Practice this for NC 3,4

The nurse is caring for a client who has the diagnosis of schizophrenia. The nurse enters the room to administer the morning dose of the prescribed antipsychotic medication. The client is drooling and has extreme muscular rigidity. After checking the client for adequate respiratory effort, what is the nurse's priority? 1. Elevate HOB and give the medication as prescribed. 2. Hold the medication and call the primary healthcare provider. 3. Report the behaviors to the on-coming shift. 4. Hold the medication, and check the vital signs.

2. Correct: The nurse should hold the medication, and report the symptoms to the primary healthcare provider. The client may be experiencing neuroleptic malignant syndrome.

The nurse is caring for a client with a fibula fracture. The primary healthcare provider makes rounds and writes prescriptions. What is the nurse's best action? Prescriptions: MSO4 8 mg IM now Advance diet as tolerated Hgb and Hct in AM 1. Check the prescription prior to sending it to the pharmacy. 2. Clarify the prescription with the primary healthcare provider. 3. Notify the pharmacy that the prescription is needed immediately. 4. Gather the supplies needed for an injection.

2. Correct: The nurse should notify the primary healthcare provider, because MSO4 is an unapproved abbreviation that presents safety concerns. MSO4 is the abbreviation for morphine sulfate. MgSO4​ is the abbreviation for magnesium sulfate. Notifying the primary healthcare provider to clarify the prescription will prevent a medication error.

The nurse is using sterile forceps to move sterile gauze to a sterile container so that cleansing solution may be applied. Which action by the nurse would compromise the sterile field? 1. Touching the dry forceps to the center of the field. 2. Placing the forceps in the outer 1-inch margin of the field. 3. Moving the forceps above the level of the table. 4. Holding the forceps at table level within sight.

2. Correct: The outer 1-inch perimeter of the field is considered non-sterile. This action would compromise the sterile field.

What should the nurse monitor in a client with a fracture of the left tibia? 1. Distal pulses of the left leg 2. Distal pulses of each leg 3. Proximal sensation of each leg 4. Proximal sensation of each arm

2. Correct: The tibia is a bone in the lower leg. The nurse should monitor pulses in the distal legs. Pulses would be monitored in both legs and not just the left leg. The comparison of pulses helps to identify differences in pulse rate and quality.

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

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

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

2., 3. & 4. Correct: Advance directives are legally binding documents. Documentation is required in the medical record as to whether an advance directive exists. If one exists, a copy should be placed in the medical record. The document is prepared by the client detailing wishes for treatment should the client become unable to make informed healthcare decisions.

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

2., 3. & 4. Correct: All are behaviors seen in children with ASD. Additionally, they often do not form interpersonal relationships with others or play well with others. They are usually not socially responsive with eye contact and facial expressions. The language characteristics may be delayed, totally absent, echolalia, unusual vocalizations, immature grammatical structures, or idiosyncratic words. Their motor behaviors may include poor coordination, tiptoe walking, peculiar hand movements such as flapping and clapping, and stereotypical body movements of rocking, dipping, swaying, or spinning.

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

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

The nurse is participating in a health promotion program. What points about fire safety in the home should be included? (SATA) 1. Smoking in bed is acceptable if you are not sleepy. 2. Keep matches and lighters away from children by storing them in a locked cabinet. 3. Install carbon monoxide smoke alarms and test monthly. 4. You may leave Christmas lights lit all night as long as the tree is artificial. 5. Have a planned route of exit and place where all family will meet.

2., 3. & 5. Correct: Keeping matches and lighters away from children by storing them in a locked cabinet can prevent fire-related deaths. Carbon monoxide smoke alarms will alarm for smoke and carbon monoxide which is an odorless gas than can kill quickly. Alarms should be tested every month and repaired or replaced immediately if malfunction occurs. A planned exit from the building and place to meet helps identify that all of the family is out of the building.

A 9 month old with asthma symptomology has montelukast sodium oral granules prescribed. The nurse knows to administer the medication in what way? 1. Mix the granules with a spoonful of baby food such as applesauce. 2. Pour the granules directly on the back of the infant's tongue. 3. Dissolve the granules in an 8 ounce (240 mL) bottle of juice. 4. Administer the medication in the morning mixed in a bowl of rice cereal.

1. Correct: Applesauce is an appropriate baby food for a 9 month old infant. The medication is being mixed with a very small amount of baby food to facilitate all of the medication being consumed.

