PEP Ch 3, 4, 5

The nurse is caring for a newly admitted client with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza ("bird flu"). Which of these prescribed actions will the nurse implement first? 1. Start oxygen using a nonrebreather mask. 2. Infuse 5% dextrose in water at 100 mL/hr. 3. Administer the first dose of oral oseltamivir. 4. Obtain blood and sputum specimens for testing.

Ans: 1 Because the respiratory manifestations associated with avian influenza are potentially life threatening, the nurse's initial action should be to start oxygen therapy. The other interventions should be implemented after addressing the client's respiratory problems

When scheduling a patient for skin testing for allergies, which information is most important for the allergy clinic nurse to include in patient teaching? 1. Avoid taking antihistamines before the skin testing. 2. Skin testing may be done with an intradermal injection. 3. Swelling and itching may occur at the site of the skin testing. 4. Patient will need to wait in the clinic for 20 minutes after the testing.

Ans: 1 Because antihistamine use before skin testing may prevent a reaction to an allergen, it is important that no antihistamine be taken before arriving for the skin testing, or the testing will have to be rescheduled. The other information may also be included, but it is not as important as avoiding any antihistamine before the skin testing takes place.

Which statement by a client with hypovolemia related to dehydration is the best indicator to the nurse of the need for additional teaching? 1. "I will drink 2 to 3 L of fluids every day." 2. "I will drink a glass of water whenever I feel thirsty." 3. "I will drink coffee and cola drinks throughout the day." 4. "I will avoid drinks containing alcohol."

ANS: 3 Mild dehydration is very common among healthy adults and is corrected or prevented easily by matching fluid intake with fluid output. Teach all adults to drink more fluids, especially water. Beverages with caffeine can increase fluid loss, as can drinks containing alcohol. These beverages should not be used to prevent or treat dehydration

A 88-year-old client who has not yet had the influenza vaccine is admitted after reporting symptoms of generalized muscle aching, cough, and runny nose starting about 24 hours previously. Which of these prescribed medications is most important for the nurse to administer at this time? 1. Oseltamivir 75 mg PO 2. Guaifenesin 600 mg PO 3. Acetaminophen 650 mg PO 4. Influenza vaccine 180 mcg IM

Ans: 1 Because antivirals are most effective when used early in influenza infection, the nurse should administer the oseltamivir as soon as possible to decrease the severity of the infection and risk of transmission to others. Guaifenesin and acetaminophen will help with the symptoms of cough and muscle aching but will not shorten the course of the client's illness or decrease risk of transmission. The influenza vaccine may still help in preventing future influenza caused by another virus

Methylprednisolone 60 mg IV is prescribed for a patient who is experiencing a systemic lupus erythematosus (SLE) exacerbation. Based on the label for the medication below, the nurse will administer ______ml 125mg/2ml

Ans: 0.96 mL When administering endocrine medications such as steroids through parenteral routes, the nurse should avoid rounding the medication. 125 mg in 2 mL equals 60 mg in 0.96 mL

A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assesses the client, which finding would the nurse instruct the student to report immediately? 1. Respiratory rate of 8 to 10 breaths/min 2. Decrease in pain level from 6 to 2 (on a scale of 1 to 10) 3. Request by the client that the room door be closed 4. Heart rate of 90 to 100 beats/min

Ans: 1 A decreased respiratory rate indicates respiratory depression, which also puts the client at risk for respiratory acidosis. All of the other findings are important and should be reported to the RN, but the respiratory rate demands urgent attention

A patient with systemic lupus erythematosus (SLE) is admitted to the hospital with acute joint inflammation. Which information obtained in the laboratory testing will be of highest concern to the nurse? 1. Elevated blood urea nitrogen level 2. Increased C-reactive protein level 3. Positive antinuclear antibody test result 4. Positive lupus erythematosus cell preparation

Ans: 1 A high number of patients with SLE develop nephropathy, so an increase in blood urea nitrogen level may indicate a need for a change in therapy or for further diagnostic testing such as a creatinine clearance test or renal biopsy. The other laboratory results are expected in patients with SLE

A patient with newly diagnosed acquired immunodeficiency syndrome (AIDS) has a 6-mm induration at 48 hours after a skin test for tuberculosis (TB). Which action will the nurse anticipate taking next? 1. Arrange for a chest x-ray to check for active TB. 2. Tell the patient that the TB test results are negative. 3. Teach the patient about multidrug treatment for TB. 4. Schedule TB skin testing again in 12 months.

Ans: 1 According to National Institutes of Health guidelines, an induration of 5 mm or greater indicates TB infection in patients with HIV and a chest radiograph will be needed to determine whether the patient has active or latent TB infection. Teaching about multidrug therapy is needed if the patient has active TB, but latent TB is treated with a single drug (usually isoniazid) only. Positive skin test results generally persist throughout the patient's lifetime and will not be repeated, although other tests such as follow-up chest radiographs and sputum testing may be used to evaluate for effective TB treatment.

Which policy implemented by the infection control nurse will most effectively reduce the incidence of catheter-associated urinary tract infections (CAUTIs)? 1. Limit the use of indwelling urinary catheters in all hospitalized clients. 2. Ensure that clients with catheters have at least a 1500-mL fluid intake daily. 3. Use urine dipstick testing to screen catheterized clients for asymptomatic bacteriuria. 4. Require the use of antimicrobial/antiseptic-impregnated catheters for catheterization.

Ans: 1 According to the Centers for Disease Control and Prevention (CDC), CAUTIs are the most common health care-acquired infection in the United States. Recommendations include avoiding the use of indwelling catheters and the removal of catheters as soon as possible. Although a high fluid intake will also help to reduce the risk for CAUTIs, 1500 mL may be excessive for some clients. The CDC recommends against routine screening for asymptomatic bacteriuria. Antimicrobial catheters are a secondary recommendation and may be appropriate if other measures are not effective in reducing the incidence of CAUTIs.

A hospitalized patient with acquired immunodeficiency syndrome (AIDS) has wasting syndrome. Which nursing action is appropriate to assign to an LPN/LVN who is providing care to this patient? 1. Administering oxandrolone 5 mg/day 2. Assessing the patient for other nutritional risk factors 3. Developing a plan of care to improve the patient's appetite 4. Providing instructions about a high-calorie, high-protein diet

Ans: 1 Administration of oral medication is included in LPN/LVN education and scope of practice. Assessment, planning of care, and teaching are more complex RN-level interventions

The nurse is evaluating a patient with human immunodeficiency virus (HIV) who is receiving trimethoprim-sulfamethoxazole (TMP-SMX) as a treatment for Pneumocystis jiroveci pneumonia. Which information is most important to communicate to the health care provider? 1. The patient reports a blistering rash. 2. The patient's fluid intake is 2 L/day. 3. The patient's potassium is 3.4 mg/dL (3.4 mmol/L). 4. The patient enjoys spending time outside in the sun.

Ans: 1 Because TMP-SMX can cause Stevens-Johnson syndrome (a life-threatening skin condition), a blistering rash indicates a need to discontinue the medication immediately. Two L/day of fluid is adequate to prevent crystalluria and renal damage associated with TMP-SMX. TMP-SMX can cause hyperkalemia; the nurse will report the potassium level to the provider, but the low potassium level is not caused by the medication. Patient teaching about photosensitivity is needed, but the nurse does not need guidance from the provider to implement this action

A client who has had recent exposure to Ebola while traveling in Africa arrives in the emergency department with fever, headache, vomiting, and multiple ecchymoses. Which action should the nurse take first? 1. Place the client in a private room. 2. Obtain heart rate and blood pressure. 3. Notify the hospital infection control nurse. 4. Ask the client to describe type of Ebola exposure.

