is evaluating a staff member's care of a client with active pulmonary tuberculosis (TB). Which of the following actions by the staff member would indicate to the nurse an understanding of the principles of infection control for tuberculosis isolation? 1. Instructing visitors to wash their hands before entering the client's room. 2. Putting on a mask, gown, and gloves before entering the client's room. 3. Placing tissues and a trash receptacle within the client's reach. 4. Asking the client to put on a clean mask each time someone enters the room.

3. "Restraints require an order from the primary health care provider." Rationale: 1. Restraints are removed every 2 hours for ROM exercises, toileting, and fluids. Assess every 15 minutes for the first hour, and then every 30 minutes. 2. Restraints should be secured to the bed, not the side rails. 4. Restraints are never PRN.

The nurse is planning a staff education program about caring for clients with restraints. Which of the following should the nurse include? 1. "Restraints should be removed once during a shift to perform passive range-of-motion (ROM) exercises for the client." 2. "Restraints should be secured to the side rails of the client's bed for quick release." 3. "Restraints require an order from the primary health care provider." 4. "Restraints may be used PRN for clients who are confused."

2. Sharing the client's blood alcohol level (BAL) test result with the police officer who brought the client to the emergency department (ED). Rationale: PHI is permitted to be discussed to police when PHI is needed to apprehend the perpetrator of a violent crime, suspect, or fugitive.

The nurse is planning a staff education program about client privacy. Which one of the following scenarios should the nurse include as an example of a violation of client privacy? 1. Discussing with an unlicensed assistive personnel (UAP) that the UAP's assigned client will require a smaller condom catheter. 2. Sharing the client's blood alcohol level (BAL) test result with the police officer who brought the client to the emergency department (ED). 3. Responding to the call light of the client who is assigned to another nurse and needs assistance in the bathroom. 4. Allowing a nursing student who has been assigned to the client to review the client's medical record.

1. "Use before touching medical equipment that will come in direct contact with the client."

The nurse is planning a staff education program about infection control guidelines. Which of the following information about alcohol-based hand rub should the nurse include? 1. "Use before touching medical equipment that will come in direct contact with the client." 2. "Avoid using when moving your hands from a contaminated body site to a clean body site during client care." 3. "Avoid using before caring for clients who have severe neutropenia." 4. "Use after contact with body excretions that do not cause your hands to be visibly soiled."

2. "The nurse has a duty to insist that the client repeat what has been said about a procedure for which consent is necessary." 3. "The primary health care provider must disclose the risks if the client declines a recommended procedure." 5. "Informed consent is not needed for emergency procedures that are in the client's best interest." Rationale: 1. The POA only steps in when the client is not able to make decisions for themselves. 4. The client should sign the consent form before any procedure or treatment, not specifically before receiving opioids.

The nurse is planning a staff education program about informed consent. Which of the following information should the nurse include? Select all that apply. 1. "An individual designated by a power of attorney for health care can provide informed consent despite the competency of the client." 2. "The nurse has a duty to insist that the client repeat what has been said about a procedure for which consent is necessary." 3. "The primary health care provider must disclose the risks if the client declines a recommended procedure." 4. "The client should sign the consent form prior to receiving prescribed opioids." 5. "Informed consent is not needed for emergency procedures that are in the client's best interest."

2. "Clients may withdraw consent after signing the informed consent form." 3. "Clients must sign the informed consent form before receiving pre-procedural medication." 4. "Nurses witness the signing of the informed consent form to confirm that consent is voluntary." 5. "The signed consent form serves as evidence that the informed consent process has taken place." Rationale: 1. While informed consent does provide some legal protection, it's primary purpose is to respect the patient's autonomy and ensure they are fully aware of risks, benefits and alternatives before they agree to a procedure or treatment.

The nurse is planning a staff education program about informed consent. Which of the following information should the nurse include? Select all that apply. 1. "The main value of informed consent is for protection against lawsuits." 2. "Clients may withdraw consent after signing the informed consent form." 3. "Clients must sign the informed consent form before receiving pre-procedural medication." 4. "Nurses witness the signing of the informed consent form to confirm that consent is voluntary." 5. "The signed consent form serves as evidence that the informed consent process has taken place."

2. "Encourage the child to empty the bladder completely." 3. "Encourage the child to maintain an adequate fluid intake." 4. "Teach the child how to properly cleanse the perineal area."