What is the nurse's best response to the pregnant client's question about appropriate exercise during pregnancy? 1. Discuss with healthcare provider your current exercise regimen and history. 2. You can continue any exercise that you have been doing before pregnancy. 3. If you haven't already started an exercise program, you should wait until after delivery. 4. Exercise is required during pregnancy for a minimum of 15 minutes each day.

1. Correct: Best advice for pregnant women. The healthcare provider can individualize according to the physical condition of the woman and the stage of pregnancy.

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

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

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

1. Correct: Needles should be recapped using a one hand scoop method to prevent accidental sticks. Two-handed method increases the risk that the nurse's non-dominant hand will be punctured with the needle. Think about it. You do not want the hand holding the cap to get close to the needle. What if you miss the needle and stick your hand? The best solution is to not recap at all. Place the needle in the sharps container at once. But if the sharps container is not close by, then the one hand scoop method is appropriate. You are not exposing one hand to the needle.

A client is admitted to the pediatric unit with a diagnosis to rule out tuberculosis (TB). What room assignment should the charge nurse make? 1. Private room and placed on airborne precautions. 2. Private room and place on protective isolation. 3. Room with a client diagnosed with a respiratory infection. 4. Room with a client who is 24 hours post appendectomy.

1. Correct: This client should be in a private room to prevent the spread by airborne contamination. In addition, the client should be placed on airborne precautions and standard precautions should be implemented. Remember, you are trying to protect staff and others without the disease from contracting TB.

A Hispanic client is considering treatment options for cancer. The client is reports needing to discuss the options with the sons before making a final decision. What should the nurse say to the client? 1. You are wanting your sons to assist you in deciding about treatment options. 2. It is really your decision about which option you choose. 3. I will be happy to discuss this issue with you. 4. This shows that you are proud of your sons.

1. Correct: This is paraphrasing the client's statement and is a therapeutic response. Within this culture, the family plays a very important role when making decisions about healthcare.

Which data collected from a client admitted with peripheral vascular disease (PVD) should the nurse identify as contributing to this diagnosis? (SATA) 1. Family history of hyperlipidemia 2. Postmenopausal 3. BMI of 24 4. Swims three times a week 5. Leg pain when walking

1., 2 & 5. Correct: A family history of hyperlipidemia, hypertension, or PVD increases the risk of a client developing PVD. Men over age 50 and postmenopausal women are at increased risk. A decline in the natural hormone estrogen may be a factor in the increased risk of heart disease among post-menopausal women. Estrogen is believed to have a positive effect on the inner layer of arterial walls, helping to keep blood vessels flexible.The risk of developing PVD also increases if the client has hyperlipidemia, cerebrovascular disease, heart disease, diabetes, hypertension, and/or renal failure. Leg pain with activity, such as walking, is a sign of PVD.

A nurse is administering medications to a client and notes that a newly prescribed medication is on the client's list of allergies. When advocating for this client, which actions should the nurse take to ensure the client's safety? (SATA) 1. Check the client's allergies against the list of client allergies documented in the medical record. 2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Discontinue the medication on the client's medication administration record (MAR). 4. Give the medication as ordered by the primary healthcare provider and administer diphenhydramine to the client. 5. Hold the medication and administer diphenhydramine to the client.

1., 2. & 3. Correct: To ensure client safety, the nurse should always check the client's allergies against the allergy list in the medical record before administering any medication. To prevent harm to the client, the nurse should advocate for the client by notifying the primary healthcare provider immediately and informing of client allergy. The nurse should discontinue the medication on the client's medication administration record (MAR) so that other staff members will not administer the medication.

In caring for a client exposed to radiation, the nurse knows that the type of damage due to radiation exposure depends on which factors? (SATA) 1. Dose rate 2. Organs exposed 3. Technician 4. Time of day 5. Type of radiation

1., 2. & 5. Correct: The extent of damage due to radiation exposure depends on the quantity of radiation delivered to the body, the dose rate, the organs exposed, the type of radiation, the duration of exposure, and the energy transfer from the radioactive wave or particle to the exposed tissue.

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

1., 2., & 3. Correct: These are correct statements about buccal administration of medication. Buccal administration involves the medication being placed between the gums and cheek, where it dissolves and becomes absorbed into the bloodstream. The cheek area has many capillaries that allow the medication to be absorbed quickly without having to pass through the digestive system. The degree of stinging experienced depends on the medication being administered. Some effects of certain medications can be lessened by digestive processes.