Ans: 1 Centers for Disease Control and Prevention guidelines recommend that the initial action be to place the client in a private room and implement standard, contact, and droplet precautions. Further assessment of the type of possible Ebola exposure, obtaining vital signs, and notification of the infection control nurse will also be needed but should be done after measures to minimize transmission of Ebola are implemented

The nurse is providing care for several clients who are at risk for acid-base imbalance. Which client is most at risk for respiratory acidosis? 1. A 68-year-old client with chronic emphysema 2. A 58-year-old client who uses antacids every day 3. A 48-year-old client with an anxiety disorder 4. A 28-year-old client with salicylate intoxication

Ans: 1 Clients at greatest risk for acute acidosis are those with problems that impair breathing. Older adults with chronic health problems are at greater risk for developing acidosis. Whereas a client who misuses antacids is at risk for metabolic alkalosis, a client with anxiety is at risk for respiratory alkalosis. A client with salicylate intoxication is at risk for metabolic acidosis

A pregnant client in the first trimester tells the nurse that she was recently exposed to the Zika virus while traveling in Southeast Asia. Which action by the nurse is most important? 1. Arrange for testing for Zika virus infection. 2. Discuss need for multiple fetal ultrasounds during pregnancy. 3. Describe potential impact of Zika infection on fetal development. 4. Assess for symptoms such as rash, joint pain, conjunctivitis, and fever.

Ans: 1 Current guidelines recommend that pregnant women who are exposed to Zika virus be tested for infection. Fetal ultrasonography is recommended for any pregnant woman who has had possible Zika virus exposure, but multiple ultrasound studies will not be needed unless test results are positive. Education about the effects of Zika infection on fetal development may be needed, but this is not the highest priority at this time. The nurse will assess for Zika symptoms, but testing for the virus will be done even if the client is asymptomatic

The client described in question 3 is also at risk for poor perfusion related to decreased plasma volume. Which assessment finding supports this risk? 1. Flattened neck veins when the client is in the supine position 2. Full and bounding pedal and post-tibial pulses 3. Pitting edema located in the feet, ankles, and calves 4. Shallow respirations with crackles on auscultation

Ans: 1 Normally, neck veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position. The other three responses are characteristic of excess fluid volume

A client is admitted to the oncology unit for chemotherapy. To prevent an acid-base problem, which finding would the nurse instruct the unlicensed assistive personnel (UAP) to report? 1. Repeated episodes of nausea and vomiting 2. Reports of pain associated with exertion 3. Failure to eat all the food on the breakfast tray 4. Client hair loss during the morning bath

Ans: 1 Prolonged nausea and vomiting can result in acid deficit that can lead to metabolic alkalosis. The other findings are important and need to be assessed but are not related to acid-base imbalances

A patient in the allergy clinic who has a rash has received diphenhydramine 50 mg PO. Which patient information is most indicative of a need for action by the nurse? 1. The patient is preparing to drive home. 2. The patient reports itching at the site of the rash. 3. The patient has a history of constipation. 4. The patient states, "My mouth feels so very dry!"

Ans: 1 Sedation is a common effect of the first-generation antihistamines, and patients should be cautioned against driving when taking medications such as diphenhydramine. Itching of the rash is expected with an allergic reaction. The patient should be taught about how to manage common antihistamine side effects such as constipation and oral dryness, but these side effects are not safety concerns.

The nurse manager in a public health department is implementing a plan to reduce the incidence of infection with human immunodeficiency virus (HIV) in the community. Which nursing action will be delegated to unlicensed assistive personnel (UAP) working for the agency? 1. Supplying injection drug users with sterile injection equipment such as needles and syringes 2. Interviewing patients about behaviors that indicate a need for annual HIV testing 3. Teaching high-risk community members about the use of condoms in preventing HIV infection 4. Assessing the community to determine which population groups to target for education

Ans: 1 Supplying sterile injection supplies to patients who are at risk for HIV infection can be done by staff members with UAP education. Assessing for high-risk behaviors, education, and community assessment are RN-level skills

Which medication order for a client with a pulmonary embolism is most important to clarify with the prescribing health care provider before administration? 1. Warfarin 1.0 mg PO 2. Morphine 2 to 4 mg IV 3. Cephalexin 250 mg PO 4. Heparin infusion at 900 units/hr

Ans: 1 The Institute for Safe Medication Practices guidelines indicate that the use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose (in this case, 10 mg). The order should be clarified before administration. The other orders are appropriate based on the client's diagnosis

The client with respiratory failure is receiving mechanical ventilation and continues to produce arterial blood gas results indicating respiratory acidosis. Which change in ventilator setting should the nurse expect to correct this problem? 1. Increase in ventilator rate from 6 to 10 breaths/min 2. Decrease in ventilator rate from 10 to 6 breaths/min 3. Increase in oxygen concentration from 30% to 40% 4. Decrease in oxygen concentration from 40% to 30%

Ans: 1 The blood gas component responsible for respiratory acidosis is carbon dioxide, thus increasing the ventilator rate will blow off more carbon dioxide and decrease or correct the acidosis. Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis

A client's potassium level is 6.7 mEq/L (6.7 mmol/L). Which intervention should the nurse delegate to the first-year student nurse whom he or she is supervising? 1. Administer sodium polystyrene sulfonate 15 g orally. 2. Administer spironolactone 25 mg orally. 3. Assess the electrocardiogram (ECG) strip for tall T waves. 4. Administer potassium 10 mEq (10 mmol/L) orally.

Ans: 1 The client's potassium level is high (normal range is 3.5 to 5 mEq/L or 3.5 to 5 mmol/L). Sodium polystyrene sulfonate removes potassium from the body through the gastrointestinal system. Spironolactone is a potassium-sparing diuretic that may cause the client's potassium level to go even higher. A KCl supplement can also raise the potassium level even higher. The beginning nursing student does not have the skill to assess ECG strips

A client with atrial fibrillation is ambulating in the hallway on the coronary step-down unit and suddenly tells the nurse, "I feel really dizzy." Which action should the nurse take first? 1. Help the client to sit down. 2. Check the client's apical pulse. 3. Take the client's blood pressure. 4. Have the client breathe deeply.

Ans: 1 The first priority for an ambulating client who is dizzy is to prevent falls, which could lead to serious injury. The other actions are also appropriate but are not as high a priority

A client who has been diagnosed with possible avian influenza is admitted to the medical unit. Which prescribed action will the nurse take first? 1. Place the client in an airborne isolation room. 2. Initiate infusion of 500 mL of normal saline bolus. 3. Ask the client about any recent travel to Asia. 4. Obtain sputum specimen and nasal cultures.

Ans: 1 The initial action should be to prevent transmission of avian influenza to other clients, visitors, or health care personnel through the use of airborne, contact, and standard isolation precautions. Initiating IV fluids, determining whether the client has been exposed to avian influenza through travel, and obtaining cultures are also appropriate, but the highest priority is to prevent spread of infection

The student nurse, under the supervision of an RN, is reviewing a client's arterial blood gas results and notes an acute increase in arterial partial pressure of carbon dioxide (Paco2) to 51 mm Hg compared with the previous results. Which statement by the student nurse indicates accurate understanding of acid-base balance for this client? 1. "When the Paco2 is acutely elevated, the blood pH should be lower than normal." 2. "This client should be taught to breathe and rebreathe in a paper bag." 3. "An elevated Paco2 always means that a client has an acidosis." 4. "When a client's Paco2 is increased, the respiratory rate should decrease to compensate."

Ans: 1 This client's Paco2 is elevated (normal is 35 to 45 mm Hg). Whenever the Paco2 level changes acutely, the pH changes to the same degree, in the opposite direction. As the amount of CO2 begins to rise above normal in brain blood and tissues, these central receptors trigger the neurons to increase the rate and depth of breathing (hyperventilation). For these reasons, answers 2, 3, and 4 are inaccurate

The nurse is preparing to change the linens on the bed of a client who has a sacral wound infected by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) items will be used? Select all that apply. 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. N95 respirator

Ans: 1, 2 A gown and gloves should be used when coming in contact with linens that may be contaminated by the client's wound secretions. The other PPE items are not necessary because transmission by splashes, droplets, or airborne means will not occur when the bed is changed

The nurse is working with a patient who has a new diagnosis of human immunodeficiency virus (HIV) and who reports current use of injectable heroin and methamphetamine. Which actions by the nurse are appropriate? Select all that apply. 1. Refer the patient to a substance abuse treatment program. 2. Plan for the patient to participate in a needle exchange program. 3. Coordinate the patient's schedule for directly observed antiretroviral drug treatment. 4. Instruct the patient that ongoing injectable drug use is a contraindication for antiretroviral therapy. 5. Provide patient education about the risk of transmitting HIV to others when sharing needles.