The nurse is planning a staff education program about the prevention of urinary tract infections (UTIs) in children. Which of the following information should the nurse include? Select all that apply. 1. "Teach the child to perform Kegel exercises." 2. "Encourage the child to empty the bladder completely." 3. "Encourage the child to maintain an adequate fluid intake." 4. "Teach the child how to properly cleanse the perineal area." 5. "Offer the child non-carbonated, decaffeinated beverage choices."

4. Avoid obtaining blood pressure measurements in the arm with the AV shunt. Rationale: 1. Sleep on unaffected side. 2. You would auscultate for the bruit and palpate for thrill to verify that the shunt is working. 3. No IV fluids through the shunt, just dialysis.

The nurse is planning care for a client who has a arteriovenous (AV) shunt in the left arm. Which of the following interventions should the nurse include in the client's plan of care? 1. Instruct the client to protect the AV shunt by tucking the left arm under the body while sleeping. 2. Check for a bruit by palpating the AV shunt. 3. Administer prescribed intravenous fluids through the AV shunt. 4. Avoid obtaining blood pressure measurements in the arm with the AV shunt.

1. "My spouse's response of "fine" when asked how the day has been may or may not be what my spouse meant to communicate." 3. "I will purchase a picture board to help my spouse express common needs, thoughts, and feelings that are difficult to communicate." 5. "I have arranged for my spouse to meet with a speech therapist twice each week to improve communication skills."

The nurse is planning care for a client who has expressive aphasia after a left-sided stroke. Which of the following statements by the client's spouse would indicate a correct understanding of the client's communication abilities and interaction needs? Select all that apply. 1. "My spouse's response of "fine" when asked how the day has been may or may not be what my spouse meant to communicate." 2. "I can anticipate what my spouse wants to say, so I complete my spouse's sentences to make communication quicker." 3. "I will purchase a picture board to help my spouse express common needs, thoughts, and feelings that are difficult to communicate." 4. "My spouse's angry response when we have a conversation makes me hesitant to try further communication." 5. "I have arranged for my spouse to meet with a speech therapist twice each week to improve communication skills."

1. Encourage the client to reminisce about happy memories. Rationale: 1. Is correct because it is possible for AD patients to retain long-term memories. 2. Redirect is protocol for dementia. Don't confront, they can't learn. 3. AD is irreversible. 4. In the moderate AD, dementia has already progressed to where the patient needs help with ADL's & planning daily activities. Asking them to plan can frustrate them & cause distress. Structured, pleasant activities that consider the person's likes & interests are the best.

The nurse is planning care for a client with moderate Alzheimer's Disease (AD). Which of the following interventions should the nurse include in the client's plan of care? 1. Encourage the client to reminisce about happy memories. 2. Confront the client when inappropriate or agitated behaviors occur. 3. Administer to the client the cholinesterase inhibitor to reverse the course of AD. 4. Provide the client with information about activity choices in the morning so the client can make plans for the day.

1. Establish a daily routine for the client. 2. Assist the client to void every 2 hours. 3. Introduce self upon interacting with the client. 4. Display a clock and calendar in the client's room.

The nurse is planning care for a client with moderate Alzheimer's disease (AD). Which of the following interventions should the nurse include in the client's plan of care? Select all that apply. 1. Establish a daily routine for the client. 2. Assist the client to void every 2 hours. 3. Introduce self upon interacting with the client. 4. Display a clock and calendar in the client's room. 5. Keep the client's television on during the day to distract the client.

2. Obtain a referral to a physical therapist for the client. Rationale: Ataxia is lack of muscle control in the arms and legs, which leads to lack of balance, coordination, and walking. Physical therapy is the area of referral for this type of issue. 1. Thick liquids is for dysphagia. 3. This is always indicated, not just in this circumstance. 4. This can be a tool for patients with expressive aphasia.

The nurse is planning care for a client with multiple sclerosis (MS) who has ataxia. Which of the following interventions should the nurse include in the client's plan of care? 1. Add thickener to thin liquids for the client. 2. Obtain a referral to a physical therapist for the client. 3. Face the client directly when speaking with the client. 4. Provide a board with pictures to help the client communicate needs.