The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which client would be appropriate for the LPN/VN to accept? (SATA) 1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM 4. Admitted 6 hours ago in adrenal insufficiency 5. In diabetic ketoacidosis receiving IV insulin

1., 2., & 3. Correct: These are stable clients that the LPN/VN can provide care. The LPN can provide medications for pain management. Since the postop client is not requiring frequent assessments and is considered stable at this point, the RN can assign the LPN to care for this client. The client having surgery in the AM is stable and will require predictable preop care the evening prior to surgery, so the LPN can care for this client as well.

Which client assignments would be appropriate for the LPN/VN to accept from the charge nurse? (SATA) 1. In Bucks traction requiring frequent pain medication. 2. Twenty four hours post appendectomy. 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM. 4. Admitted 6 hours ago in adrenal insufficiency. 5. Client newly diagnosed with Type 2 diabetes.

1., 2., & 3. Correct: These clients are stable and require predictable care that can be done appropriately by the LPN/VN.

Which nursing interventions are appropriate for an adult client with constipation? (SATA) 1. Allow adequate time for defecation. 2. Provide privacy for bowel elimination. 3. Suggest increasing fluid intake. 4. Encourage client to increase fiber in the diet. 5. Encourage the client to delay the urge to defecate until after a meal.

1., 2., 3. & 4. Correct: Clients should have ample time for defecation. Rushing the client may lead to a client ignoring the urge. Since clients may be hesitant to have a bowel movement in the presence of others, privacy should be provided. (The nurse may need to stay with weak or disabled clients.) Increasing fluid intake will lead to softer stools. This makes defecation easier. Fiber deficiencies may contribute to constipation. Fiber in the diet adds bulk to the stools which help them pass more readily through the intestines.

Which observations should be made by the nurse in the home environment that may prevent threats to the safety of a toddler? (SATA) 1. Do stairs have guard gates? 2. Are safety covers on electrical outlet plugs? 3. Is the swimming pool inaccessible to the toddler? 4. Are cleaning supplies located out of the toddler's reach? 5. Are stairs brightly lit?

1., 2., 3. & 4. Correct: Toddlers may fall if left unsupervised around stairs. Make sure that gates are in place and that they are used. Toddlers are at risk for exploring the outlets by putting metal objects into the outlets or putting their fingers in them. They should be covered unless in use. Toddlers can drown in small amounts of water and they may try to explore swimming pools if they are accessible. Pools should have fences or locking stairs and the child should never be left unsupervised around the pool. Toddlers are curious and may get into cabinets containing harmful substances.

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

1., 2., 3. & 5. Correct: One of the most common problems after hip surgery is dislocation. Until the hip prosthesis stabilizes, it is necessary to follow these instructions for proper positioning to avoid dislocation. Flexion and movement of the leg on the affected side past midline should be avoided. These precautions are needed to keep the new head of the femur in the acetabulum and prevent dislocation until healing and tissues are strong enough to hold the joint in place.

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

1., 2., 3. Correct: These are true statements. The Guthrie test is a screening blood test for phenylketonuria (PKU). A positive test indicates decreased metabolism of phenylalanine, leading to phenylketonuria. The normal level of phenylalanine in newborns is 0.5 to 1 mg/dl. The Guthrie test detects levels greater than 4 mg/dl. Only fresh heel blood, not cord blood, can be used for the test. The main objective for diagnosing and treating this disorder is to prevent cognitive impairment.

A nurse is contributing to an educational program for adults considering smoking cessation. What information should the nurse include? (SATA) 1. Nicotine is the drug in tobacco products that produces dependence. 2. Withdrawal symptoms may include irritability, difficulty concentrating, and increased appetite. 3. Stopping smoking reduces the risk of coronary heart disease. 4. All smokers need to have a prescription for bupropion SR in order to quit. 5. Refer to smoking quit-lines that offer free support, advice, and counseling from experienced coaches.

1., 2., 3., 5. Correct: These are correct statements. Nicotine is the drug in tobacco products that produces dependence. Other withdrawal symptoms include anxiety and cravings for a cigarette. There are many health benefits to smoking cessation, including reducing the risk of coronary heart disease, stroke, peripheral vascular disease, and COPD as well as reducing the risk for infertility in women. Clients should be referred to educational programs and support groups.

A nurse is giving a report to another nurse during a shift change. Which information provided during a change-of-shift report is essential to ensure continuity of client care? (SATA) 1. Priorities for client care. 2. Medications and allergies. 3. Normal lab results. 4. Client needs and responses to prior treatments. 5. Current course of illness.