Ans: 1, 2, 3, 5 Current guidelines indicate that antiretroviral therapy for HIV should be initiated as soon as possible after HIV diagnosis. Although ongoing substance abuse is a risk factor for poor adherence, antiretroviral therapy can be initiated when strategies to improve adherence are used. Strategies include directly observing patients taking medications, needle exchange programs, and referring patients for substance abuse treatment.

When the nurse is educating a group of women of childbearing age about the Zika virus, which information will be included? Select all that apply. 1. Women who are pregnant will be asked about possible Zika exposure at each prenatal visit. 2. Testing for recent infection with the Zika virus is available for women who may have been exposed to Zika. 3. There is a high risk for maternal death when women are infected with the Zika virus during pregnancy. 4. Women who are trying to get pregnant should avoid travel to geographic areas with active Zika virus transmission. 5. Barrier methods such as condoms should be used during intercourse if the sex partner has possible Zika exposure.

Ans: 1, 2, 4, 5 National guidelines recommend that all pregnant women be assessed for Zika exposure at each prenatal visit, that women who may have been exposed be tested, that women who are anticipating pregnancy should avoid travel to areas where they might be exposed to Zika, and that barrier methods be used if the sex partner has been exposed to Zika infection. Congenital defects to the fetus occur if there is Zika infection during pregnancy, but the maternal infection is usually mild and nonfatal

The nursing care plan for an older client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? Select all that apply. 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Assess skin turgor by pinching the skin over the back of the hand 4. Observing the lips, tongue, and mucous membranes 5. Providing mouth care every 2 hours while the client is awake 6. Seeking a dietary consult to increase fluids on meal trays

Ans: 1, 2, 4, 5 The LPN/LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes, which contain agents such as alcohol. To assess skin turgor in an older adult, skin tenting is best checked by pinching the skin over the sternum or on the forehead rather than the back of the hand. With aging, the skin loses elasticity and tents on hands and arms even when the adult is well hydrated. Initiating a dietary consult is within the purview of the RN or health care provider

The nurse is completing a history for an older client at risk for an acidosis imbalance. Which questions would the nurse be sure to ask? Select all that apply. 1. "Which drugs to you take on a daily basis?" 2. "Do you have any problems with breathing?" 3. "When was your last bowel movement?" 4. "Have you experienced any activity intolerance or fatigue in the past 24 hours?" 5. "Over the past month have you had any dizziness or tinnitus?" 6. "Do you have episodes of drowsiness or decreased alertness?"

Ans: 1, 2, 4, 6 Collect data about risk factors related to the development of acidosis. Older adults may be taking drugs that disrupt acid-base balance, especially diuretics and aspirin. Ask about specific risk factors, such as any type of breathing problem. Also ask about headaches, behavior changes, increased drowsiness, reduced alertness, reduced attention span, lethargy, anorexia, abdominal distention, nausea or vomiting, muscle weakness, and increased fatigue. Ask the client to relate activities of the previous 24 hours to identify activity intolerance, behavior changes, and fatigue. Answers 3 and 5 are not common concerns with acidosis

The nurse is caring for a client who is intubated and receiving mechanical ventilation. Which nursing actions are most essential in reducing the client's risk for ventilator-associated pneumonia (VAP)? Select all that apply. 1. Keep the head of the client's bed elevated to at least 30 degrees. 2. Assess the client's readiness for extubation at least daily. 3. Ensure that the pneumococcal vaccine is administered. 4. Use a kinetic bed to continuously change the client's position. 5. Provide oral care with chlorhexidine solution at least daily.

Ans: 1, 2, 5 The ventilator bundle developed by the Institute for Healthcare Improvement includes recommendations for continuous elevation of the head of the bed, daily assessment for extubation readiness, and daily oral care with chlorhexidine solution. Pneumococcal immunization will prevent pneumococcal pneumonia, but it is not designed to prevent VAP. The use of a kinetic bed may also be of benefit to the client, but it is not considered essential

The nurse is supervising an LPN/LVN who says, "I gave the client with myasthenia gravis 90 mg of neostigmine instead of the ordered 45 mg!" In which order should the nurse perform the following actions? 1. Assess the client's heart rate. 2. Complete a medication error report. 3. Ask the LPN/LVN to explain how the error occurred. 4. Notify the health care provider of the incorrect medication dose.

Ans: 1, 4, 3, 2 The first action after a medication error should be to assess the client for adverse outcomes. The nurse should evaluate this client for symptoms such as bradycardia and excessive salivation, which indicate cholinergic crisis, a possible effect of excessive doses of anticholinesterase medications such as neostigmine. The health care provider should be rapidly notified so that treatment with atropine can be ordered to counteract the effects of the neostigmine, if necessary. Determining the circumstances that led to the error will help decrease the risk for future errors and will be needed to complete the medication error report

The client has an order for hydrochlorothiazide (HCTZ) 10 mg orally every day. What should the nurse be sure to include in a teaching plan for this drug? Select all that apply. 1. "Take this medication in the morning." 2. "This medication should be taken in two divided doses when you get up and when you go to bed." 3. "Eat foods with extra sodium every day." 4. "Inform your prescriber if you notice weight gain or increased swelling." 5. "You should expect your urine output to increase." 6. "Your health care provider may also prescribe a potassium supplement."

Ans: 1, 4, 5, 6 HCTZ is a thiazide diuretic. It should not be taken at night because it will cause the client to wake up to urinate. This type of diuretic causes a loss of potassium, so the nurse should teach the client about eating foods rich in potassium and that the health care provider may prescribe a potassium supplement. Weight gain and increased edema should not occur while the client is taking this drug, so these should be reported to the prescriber

The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to a new-graduated RN. Which actions can the new-graduate RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Providing oral care every 3 to 4 hours 2. Monitoring for indications of dehydration 3. Administering 0.45% saline by IV line 4. Record urine output when client voids 5. Assessing daily weights for trends 6. Help the client change position every 2 hours

Ans: 1, 4, 6 Providing oral care, assisting clients to reposition, and recording urine output are within the scope of practice of the UAP. Monitoring and assessing clients, as well as administering IV fluids, require the additional education and skills of the RN.

While administering vancomycin 500 mg IV to a client with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection, the nurse notices that the client's neck and face are becoming flushed. Which action should the nurse take next? 1. Discontinue the vancomycin infusion. 2. Slow the rate of the vancomycin infusion. 3. Obtain an order for an antihistamine. 4. Check the client's temperature.

Ans: 2 "Red man" syndrome occurs when vancomycin is infused too quickly. Because the client needs the medication to treat the infection, vancomycin should not be discontinued. Antihistamines may help decrease the flushing, but vancomycin should be administered over at least 60 minutes to avoid vasodilation. Although the client's temperature will be monitored, a temperature elevation is not the most likely cause of the client's flushing

The hospital employee health nurse is completing a health history for a newly hired staff member. Which information given by the new employee most indicates the need for further nursing action before the new employee begins orientation to patient care? 1. The employee takes enalapril for hypertension. 2. The employee has allergies to bananas, avocados, and papayas. 3. The employee received a tetanus vaccination 3 years ago. 4. The employee's tuberculin skin test has a 5-mm induration at 48 hours.