4. Implement droplet precautions.

The nurse is planning care for a pediatric client being admitted with pertussis. Which one the following interventions should the nurse include in the client's plan of care? 1. Keep the client NPO. 2. Place a dehumidifier in the client's room. 3. Encourage the client to ambulate frequently. 4. Implement droplet precautions.

2. "TPN can be administered through a peripherally inserted central catheter (PICC)." 3. "Clients receiving TPN should be weighed daily." 4. "An infusion pump is used to deliver TPN." 5. "Serum glucose levels should be monitored in clients receiving TPN." Rationale: 1. TPN tubing is changed daily (every 24 hours.)

The nurse is preparing a staff education program about total parenteral nutrition (TPN). Which of the following information should the nurse include? Select all that apply. 1. "The TPN intravenous tubing should be changed once a week." 2. "TPN can be administered through a peripherally inserted central catheter (PICC)." 3. "Clients receiving TPN should be weighed daily." 4. "An infusion pump is used to deliver TPN." 5. "Serum glucose levels should be monitored in clients receiving TPN."

1. Heart block. Rationale: Beta blockers will further depress the cardiac rhythm. Beta blockers are indicated in MI, HF, and angina pectoris.

The nurse is preparing to administer a beta blocker to a client. Which of the following would be a contraindication to administer the medication? 1. Heart block. 2. Myocardial infarction (MI). 3. Heart failure. 4. Angina pectoris.

4. Verify with another nurse that the client's room number is on both the blood product label and the client's identification band. Rationale: You always verify blood products with another nurse. Blood should only be given with normal saline and infused with an 18 or 20 gauge needle.

The nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client. Which of the following actions should the nurse take? 1. Assess the client's recent urine output. 2. Prime a Y-tubing blood administration set with lactated Ringer's solution. 3. Ensure that the client has a peripheral venous access device (VAD) that is 24-gauge or larger. 4. Verify with another nurse that the client's room number is on both the blood product label and the client's identification band.

4. Blood urea nitrogen (BUN) and serum creatinine. Rationale: Aminoglycosides are ototoxic and nephrotoxic.

The nurse is preparing to administer an aminoglycoside. Which of the following laboratory test results should the nurse review before administering the medication? 1. Serum electrolyte level and serum uric acid level. 2. Hemoglobin (Hgb) and white blood cell (WBC) count. 3. Serum ammonia level and serum glucose level. 4. Blood urea nitrogen (BUN) and serum creatinine.

1. Check the medication dosage in a medication reference source.

The nurse is preparing to administer lorazepam 2mg, IV, now to a client who is scheduled for surgery in 30minutes. The nurse is unfamiliar with the dosage for the medication. Which of the following actions should the nurse take next? 1. Check the medication dosage in a medication reference source. 2. Ask another nurse whether the prescribed dose is a safe dose. 3. Clarify that the dose is correct with the primary health care provider. 4. Contact the pharmacist to verify the safe dosage range for the medication.

3. Assign the client to a private room with monitored negative air pressure.

The nurse is preparing to admit a client who has pleuritic chest pain and is reporting a cough productive of yellow sputum for the past 1 week. The client has a pulse oximetry reading of 90% on room air. Which of the following infection control precautions should the nurse implement? 1. Use a stethoscope that is designated for use with the client only. 2. Wear sterile gloves when inserting a peripheral venous access device (VAD). 3. Assign the client to a private room with monitored negative air pressure. 4. Place a box of surgical masks inside the client's room.

1. Ask the client to open and close the fist multiple times.

The nurse is preparing to insert a peripheral venous access device (VAD) for a client. Which of the following actions should the nurse take? 1. Ask the client to open and close the fist multiple times. 2. Tap the client's vein multiple times to promote dilation. 3. Apply the tourniquet 9 to 10 inch (22.5 to 25 cm) above the venipuncture site. 4. Palpate for a vein after cleansing the selected site.

1. Computed tomography (CT) scan of the abdomen with intravenous contrast media. Rationale: CT's use iodinated contrast which is harmful to the kidneys and therefore is contraindicated in a client with AKI.

The nurse is reviewing the orders of a client who has acute kidney injury. Which of the following orders should the nurse clarify? 1. Computed tomography (CT) scan of the abdomen with intravenous contrast media. 2. Urine specimen for urinalysis. 3. Blood specimen for arterial blood gas (ABG). 4. Referral to registered dietitian for parenteral nutrition evaluation.