1., 2., 4. & 5. Correct: The essential components of an effective change-of-shift report that will ensure the continuity of client care should include information about priorities for client care. Information about the client's medications and allergies must be communicated in order to provide safe, competent client care. To ensure continuity of care, information about the client's needs and responses to prior treatments should be shared. Information about events related to the current course of illness are essential for ongoing client care.

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

1., 2., 4., & 5. Correct: By the age of two, the recommended doses of DTaP, IPV, MMR, Hib, varicella, pneumococcal, hepatitis B and rotovirus vaccines should have been received. The nurse should clarify this with the parent.

While examining a client's health history, which data indicates to the nurse that the client is at increased risk for developing cancer? (SATA) 1. Family history 2. Alcohol consumption 3. Spicy diet 4. Human papillomavirus 5. Tobacco use

1., 2., 4., & 5. Correct: Family history of cancer increases the risk for having the same type of cancer. Alcohol and tobacco use increase the risk of cancer. When used together, they have a synergistic effect. Human papillomavirus (HPV) increases the risk of cervical, head, and neck cancers.

Which manifestations, if noted in a pregnant client, would the nurse need to report to the primary healthcare provider? (SATA) 1. Calf muscle irritability 2. Facial edema 3. Pressure on the bladder 4. Blurry vision 5. Epigastric pain

1., 2., 4., & 5. Correct: These are danger signs/symptoms of pregnancy and need further investigation by the primary HCP. These signs could indicate preeclampsia, fluid and electrolyte disturbances, and other high risk complications during pregnancy.

Which prescription can the LPN/VN implement when assisting an RN with the care of a client diagnosed with an abdominal aortic aneurysm? (SATA) 1. Obtain vital signs every 15 minutes. 2. Insert a urinary catheter for hourly urinary outputs. 3. Place a PICC line for fluid management. 4. Provide morphine 1 mg per PCA pump at a 10 minute lockout.

1., 3. & 4. Correct: Dementia is characterized by a slow onset of symptoms over months to years. Dementia progresses to noticeable changes in personality. Dementia progresses to noticeable changes in attention span.

A client diagnosed with cancer has been losing weight. How should the nurse reinforce teaching for the client regarding methods for improving nutritional status to maintain weight? (SATA) 1. Add butter to foods. 2. Drink a cup of cubed beef broth. 3. Add powdered creamer to milkshake. 4. Use biscuits to make sandwiches. 5. Eat fish sauteed in olive oil. 6. Put honey on top of hot cereal.

1., 3., 4., & 6. Correct: Butter added to foods adds calories. This client needs more calories and more protein. Spread peanut butter or other nut butters, which contain protein and healthy fats, on toast, bread, apple or banana slices, crackers or celery. Use croissants or biscuits to make sandwiches which provides more calories. Add powdered creamer or dry milk powder to hot cocoa, milkshakes, hot cereal, gravy, sauces, meatloaf, cream soups, or puddings to add more calories. Top hot cereal with brown sugar, honey, dried fruit, cream or nut butter.

What signs/symptoms does the nurse expect indomethacin to manage? (SATA) 1. Pain 2. Inflammation 3. Fever 4. Cough 5. Urticaria

1.,2., & 3. Correct: Indomethacin is a non-steroidal anti-inflammatory agent used to treat pain, inflammation, and fever.

Which finding in a client 5 hours post open cholecystectomy would require the nurse to notify the surgeon? 1. Absent bowel sounds. 2. Jackson Pratt drain has 90 mL of blood. 3. Urinary output of 200 mL since return from surgery. 4. Client report of abdominal pain of 8/10.

2. Correct. An open cholecystectomy will usually result in the placement of a drain. The drainage should be green (bile). Blood is a problem and needs immediate intervention.

An unlicensed assistive personnel (UAP), assigned to take care of a client who is HIV positive, refuses the assignment, stating fear of personal injury. What action should the LPN/VN take first? 1. Re-assign the client to a UAP who does not mind caring for HIV positive clients. 2. Inform the UAP that refusing client care is not acceptable practice. 3. Have the UAP document rationale and support for refusing the client assignment. 4. Transfer the UAP to a unit where there are no HIV positive clients.