Ans: 2 A high incidence of latex allergy in seen in individuals with allergic reactions to these fruits. More information or testing is needed to determine whether the new employee has a latex allergy, which might affect the ability to provide direct patient care. The other findings are important to include in documenting the employee's health history but do not affect the ability to provide patient care

A client who has frequent watery stools and a possible Clostridium difficile infection is hospitalized with dehydration. Which nursing action should the charge nurse assign to an LPN/LVN? 1. Performing ongoing assessments to determine the client's hydration status 2. Explaining the purpose of ordered stool cultures to the client and family 3. Administering the prescribed metronidazole 500 mg PO to the client 4. Reviewing the client's medical history for any risk factors for diarrhea

Ans: 3 LPN/LVN scope of practice and education include administration of medications. Assessment of hydration status, client and family education, and assessment of client risk factors for diarrhea should be done by the RN

An experienced LPN/LVN reports to the RN that a client's blood pressure and heart rate have decreased, and when his face was assessed, one side twitches. What action should the RN take at this time? 1. Reassess the client's blood pressure and heart rate. 2. Review the client's morning calcium level. 3. Request a neurologic consult today. 4. Check the client's pupillary reaction to light.

Ans: 2 A positive Chvostek sign (facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front of the ear) is a neurologic manifestation of hypocalcemia. The heart rate may be slower or slightly faster than normal, with a weak, thready pulse. Severe hypocalcemia causes severe hypotension. The LPN/LVN is experienced and possesses the skills to accurately measure vital signs

Which of these patients cared for by the nurse in the clinic presents the highest risk for infection with human immunodeficiency virus (HIV) during sexual intercourse? 1. Uninfected man who reports performing oral intercourse with an HIV-infected woman 2. Uninfected man who is the receiver during anal intercourse with an HIV-infected man 3. Uninfected woman who has had vaginal intercourse with an HIV-infected man 4. Uninfected woman who has performed oral intercourse with an HIV-infected woman

Ans: 2 Because anal intercourse allows contact of the infected semen with mucous membrane and causes tearing of mucous membrane, there is a high risk of transmission of HIV. HIV can be transmitted through oral or vaginal intercourse as well but not as easily.

A patient who has human immunodeficiency virus (HIV) and is taking nucleoside reverse transcriptase inhibitors and a protease inhibitor is admitted to the psychiatric unit with a panic attack. Which information about the patient is most important to discuss with the health care provider? 1. The patient exclaims, "I'm afraid I'm going to die right here!" 2. The prescribed patient medications include midazolam 2 mg IV immediately. 3. The patient is diaphoretic and tremulous and reports dizziness. 4. The symptoms occurred suddenly while the patient was driving to work.

Ans: 2 Because protease inhibitors decrease the metabolism of many drugs, including midazolam, serious toxicity can develop when protease inhibitors are given with other medications. Midazolam should not be given to this patient. The other patient data are consistent with the patient's diagnosis of panic attack and do not indicate an urgent need to communicate with the provider.

Which action by the infection control nurse in an acute care hospital will be most effective in reducing the incidence of health care-associated infections? 1. Require nursing staff to don gowns to change wound dressings for all clients. 2. Ensure that dispensers for alcohol-based hand rubs are available in all client care areas. 3. Screen all newly admitted clients for colonization or infection with methicillin-resistant Staphylococcus aureus (MRSA). 4. Develop policies that automatically start antibiotic therapy for clients colonized by multidrug-resistant organisms

Ans: 2 Because the hands of health care workers are the most common means of transmission of infection from one client to another, the most effective method of preventing the spread of infection is to make supplies for hand hygiene readily available for staff to use. Wearing a gown to care for clients who are not on contact precautions is not necessary. Although some hospitals have started screening newly admitted clients for MRSA, this is not considered a priority action according to current national guidelines. Because administration of antibiotics to individuals who are colonized by bacteria may promote development of antibiotic resistance, antibiotic use should be restricted to clients who have clinical manifestations of infection

The nurse notices that the health care provider omits hand hygiene after leaving a client's hospital room. Which action by the nurse is best at this time? 1. Report the health care provider to the infection control department. 2. Offer the health care provider an alcohol based hand sanitizing fluid. 3. Provide the health care provider with a list of upcoming inservices on hand hygiene. 4. Remind the health care provider about the importance of minimizing infection spread.

Ans: 2 Because the most immediate need is to ensure that hand hygiene is accomplished, the nurse should offer an alcohol-based cleaner to the health care provider. The other actions may also be needed, especially if there is a pattern of nonadherence to hand hygiene, but further assessment is necessary before these actions are taken

When the occupational health nurse is teaching unlicensed assistive personnel (UAP) about bloodborne pathogen exposure and human immunodeficiency virus (HIV) risk, which information is most important to emphasize? 1. Occupational transmission of HIV from patients to health care workers is relatively rare. 2. Occupational exposure to HIV-containing fluids should be reported immediately to the supervisor. 3. Treatment for occupational exposure to HIV may include use of antiretroviral medications. 4. Postexposure treatment will include HIV testing at baseline and at several intervals after the exposure.

Ans: 2 Centers for Disease Control and Prevention guidelines indicate that if postexposure prophylaxis is to be used, antiretroviral drugs should be started as soon as possible, preferably within hours of the exposure. It is important that staff understand that reporting the possible exposure is a priority so that so that rapid assessment and treatment can be initiated. The other statements are also true but will not impact on the efficacy of any needed treatment

Which information about a client who has meningococcal meningitis is the best indicator that the nurse can discontinue droplet precautions? 1. Pupils are equal and reactive to light. 2. Appropriate antibiotics have been given for 24 hours. 3. Cough is productive of clear, nonpurulent mucus. 4. Temperature is lower than 100°F (37.8°C)

Ans: 2 Current Centers for Disease Control and Prevention evidence-based guidelines indicate that droplet precautions for clients with meningococcal meningitis can be discontinued when the client has received antibiotic therapy (with drugs that are effective against Neisseria meningitidis) for 24 hours. The other information may indicate that the client's condition is improving but does not indicate that droplet precautions should be discontinued

The nurse is caring for a confused and agitated client who has wrist restraints in place on both arms. Which action included in the client plan of care can be assigned to an LPN/LVN? 1. Determining whether the client's mental status justifies the continued use of restraints 2. Undoing and retying the restraints to improve client comfort 3. Reporting the client's status and continued need for restraints to the health care provider 4. Explaining the purpose of the restraints to the client's family members

Ans: 2 Hospital staff who have been trained in the appropriate application of restraints may reposition the restraints. Evaluation of the continued need for restraints, communication with the provider about the client's status, and teaching of the family require RN-level education and scope of practice.

Which specific instruction does the charge nurse give the unlicensed assistive personnel (UAP) helping to provide care for a client who is at risk for metabolic acidosis? 1. Check to see that the client keeps his oxygen in place at all times. 2. Inform the nurse immediately if the client's respiratory rate and depth increases. 3. Record any episodes of reflux or constipation. 4. Keep the client's ice water pitcher filled at all times.

Ans: 2 If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises. Breaths are deep and rapid and not under voluntary control, a pattern called Kussmaul respiration. The client may not require oxygen. Although it's important to record reflux and constipation, this is not related to metabolic acidosis nor is keeping the water pitcher full specific to this condition.

The nurse assesses a 24-year-old patient with rheumatoid arthritis who is considering using methotrexate for treatment. Which patient information is most important to communicate to the health care provider? 1. The patient has many concerns about the safety of the drug. 2. The patient has been trying to get pregnant. 3. The patient takes a daily multivitamin tablet. 4. The patient says that she has taken methotrexate in the past

Ans: 2 Methotrexate is teratogenic and should not be used by patients who are pregnant. The health care provider will need to discuss the use of contraception during the time the patient is taking methotrexate. The other patient information may require further patient assessment or teaching but does not indicate that methotrexate may be contraindicated for the patient.

The client has a nasogastric (NG) tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate and depth has decreased. What is the nurse's best response? 1. "It's common for clients with uncomfortable equipment such as NG tubes to have a lower rate of breathing." 2. "The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism." 3. "Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem." 4. "The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis."