4. Had colon cancer and received chemotherapy treatments. Rationale: Chemotherapy is known to cause leukemia, and chemo has a greater risk than radiation to cause leukemia.

The nurse is screening clients for those at increased risk for developing cancer. At highest risk for developing leukemia is the client who: 1. Received more than 3 blood transfusions. 2. Has a magnetic resonance imaging (MRI) scan annually. 3. Has polycythemia vera and requires phlebotomy treatments. 4. Had colon cancer and received chemotherapy treatments.

4. "I take echinacea every day to help improve my immune system." Rationale: Echinacea consumption every day can damage the liver and immunosuppressed the client.

The nurse is talking with a client who has a positive laboratory test result for human immunodeficiency virus (HIV) infection. Which of the following statements by the client would require follow-up? 1. "I try to eat a well-balanced diet." 2. "I avoid crowds when I go outside the house." 3. "I am taking a vitamin C tablet daily to help prevent infections." 4. "I take echinacea every day to help improve my immune system."

3. "You did the best you could in very difficult circumstances." 5. "You are safe here." Rationale: 2. You wouldn't promote a shower yet because the nurse needs to collect physical evidence.

The nurse is talking with a client who has been sexually assaulted. The client states, "I never should have walked home late at night. I am to blame for what has happened to me." Which of the following would be an appropriate response for the nurse to make? Select all that apply. 1. "The police officers who brought you into the hospital will be with you during this interview." 2. "You should take a warm, calming shower in order to feel more relaxed." 3. "You did the best you could in very difficult circumstances." 4. "Sometimes the victim's behavior causes the violence." 5. "You are safe here."

1. "How will you be getting home after the procedure?" 2. "Do you have access to a thermometer after you leave here?" 3. "What allergies do you have?"

The nurse is talking with a client who is scheduled for endoscopic retrograde cholangiopancreatography (ERCP) in 2 hours in the outpatient department. Which of the following questions would be important for the nurse to ask? Select all that apply. 1. "How will you be getting home after the procedure?" 2. "Do you have access to a thermometer after you leave here?" 3. "What allergies do you have?" 4. "Are you wearing dentures?" 5. "Do you have external hemorrhoids?"

1. "Use your hands and arms to support your body weight." Rationale: 1. Is true, but watch out if it isn't 2-3 finger-widths, because crutch paralysis can occur. S/S: Paresis & Paresthesias in wrist & hands. 2. Is a fall risk. 3. Crutches should be 6 inches in front & 6 inches lateral. 4. Elbow should be bent at a 30 degree angle.

The nurse is teaching a client how to ambulate using crutches. Which of the following information should the nurse include? 1. "Use your hands and arms to support your body weight." 2. "Wear slippers when ambulating with the crutches in your home." 3. "Maintain the crutches 12inch (30cm) in front of your feet while standing." 4. "Adjust the hand grips of the crutches so that your elbows are fully extended."

2. "You may be prescribed a bulk-forming laxative." Rationale: There's no need to restrict fluids or diet. Diet does not cause diverticulitis exacerbations.

The nurse is teaching a client newly diagnosed with diverticulosis. Which of the following information should the nurse include? 1. "Limit your daily fluid intake to 2L to avoid bloating." 2. "You may be prescribed a bulk-forming laxative." 3. "Limit your intake of dairy products such as milk and yogurt." 4. "You should avoid consuming cooked vegetables."

1. "Carry emergency identification with you listening your condition and medication regimen." Rationale: 2. Propylthiouracil and methimazole both cause neutropenia and agranulocytosis at therapeutic doses. 3. You will experience weight gain (slowed metabolism).

The nurse is teaching a client who is receiving newly prescribed propylthiouracil. Which of the following information should the nurse include? 1. "Carry emergency identification with you listening your condition and medication regimen." 2. "The medication dose will need to be reduced if you develop agranulocytosis." 3. "You will experience weight loss if the medication is effective." 4. "Increase your daily intake of foods containing iodine."

1. "You will be asked to urinate when starting the collection, and the initial urine will be discarded." 2. "A sign will be posted on the bathroom door as a reminder to save your urine." 3. "You will be asked to void at the end of the designated time period to complete the urine collection." Rationale: 24-hour urine collection: 1st urine of the day (right after awakening) is discarded. Save all urine, a sign posted on the door is a helpful reminder. Lastly, void at the end of the designated time period to record all of the urine output in a 24-hour period and send to the lab. Don't send at the end of each shift because the collection is not completed yet.