2. Correct. Any UAP who feels compelled to refuse to provide care for a particular type of client faces an ethical dilemma. The reasons given for refusal range from a conflict of personal values to fear of personal risk of injury. Such instances have increased since the advent of acquired immunodeficiency syndrome (AIDS) as a major health problem. To avoid facing these moral and ethical situations, a UAP can follow certain strategies. For example, when applying for a job, one should ask questions regarding the client population. If one is uncomfortable with a particular situation, then not accepting the position would be an option. Denial of care, or providing substandard nursing care to some members of our society, is not acceptable nursing practice.

Which prescription can the LPN/VN implement when assisting an RN with the care of a client diagnosed with an abdominal aortic aneurysm? 1. Obtain vital signs every 15 minutes. 2. Insert a urinary catheter for hourly urinary outputs. 3. Place a PICC line for fluid management. 4. Provide morphine 1 mg per PCA pump at a 10 minute lockout.

2. Correct. Inserting a urinary catheter is within the scope of practice for the LPN. This task does not include further assessment of the urinary output, which the RN will perform.

The nurse is reinforcing teaching to a client, newly diagnosed with diabetes, about the action of regular insulin. The nurse verifies client understanding when the client verbalizes being at greatest risk for developing hypoglycemia at what time following the 8:00 a.m. dose of regular insulin? 1. 8:30 AM 2. 11:00 AM 3. 1:30 PM 4. 4:00 PM

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

The family member of a schizophrenic client asks the nurse why the client is receiving chlorpromazine and benztropine. What is the best response by the nurse? 1. The chlorpromazine makes the benztropine more effective so a smaller dose of both drugs can be used. 2. Benztropine is given to treat the side effects produced by the chlorpromazine. 3. Chlorpromazine is used for severe hiccups that can occur with the use of benztropine. 4. Chlorpromazine is used for psychosis, and benztropine is used for preventing agranulocytosis.

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

A client received a severe burn to the right hand. When dressing the wound, it is important for the nurse to do what? 1. Apply a wet to dry dressing for debridement. 2. Wrap each digit individually to prevent webbing. 3. Open blisters to allow drainage prior to dressing. 4. Allow the client to do as much of the dressing change as possible.

2. Correct: Each finger must be wrapped individually to prevent webbing. If not done appropriately, the client could develop contractures and lose functional use of the hand.

The nurse is assigned to care for a client with the diagnosis of schizophrenia. The client tells the nurse, "I am having trouble tuning out the voices." What is the nurse's best response to this statement? 1. "There is nothing to help with this problem." 2. "You might hum when the voices are so troublesome." 3. "Ask your primary healthcare provider to increase your medication." 4. "Wear earplugs to block out the voices."

2. Correct: Humming or listening to music may help to decrease the intrusive voices. This increases time spent in reality based activities and decreases preoccupation with delusional and hallucinatory experiences.

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

2. Correct: Indwelling catheter insertion is a sterile procedure. If contamination occurs, do not turn back on sterile field. Get on the call light to request another urinary catheter and sterile gloves to continue the procedure. Continuing the procedure with contaminated equipment would jeopardize the client's safety.

The nurse should teach the client with chronic pancreatitis how to monitor for which problem that can occur as a result of the disease? 1. Hypertension 2. Diabetes 3. Hypothyroidism 4. Graves disease

2. Correct: Insulin is produced in the pancreas. When the client has chronic pancreatitis, the pancreas becomes unable to produce insulin, thus resulting in diabetes.

The client has been prescribed hydrochlorothiazide for treatment of hypertension. What client comment indicates adequate understanding of the side effects of the drug? 1. "I must limit my intake of citrus food." 2. "I must increase my intake of foods containing potassium." 3. "I can expect an increase in my potassium level." 4. "I love sitting in the sun in the summer."

2. Correct: Loop diuretics cause an increase in potassium excretion, thus serum potassium levels are decreased.

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

2. Correct: Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce a new food during an illness.

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

2. Correct: Nurses must be aware of clients' specific cultural or religious beliefs in order to provide appropriate care and discharge planning. Asian societies have a deep respect for others and making eye contact with the nurse would be considered rude and offensive. The nurse is considered superior to the client, so direct eye contact with a superior shows a lack of respect. This client is displaying attentiveness while also showing respect for the nurse.

The primary healthcare provider has prescribed KCL 20 mEq by mouth once a day. The pharmacy has dispensed KCL 8 mEq/5 mL. How many mL will the nurse administer? Round answer using one decimal point.