Ans: 2 Nasogastric suctioning can result in a decrease in acid components and metabolic alkalosis. The client's decrease in rate and depth of ventilation is an attempt to compensate by retaining carbon dioxide. The first response may be true, but it does not address all the components of the question. The third and fourth answers are inaccurate.

The nurse is supervising a student nurse who is caring for a patient with human immunodeficiency virus (HIV). The patient has severe esophagitis caused by Candida albicans. Which action by the student requires the most rapid intervention by the nurse? 1. Putting on a mask and gown before entering the patient's room 2. Giving the patient a glass of water after administering the prescribed oral nystatin suspension 3. Suggesting that the patient should order chile con carne or chicken soup for the next meal 4. Placing a "No Visitors" sign on the door of the patient's room

Ans: 2 Nystatin should be in contact with the oral and esophageal tissues as long as possible for maximum effect. The other actions are also inappropriate and should be discussed with the student but do not require action as quickly. HIV-positive patients do not require droplet or contact precautions or visitor restrictions to prevent opportunistic infections. Hot or spicy foods are not usually well tolerated by patients with oral or esophageal fungal infections.

Which blood test result would the nurse be sure to monitor for the client taking hydrochlorothiazide (HCTZ)? 1. Sodium level 2. Potassium level 3. Chloride level 4. Calcium level

Ans: 2 Potassium is lost when a client is taking HCTZ, and potassium level should be monitored regularly

The nurse has been floated to the telemetry unit for the day. The monitor technician informs the nurse that the client has developed prominent U waves. Which laboratory value should be checked immediately? 1. Sodium 2. Potassium 3. Magnesium 4. Calcium

Ans: 2 Suspect hypokalemia and check the client's potassium level. Common ECG changes with hypokalemia include ST-segment depression, inverted T waves, and prominent U waves. Clients with hypokalemia may also develop heart block. Other abnormal electrolyte levels can affect cardiac rhythms, but the occurrence of U waves is associated with low potassium levels

The unlicensed assistive personnel (UAP) reports to the nurse that a client seems very anxious, and vital sign measurement included a respiratory rate of 38 breaths/min. Which acid-base imbalance should the nurse suspect? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

Ans: 2 The client is most likely hyperventilating and blowing off carbon dioxide. This decrease in carbon dioxide will lead to an increase in pH and cause respiratory alkalosis. Eliminating carbon dioxide would lead to an alkalosis. Metabolic imbalances would be related to renal changes

Which client would the charge nurse assign to the step-down unit nurse who was floated to the intensive care unit for the day? 1. A 68-year-old client on a ventilator with acute respiratory failure and respiratory acidosis 2. A 72-year-old client with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent 3. A newly admitted 56-year-old client with diabetic ketoacidosis receiving an insulin drip 4. A 38-year-old client on a ventilator with narcotic overdose and respiratory alkalosis

Ans: 2 The client with COPD, although ventilator dependent, is in the most stable condition of the clients in this group and should be assigned to the float nurse from the step-down unit. Clients with acid-base imbalances often require frequent laboratory assessment and changes in therapy to correct their disorders. In addition, the client with diabetic ketoacidosis is a new admission and require an in-depth admission assessment. All three of these clients need care from an experienced critical care nurse.

The nurse is working in a hospice facility for patients with acquired immunodeficiency syndrome (AIDS). The facility is staffed with LPNs/LVNs and unlicensed assistive personnel (UAP). Which action will the nurse assign to the LPN/LVN? 1. Assessing patients' nutritional needs and individualizing diet plans to improve nutrition 2. Collecting data about the patients' responses to medications used for pain and anorexia 3. Developing UAP training programs about how to lower the risk for spreading infections 4. Assisting patients with personal hygiene and other activities of daily living as needed

Ans: 2 The collection of data used to evaluate the therapeutic and adverse effects of medications is included in LPN/LVN education and scope of practice. Assessment, planning, and developing teaching programs are more complex skills that require RN education. Assistance with hygiene and activities of daily living should be delegated to the UAP

An 18-year-old college student with an exacerbation of systemic lupus erythematosus (SLE) has been receiving prednisone 20 mg/day for 4 days. Which action prescribed by the health care provider is most important for the nurse to question? 1. Discontinue prednisone after today's dose. 2. Give a "catch-up" dose of varicella vaccine. 3. Check the patient's C-reactive protein level. 4. Administer ibuprofen 800 mg PO TID.

Ans: 2 The varicella (chickenpox) vaccine is a live-virus vaccine and should not be administered to patients who are receiving immunosuppressive medications such as prednisone. The other medical actions may need some further clarification by the nurse. Prednisone doses should be tapered gradually when patients have received long-term steroid therapy, but tapering is not usually necessary for short-term prednisone use. Measurement of C-reactive protein level is not the most specific test for monitoring treatment, but the test is inexpensive and frequently used. High doses of nonsteroidal anti-inflammatory drugs such as ibuprofen are more likely to cause side effects such as gastrointestinal bleeding but are useful in treating the joint pain associated with exacerbations of SLE

The nurse notes white powder on the arms and chest of a client who arrives at the emergency department and reports possible anthrax contamination. Which action included in the hospital protocol for possible anthrax exposure will the nurse take first? 1. Notify hospital security personnel about the client. 2. Escort the client to a decontamination room. 3. Give ciprofloxacin 500 mg PO. 4. Assess the client for signs of infection.

Ans: 2 To prevent contamination of staff or other clients by anthrax, decontamination of the client by removal and disposal of clothing and showering are the initial actions in possible anthrax exposure. Assessment of the client for signs of infection should be performed after decontamination. Notification of security personnel (and local and regional law enforcement agencies) is necessary in the case of possible bioterrorism, but this should occur after decontaminating and caring for the client. According to the Centers for Disease Control and Prevention guidelines, antibiotics should be administered only if there are signs of infection or the contaminating substance tests positive for anthrax

Initiation of subcutaneous etanercept for a patient with rheumatoid arthritis is being considered. Which patient information is most important for the nurse to communicate with the health care provider? 1. The patient is currently taking methotrexate. 2. The patient has a positive tuberculin skin test result. 3. The patient has had type 2 diabetes for 5 years. 4. The patient is anxious about having to self-inject.

Ans: 2 Tumor necrosis factor antagonists such as etanercept suppress immune function and increase the risk for reactivation of latent tuberculosis (TB). Further assessment for and possible treatment of TB will be needed before starting etanercept therapy. The other data will be communicated and may require patient monitoring or teaching but are not contraindications to starting etanercept

The client has fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to unlicensed assistive personnel (UAP)? 1. Administering IV fluids as prescribed by the physician 2. Providing straws and offering fluids between meals 3. Developing a plan for added fluid intake over 24 hours 4. Teaching family members to assist the client with fluid intake

Ans: 2 UAPs can reinforce additional fluid intake when it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice of an RN.

Four clients arrive simultaneously at the emergency department. Which client requires the most rapid action by the triage nurse to protect other clients from infection? 1. A 3-year-old client who has paroxysmal coughing and whose sibling has pertussis 2. A 5-year-old client who has a new pruritic rash and a possible chickenpox infection 3. A 62-year-old client who has an ongoing methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection 4. A 74-year-old client who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight

Ans: 2 Varicella (chickenpox) is spread by airborne means and could be rapidly transmitted to other clients in the emergency department. The child with the rash should be quickly isolated from the other clients through placement in a negative-pressure room. Droplet or contact precautions (or both) should be instituted for the clients with possible pertussis and MRSA infection, but this can be done after isolating the child with possible chickenpox. The client who has been exposed to TB does not place other clients at risk for infection because there are no symptoms of active TB.