The nurse is teaching a client who is scheduled for a 24-hour urine collection. Which of the following information should the nurse include? Select all that apply. 1. "You will be asked to urinate when starting the collection, and the initial urine will be discarded." 2. "A sign will be posted on the bathroom door as a reminder to save your urine." 3. "You will be asked to void at the end of the designated time period to complete the urine collection." 4. "You should discard urine that is dark or pink in color." 5. "The collected urine will be sent to the laboratory at the end of each shift."

2. "Do not bend the affected hip more than 90 degrees after surgery." 3. "Skin preparation and cleansing is mandatory before surgery. 4. "Use an elevated toilet seat for at least 6 weeks after surgery." Rationale: Posterior approach precautions: •Do not bend the hip more than 90 degrees. •Do not cross legs or feet. •Do not roll or lie on the un-operated side for 1st 6 weeks. •Do not twist the upper body when standing. •Sleep on the back for 1st 6 weeks. The patient may benefit from a shower chair or elevated seat from home use. Avoid bathing for 8 to 12 weeks (flexed and bent down in the tub).

The nurse is teaching a client who is scheduled for a total hip arthroplasty VIA a posterior approach. Which of the following information should the nurse include? Select all that apply. 1. "The type of prosthesis used is based on the muscle strength and joint function of your upper extremities." 2. "Do not bend the affected hip more than 90 degrees after surgery." 3. "Skin preparation and cleansing is mandatory before surgery. 4. "Use an elevated toilet seat for at least 6 weeks after surgery." 5. "You can resume sexual intercourse after surgery if your partner is in a dependent position."

1. Use distraction when the client becomes agitated. 2. Place calendars within clear view of the client. 3. Use short, simple sentences and provide step-by-step instructions for the client. 5. Encourage the client to participate in a daytime exercise program to promote restful sleep at night.

The nurse is teaching the family member of a client with moderate Alzheimer's disease (AD). Which of the following interventions should the nurse include in the teaching? Select all that apply. 1. Use distraction when the client becomes agitated. 2. Place calendars within clear view of the client. 3. Use short, simple sentences and provide step-by-step instructions for the client. 4. Avoid reminiscing with the client about past experiences in order to avoid feelings of loss and loneliness. 5. Encourage the client to participate in a daytime exercise program to promote restful sleep at night.

1. The client gave consent voluntarily. 2. The client received adequate disclosure. 4. The client understands the scheduled procedure or treatment. Rationale: 3. The PCP explains the procedure and the nurse witnesses the consent. Only 1 RN is needed to witness this.

The nurse is witnessing the client's signature on a consent form. Which of the following conditions should the nurse recognize must be met to ensure the consent is valid? Select all that apply. 1. The client gave consent voluntarily. 2. The client received adequate disclosure. 3. The consent form is witnessed by 2 health care professionals. 4. The client understands the scheduled procedure or treatment. 5. The consent form is signed within 24 hours of the scheduled procedure or treatment.

4. Placement of the palms at the level of the tenth ribs with thumbs pointing to the xiphoid process, then asking the client to inhale.

The nurse observes a coworker who is assessing a client's thoracic expansion. Which of the following would indicate that the coworker is using the correct assessment technique? 1. Percussion from the apex of the scapula downward on each side. 2. Placement of the hands flat on the back with the thumbs at the level of the tenth ribs pointing to the spine, then asking the client to inhale. 3. Measurement of the anteroposterior diameter of the chest. 4. Placement of the palms at the level of the tenth ribs with thumbs pointing to the xiphoid process, then asking the client to inhale.

3. "My child's eyes may be sensitive to light until the infection resolves." Rationale: 2. Cleaning the eyelids and eyelashes is not necessary and may further irritate the eyes. 4. Bacterial conjunctivitis is typically treated with antibiotic eye drops or ointment.

The nurse taught the parent of a 9-year-old child who has been newly diagnosed with bacterial conjunctivitis. Which of the following statements by the parent would indicate a correct understanding of the teaching? 1. "The infection produces profuse watery discharge." 2. "I should clean my child's eyelids and eyelashes with soap and water prior to instilling the medication." 3. "My child's eyes may be sensitive to light until the infection resolves." 4. "The prescribed corticosteroid eyedrops should be used for 1 week."