A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will the nurse need to put on when preparing to assess the client? Select all that apply. 1. Surgical face mask 2. N95 respirator 3. Gown 4. Gloves 5. Goggles 6. Shoe covers

Ans: 2, 3, 4 Because herpes zoster (shingles) is spread through airborne means and by direct contact with the lesions, the nurse should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves. Surgical face masks filter only large particles and do not provide protection from herpes zoster. Goggles and shoe covers are not needed for airborne or contact precautions

Which actions should the nurse delegate to an unlicensed assistive personnel (UAP) for the client with diabetic ketoacidosis? Select all that apply. 1. Checking fingerstick glucose results every hour 2. Recording intake and output every hour 3. Measuring vital signs every 15 minutes 4. Assessing for indicators of fluid imbalance 5. Notifying the provider of changes in glucose level 6. Assisting the client to reposition every 2 hours

Ans: 2, 3, 6 The UAP's training and education includes how to measure vital signs, record intake and output, and reposition clients. Performing fingerstick glucose checks and assessing clients requires additional education and skill, as possessed by licensed nurses. Notifying the provider of glucose changes is within the scope of practice for licensed nurses. Some facilities may train experienced UAPs to perform fingerstick glucose checks and change their role descriptions to designate their new skills, but this task is beyond the normal scope of practice of a UAP

A patient with a history of liver transplantation is receiving cyclosporine, prednisone, and mycophenolate. Which finding is of most concern? 1. Gums that appear very pink and swollen 2. Blood glucose level of 162 mg/dL (9 mmol/L) 3. Nontender lump above the clavicle 4. Grade 1 + pitting edema in the feet and ankles

Ans: 3 Patients taking immunosuppressive medications are at increased risk for development of cancer. A nontender swelling or lump may signify that the patient has lymphoma. The other data indicate that the patient is experiencing common side effects of the immunosuppressive medications.

The unlicensed assistive personnel (UAP) asks the nurse why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is the RN's best response? 1. "The client's low phosphorus is probably due to malnutrition." 2. "The client is just worn out from not getting enough rest." 3. "The client's skeletal muscles are weak because of the low phosphorus." 4. "The client will do more for himself when his phosphorus level is normal."

Ans: 3 A musculoskeletal manifestation of low phosphorus levels is generalized muscle weakness, which may lead to acute muscle breakdown (rhabdomyolysis). Phosphate is necessary for energy production in the form of adenosine triphosphate, and when not produced, leads to generalized muscle weakness. Although the other statements are true, they do not answer the UAP's question

The nurse is caring for four clients who are receiving IV infusions of normal saline. Which client is at highest risk for bloodstream infection? 1. Client with an implanted port in the right subclavian vein 2. Client who has a midline IV catheter in the left antecubital fossa 3. Client who has a nontunneled central line in the left internal jugular vein 4. Client with a peripherally inserted central catheter (PICC) line in the right upper arm

Ans: 3 According to Centers for Disease Control and Prevention guidelines, several factors increase the risk for infection for this client: central lines are associated with a higher infection risk, jugular vein lines are more prone to infection, and the line is nontunneled. Peripherally inserted IV lines such as PICC lines and midline catheters are associated with a lower incidence of infection. Implanted ports are placed under the skin and are the least likely central line to be associated with catheter infection

A patient with wheezing and coughing caused by an allergic reaction is admitted to the emergency department. Which medication will the nurse anticipate administering first? 1. Methylprednisolone 100 mg IV 2. Cromolyn 20 mg via nebulizer 3. Albuterol 3 mL via nebulizer 4. Aminophylline 500 mg IV

Ans: 3 Albuterol is the most rapidly acting of the medications listed. Corticosteroids are helpful in preventing and treating allergic reactions but are not rapidly acting. Cromolyn is used as a prophylactic medication to prevent asthma attacks but not to treat acute attacks. Aminophylline is not a first-line treatment for bronchospasm

A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to the unlicensed assistive personnel (UAP) who is assisting with the client's care? 1. Teaching the client and family members about means to prevent transmission of VRE 2. Communicating with other departments when the client is transported for ordered tests 3. Implementing contact precautions when providing care for the client 4. Monitoring the results of ordered laboratory culture and sensitivity tests

Ans: 3 All hospital personnel who care for the client are responsible for correct implementation of contact precautions. The other actions should be carried out by licensed nurses, whose education covers monitoring of laboratory results, client teaching, and communication with other departments about essential client data.

The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care unit. The client describes an oral intake of about 1400 mL/day. What is the RN's priority concern? 1. Ask the client about his or her bowel movements. 2. Have the client complete a diet diary for the past 2 days. 3. Instruct the client to increase oral intake to 2 to 3 L/day. 4. Ask the client to describe his urine output.

Ans: 3 An adult should take in about 2 to 3 L of fluid daily from food and liquids. Although the RN would want to know about bowel movements, dietary intake, and urine output, in this case, the priority is that the client is not taking in enough oral fluids.

A client who has been infected with the Ebola virus has an emesis of 750 mL of bloody fluid and complains of headache, nausea, and severe lightheadedness. Which action included in the treatment protocol should the nurse take first? 1. Give acetaminophen 650 mg PO. 2. Administer ondansetron 4 mg IV. 3. Infuse normal saline at 500 mL/hr. 4. Increase oxygen flow rate to 6 L/min.

Ans: 3 Because hypovolemia is a major concern with Ebola infection and IV fluid infusion has been demonstrated to improve outcomes, the nurse's first action will be to infuse normal saline. Treatment of nausea and headache are appropriate and should be implemented next. There is no indication that this client is hypoxemic, although clients with Ebola may develop multiorgan failure and require respiratory support

The nurse admits four clients with infections to the medical unit, but only one private room is available. Which client is most appropriate to assign to the private room? 1. Client with diarrhea caused by C. difficile 2. Client with vancomycin-resistant enterococcus (VRE) infection 3. Client with a cough who may have active tuberculosis (TB) 4. Client with toxic shock syndrome and fever

Ans: 3 Clients with infections that require airborne precautions (e.g., TB) need to be in private rooms. Clients with infections that require contact precautions (e.g., those with C. difficile VRE infections) should ideally be placed in private rooms; however, they can be placed in rooms with other clients with the same diagnosis. Standard precautions are required for the client with toxic shock syndrome

The nurse is preparing to insert a peripherally inserted central catheter (PICC) in a client's left forearm. Which solution will be best for cleaning the skin prior to the PICC insertion? 1. 70% isopropyl alcohol 2. Povidone-iodine solution 3. 0.5% chlorhexidine in alcohol 4. Betadine followed by 70% isopropyl alcohol

Ans: 3 Current Institute for Healthcare Improvement guidelines indicate that chlorhexidine is more effective than the other options at reducing the risk for central line-associated bloodstream infections. The other solutions provide some decrease in the number of microorganisms on the skin but are not as effective as chlorhexidine

The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant Staphylococcus aureus (VRSA). Which nursing action can be assigned to an LPN/LVN? 1. Planning ways to improve the client's oral protein intake 2. Teaching the client about home care of the leg ulcer 3. Obtaining wound cultures during dressing changes 4. Assessing the risk for further skin breakdown

Ans: 3 LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound culture. Teaching, assessment, and planning of care are complex actions that should be carried out by the RN.

A 70-kg client who has had unprotected sexual intercourse with a partner who has hepatitis B is to receive 0.06 mL/kg of hepatitis B immune globulin. The immune globulin is available in a 5-mL vial. The nurse will plan to administer ____________________ mL.

Ans: 4.2 mL 0.06 mL × 70 kg = 4.2 mL

When the community health nurse is counseling a client who has an acute Zika virus infection, which information is most important to include? 1. Drink fluids to prevent dehydration. 2. Use acetaminophen to reduce pain and fever. 3. Apply insect repellant frequently to prevent mosquito bites. 4. Symptoms of Zika infection include fever, red eyes, rash, and joint pain.

Ans: 3 Prevention of Zika transmission is the priority because Zika infection usually causes a relatively mild and short-duration illness. Because mosquitos spread Zika infection from infected individuals to others, it is essential that the client use insect repellant consistently during the active infection. The other information is correct but will not assist in decreasing the risk to the community

A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would the nurse be sure to monitor? 1. Hypokalemia 2. Hyperkalemia 3. Hyponatremia 4. Hypernatremia

Ans: 3 SIADH results in a relative sodium deficit caused by excessive retention of water.

The nurse at the infectious disease clinic has four clients waiting to be seen. Which client should the nurse see first? 1. Client who has a 16-mm induration after a tuberculosis (TB) skin test 2. Client who has human immunodeficiency virus and a low CD4 count 3. Client who has swine influenza (H1N1) and reports increased dyspnea 4. Client who has been exposed to Zika virus and has a rash and joint pain

Ans: 3 The client with increased dyspnea should be seen first because rapid actions such as oxygen administration and IV fluids may be needed. The other clients will require further assessment, counseling, or treatment, but they do not have potentially life-threatening symptoms or diagnoses

The nurse has received a needlestick injury after giving a client an intramuscular injection, but has no information about whether the client has human immunodeficiency virus (HIV) infection. What is the most appropriate method of obtaining this information about the client? 1. The nurse should personally ask the client to authorize HIV testing. 2. The charge nurse should tell the client about the need for HIV testing. 3. The occupational health nurse should discuss HIV status with the client. 4. HIV testing should be performed the next time blood is drawn for other tests.

Ans: 3 The staff member who is most knowledgeable about the regulations regarding HIV prophylaxis and about how to obtain a client's HIV status and/or order HIV testing is the occupational health nurse. It is unethical for the nurse to personally ask the client to consent to HIV testing or to perform unauthorized HIV testing. The charge nurse is not responsible for obtaining this information (unless the charge nurse is also in charge of occupational health)

A patient who has received a kidney transplant has been admitted to the medical unit with acute rejection and is receiving IV cyclosporine and methylprednisolone. Which staff member is best to assign to care for this patient? 1. RN who floated to the medical unit from the coronary care unit for the day 2. RN with 3 years of experience in the operating room who is orienting to the medical unit 3. RN who has worked on the medical unit for 5 years and is working a double shift today 4. Newly graduated RN who needs experience with IV medication administration

Ans: 3 To be most effective, cyclosporine must be mixed and administered in accordance with the manufacturer's instructions, so the RN who is likely to have the most experience with the medication should care for this patient or monitor the new graduate carefully during medication preparation and administration. The coronary care unit float nurse and the nurse who is new to the unit would not have experience with this medication.

A few minutes after the nurse has given an intradermal injection of an allergen to a patient who is undergoing skin testing for allergies, the patient reports feeling anxious, short of breath, and dizzy. Which action included in the emergency protocol should the nurse take first? 1. Start oxygen at 6 L/min using a face mask. 2. Obtain IV access with a large-bore IV catheter. 3. Give epinephrine 0.5 mg intramuscularly. 4. Administer albuterol per nebulizer mask.

Ans: 3 World Allergy Organization guidelines indicate that intramuscular epinephrine should be the initial drug for treatment of anaphylaxis. Giving epinephrine rapidly at the onset of an anaphylactic reaction may prevent or reverse cardiovascular collapse as well as airway narrowing caused by bronchospasm and inflammation. Oxygen use is also appropriate, but oxygen delivery will be effective only if airways are open. Albuterol may also be administered to decrease airway narrowing but would not be the first therapy used for anaphylaxis. IV access will take longer to establish and should not be the first intervention

The nurse is preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will the nurse perform the following actions? 1. Remove N95 respirator. 2. Take off goggles. 3. Remove gloves. 4. Take off gown. 5. Perform hand hygiene.

Ans: 3, 2, 4, 1, 5 This sequence will prevent contact of the contaminated gloves and gown with areas (e.g., the hair) that cannot be easily cleaned after client contact and stop transmission of microorganisms to the nurse and to other clients. If the nurse is wearing a disposable gown, the gown and gloves can be removed simultaneously by grasping the front of the gown and breaking the ties and then peeling the gloves off while removing the gown. The correct method for donning and removal of PPE has been standardized by agencies such as the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration

In which order will the nurse take these actions before doing wound irrigation and a dressing change for a client who has a wound infected with methicillin-resistant Staphylococcus aureus (MRSA)? 1. Don gloves. 2. Put on gown. 3. Perform hand hygiene. 4. Place goggles over eyes. 5. Put on mask to cover nose and mouth.

Ans: 3, 2, 5, 4, 1 Centers for Disease Control and Prevention guidelines recommend initially hand hygiene and then donning of gown, mask, goggles, and finally gloves to protect staff members and limit the spread of contamination. Goggles and a mask (or use of a face shield) will be needed with this dressing change because of the possibility of splashing during wound irrigation

A patient seen in the sexually transmitted disease clinic has just tested positive for human immunodeficiency virus (HIV) with a rapid HIV test. Which action will the nurse take next? 1. Ask about patient risk factors for HIV infection. 2. Send a blood specimen for Western blot testing. 3. Provide information about antiretroviral therapy. 4. Discuss the positive test results with the patient.

Ans: 4 A major purpose of HIV testing for asymptomatic patients is to ensure that HIV-positive individuals are aware of their HIV status, take actions to prevent HIV transmission, and effectively treat the HIV infection. According to current national guidelines, the other actions are also appropriate, but the initial action will be to communicate the test results to the patient. Rapid HIV testing must be confirmed by another test, usually the Western blot test. Antiretroviral therapy is recommended for all HIV-positive patients. Risk factor information will be used in tracking patient contacts and in teaching the patient how to reduce the risk for transmission to others

The RN is reviewing the client's morning laboratory results. Which of these results is of most concern? 1. Serum potassium level of 5.2 mEq/L (5.2 mmol/L) 2. Serum sodium level of 134 mEq/L (134 mmol/L) 3. Serum calcium level of 10.6 mg/dL (2.65 mmol/L) 4. Serum magnesium level of 0.8 mEq/L (0.4 mmol/L)

Ans: 4 Although all of these laboratory values are outside of the normal range, the magnesium level is furthest from normal. With a magnesium level this low, the client is at risk for ECG changes and life-threatening ventricular dysrhythmias

After change-of-shift report, which newly admitted patient should the nurse assess first? 1. A patient with human immunodeficiency virus (HIV) whose CD4 count is 45 mm3 (45 cells/mcL) 2. A patient with acute kidney transplant rejection who has a scheduled dose of prednisone due 3. A patient with graft-versus-host disease who has frequent liquid stools 4. A patient with hypertension who has angioedema after receiving lisinopril

Ans: 4 Because angioedema may cause airway obstruction, this patient should be assessed for any difficulty breathing, and treatment should be started immediately. The other patients also will need to be assessed as quickly as possible, but the patient with potential airway difficulty will need the most rapid care

The health care provider has written these orders for a client with a diagnosis of pulmonary edema. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? 1. Weigh the client every morning. 2. Maintain accurate intake and output records. 3. Restrict fluids to 1500 mL/day. 4. Administer furosemide 40 mg IV push.

Ans: 4 Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The other orders are important but are not urgent

Which order prescribed for a client with hypercalcemia would the nurse be sure to question? 1. 0.9% saline at 50 mL/hr IV 2. Furosemide 20 mg orally each morning 3. Apply cardiac telemetry monitoring 4. Hydrochlorothiazide (HCTZ) 25 mg orally each morning

Ans: 4 Calcium excretion is decreased with thiazide diuretics (e.g., HCTZ), so the calcium level is at risk for going even higher. Loop diuretics (e.g., furosemide) increase calcium excretion. The addition of IV fluids and cardiac monitoring are appropriate actions for monitoring and treating a client with hypercalcemia

The nurse is preparing to discharge a client whose calcium level was low but is now just barely within the normal range (9 to 10.5 mg/dL [2.25 to 2.63 mmol/L]). Which statement by the client indicates the need for additional teaching? 1. "I will call my doctor if I experience muscle twitching or seizures." 2. "I will make sure to take my vitamin D with my calcium each day." 3. "I will take my calcium citrate pill every morning before breakfast." 4. "I will avoid dairy products, broccoli, and spinach when I eat."

Ans: 4 Clients with low calcium levels should be encouraged to eat dairy products, seafood, nuts, broccoli, and spinach, which are all good sources of dietary calcium. The other three options indicate correct understanding of calcium therapy

Which finding will be most important for the nurse to report to the health care provider about a patient who is taking prednisone chronically after an organ transplant? 1. Multiple arm bruises 2. Sodium level of 146 mEq/dL (146 mmol/L) 3. Blood glucose of 110 mg/dL (6.1 mmol/L) 4. Black-colored stools

Ans: 4 Dark green or black stools may indicate gastrointestinal bleeding, a possible adverse effect of oral steroid use, and further assessment and treatment are needed. Although thinning of the skin, electrolyte disturbances, and changes in glucose metabolism also occur with steroids, bruising and mild changes in sodium or glucose level do not require treatment.

The nurse is checking medication prescriptions that were received by telephone for a client with hypertensive crisis and tachycardia. Which medication is most important to clarify with the health care provider? 1. Carvedilol 12.5 mg PO BID daily 2. Hydrochlorothiazide 25 mg PO daily 3. Labetalol 20 mg IV over a 2-min time period now 4. Hydroxyzine 50 mg PO as needed (PRN) systolic blood pressure greater than 160 mm Hg

Ans: 4 Hydroxyzine is a first-generation antihistamine that is used to treat patients with anxiety and pruritus. It is likely that the correct medication is hydralazine, a vasodilator that is used to treat hypertension. Hydroxyzine and hydralazine are "look-alike, sound-alike" drugs that have been identified by the Institute for Safe Medication Practices (ISMP) as being at high risk for involvement in medication errors. All treatment prescriptions that are communicated by telephone should be reconfirmed with the health care provider; however, the most important order to clarify is the hydroxyzine, which is likely an error

A healthy 65-year-old client who cares for a newborn grandchild has a clinic appointment in May. The client needs several immunizations but tells the nurse, "I hate shots! I will only take one today." Which immunization is most important to give? 1. Influenza 2. Herpes zoster 3. Pneumococcal 4. Tetanus, diphtheria, pertussis

Ans: 4 Individuals who have contact with infants should be immunized against pertussis to avoid infection and to prevent transmission to the infant. The influenza and pneumococcal vaccines can be administered later in the year, before the influenza season. The herpes zoster vaccine is important to prevent shingles in the client but does not need to be administered today.

The nurse is caring for a patient with rheumatoid arthritis who is taking naproxen twice a day to reduce inflammation and joint pain. Which symptom is most important to communicate to the health care provider? 1. Joint pain worse in the morning 2. Dry eyes bilaterally 3. Round and moveable nodules under the skin 4. Dark-colored stools

Ans: 4 Naproxen, a nonsteroidal anti-inflammatory drug, can cause gastrointestinal bleeding, and the stool appearance indicates that blood may be present in the stool. The health care provider should be notified so that actions such as testing a stool specimen for occult blood and administering proton pump inhibitors can be prescribed. The other symptoms are common in patients with rheumatoid arthritis and require further assessment or intervention, but they do not indicate that the patient is experiencing adverse effects from the medications

The nurse is admitting an older adult client to the acute care medical unit. Which assessment factor alerts the nurse that this client has a risk for acid-base imbalances? 1. History of myocardial infarction (MI) 1 year ago 2. Antacid use for occasional indigestion 3. Shortness of breath with extreme exertion 4. Chronic renal insufficiency

Ans: 4 Risk factors for acid-base imbalances in older adults include chronic kidney disease and pulmonary disease. Occasional antacid use will not cause imbalances, although antacid abuse is a risk factor for metabolic alkalosis. The MI occurred 1 year ago and is no longer a risk factor

The nurse is caring for a client who experiences frequent generalized tonic-clonic seizures associated with periods of apnea. The nurse must be alert for which acid-base imbalance? 1. Respiratory alkalosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Metabolic acidosis

Ans: 4 Seizures may be associated with apnea and thus hypoxemia and lactic acidosis. Lactic acidosis, a form of metabolic acidosis, occurs when cells use glucose without adequate oxygen (anaerobic metabolism); glucose then is incompletely broken down and forms lactic acid. This acid releases hydrogen ions, causing acidosis. Lactic acidosis occurs whenever the body has too little oxygen to meet metabolic oxygen demands (e.g., heavy exercise, seizure activity, reduced oxygen)

Which infection control activity should the charge nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Screening clients for upper respiratory tract symptoms 2. Asking clients about the use of immunosuppressant medications 3. Demonstrating correct hand washing to the clients' visitors 4. Disinfecting blood pressure cuffs after clients are discharged

Ans: 4 The UAP can follow agency policy to disinfect items that come in contact with intact skin (e.g., blood pressure cuffs) by cleaning with chemicals such as alcohol. Teaching and assessment for upper respiratory tract symptoms or use of immunosuppressants require more education and a broader scope of practice, and these tasks should be performed by licensed nurses

A hospitalized 88-year-old client who has been receiving antibiotics for 10 days tells the nurse about having frequent watery stools. Which action will the nurse take first? 1. Notify the health care provider about the stools. 2. Obtain stool specimens for culture. 3. Instruct the client about correct hand washing. 4. Place the client on contact precautions.

Ans: 4 The client's age, history of antibiotic therapy, and watery stools suggest that he may have C. difficile infection. The initial action should be to place him on contact precautions to prevent the spread of C. difficile to other clients. The other actions are also needed and should be taken after placing the client on contact precautions

The nurse obtains this information when assessing a patient with human immunodeficiency virus (HIV) who is taking antiretroviral therapy. Which finding is most important to report to the health care provider? 1. The blood glucose level is 144 mg/dL (8 mmol/L). 2. The hemoglobin level is 10.9 g/dL (109 g/L). 3. The patient reports frequent nausea. 4. The patient's viral load has increased.

Ans: 4 The increase in viral load indicates ineffective therapy, which will require further evaluation and treatment. The patient may not be adhering to the prescribed regimen, or resistance to the antiviral medications may have developed. Nausea, anemia, and hyperglycemia are common adverse effects with antiretroviral therapy and may require further evaluation, but the most concerning finding is the lack of effectiveness of the medications

The unlicensed assistive personnel (UAP) reports to the nurse that a client's urine output for the past 24 hours has been only 360 mL. What is the nurse's priority action at this time? 1. Place an 18-gauge IV in the nondominant arm. 2. Elevate the client's head of bed at least 45 degrees. 3. Instruct the UAP to provide the client with a pitcher of ice water. 4. Contact and notify the health care provider immediately.

Ans: 4 The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL. This minimum volume is called the obligatory urine output. If the 24-hour urine output falls below the obligatory output amount, wastes are retained and can cause lethal electrolyte imbalances, acidosis, and a toxic buildup of nitrogen. The client may need additional fluids (IV or oral) after the cause of the low urine output is determined. Elevating the head of the bed will not help with urine output. Notifying the health care provider is the first priority in this case

The RN is providing care for a client diagnosed with dehydration and hypovolemic shock. Which prescribed intervention from the health care provider should the RN question? 1. Blood pressure every 15 minutes 2. Place two 18-gauge IV lines 3. Oxygen at 3 L via nasal cannula 4. IV 5% dextrose in water (D5W) to run at 250 mL/hr

Ans: 4 To correct hypovolemic shock with dehydration, the client needs IV fluids that are isotonic and will increase intravascular volume, such as normal saline. With D5W, the body rapidly metabolizes the dextrose and the solution becomes hypotonic. All of the other interventions are appropriate for a client with shock.

A patient with human immunodeficiency virus (HIV) who has been started on antiretroviral therapy is seen in the clinic for follow-up. Which test will be best to monitor when determining the response to therapy? 1. CD4 level 2. Complete blood count 3. Total lymphocyte percent 4. Viral load

Ans: 4 Viral load testing measures the amount of HIV genetic material in the blood, so a decrease in viral load indicates that the antiretroviral therapy is effective. The CD4 level, total lymphocytes, and complete blood count will also be used to assess the impact of HIV on immune function but will not directly measure the effectiveness of antiretroviral therapy