8 mEq : 5 mL = 20 mEq : x mL 8 x = 100 x = 12.5

Prior to entering an isolation room, what order should the nurse apply personal protective equipment? Place goggles snugly around face and eyes. Apply clean gloves. Perform hand hygiene. Put mask on, covering mouth and nose. Apply gown, tying at neck and waist.

First, perform hand hygiene Second, apply gown. Tying at neck and waist Third, put mask on, covering mouth and nose Fourth, place goggles snugly around face and eyes Fifth, apply clean gloves

The primary healthcare provider prescribes an intravenous infusion of D5 W at 125 mL per hour. The tubing has a drop factor of 20 gtt/mL. How many drops per minute should the nurse administer? Round answer to the nearest whole number.

The formula is: mL per hour x drop factor time 125 x 20 = 2500 = 41.666 = 42 60 60 Since partial drops cannot be counted, always round to the nearest whole number which, is 42.

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

2., 4., & 5. Correct: Liquefy secretions by increasing oral intake to at least eight, 8 ounce glasses of liquid/day unless fluid restrictions are required. Incentive spirometry helps keep alveoli open and prevents further pneumonia and atelectasis. Prescribed percussion can assist with loosening secretions for expectoration.

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

2., 4., & 5. Correct: Liquefy secretions by increasing oral intake to at least eight, 8 ounce glasses of liquid/day unless fluid restrictions are required. Incentive spirometry helps keep alveoli open and prevents further pneumonia and atelectasis. Prescribed percussion can assist with loosening secretions for expectoration.

A nurse is discussing with several unlicensed assistive personnel (UAP) about a dietary prescription for clear liquids. Which selections by the UAP indicate to the nurse an understanding of a clear liquid diet? (SATA) 1. Vanilla custard 2. Lemon jello 3. Tomato juice 4. Sprite 5. Banana popsicle

2., 4., & 5. Correct: These are considered clear liquids. You can see through them. The banana popsicle and lemon jello in a liquid state can be seen through.

Based on expected growth and development for a 7 month old infant, what would the nurse anticipate that the mother would report at the infant's well-baby visit? 1. Has slight head lag when pulled to sitting position. 2. Walks holding onto furniture. 3. Able to sit, leaning forward on both hands. 4. Has neat pincer grasp.

3. Correct: A 7 month old is not expected to be able to sit fully unsupported but is able to sit by leaning forward on both hands.

The nurse is caring for a diabetic client. The client's glucose level at 0700 is 265. What is the nurse's best action? Prescriptions: 40 units NPH insulin every AM Regular Insulin per Sliding Scale both AC and HS Sliding Scale: Blood glucose < 200: 0 units Blood glucose 200-249: 2 units Blood glucose 250-299: 4 units Blood glucose 300-349: 6 units Blood glucose 350-399: 8 units Blood glucose 400 or >: Call primary healthcare provider 1. Hold the NPH and regular insulin 2. Give 8 units of regular insulin and hold the NPH 3. Give the NPH and 4 units of regular insulin 4. Give 40 units of NPH and hold the regular insulin

3. Correct: According to the prescription and sliding scale, the client will need 40 units of NPH and 4 units of regular insulin for a glucose level of 250-299.

A nurse is caring for a client who has chest pain. Which statement made by the client leads the nurse to suspect angina instead of a myocardial infarction (MI)? 1. I became dizzy when I stood up. 2. I was nauseated and began vomiting. 3. The pain started in my chest and stopped after I sat down. 4. The pain was not relieved after taking 3 nitroglycerine tablets.

3. Correct: Chest pain brought on by exercise and stopped with rest is the hallmark of angina. If it were a MI, the pain would continue even with rest or position changes.

A low income family with children lives in an old, run-down apartment building situated close to a salvage yard in a poor neighborhood. Which risk factor identified by the nurse takes highest priority in the health screening for this family? 1. Immunization status 2. School-related problems 3. Lead poisoning 4. Signs of child abuse

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

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

3. Correct: Soiled linen should be placed in a leak proof container for transport off the unit to the laundry. Make sure the linen bags are not overfilled which would prevent complete closure.

A female client considers using spermicidal agents because she wants both birth control and protection from sexually transmitted infections (STIs). What should the nurse explain regarding spermicidal agents? 1. Effective in reducing vaginal fungal infections such as Candida albicans. 2. Eliminates bacterial and viral sexually transmitted infections (STIs). 3. Most effective when used in conjunction with other barrier methods. 4. Are used on an "as-needed" basis and exhibit few side effects.

3. Correct: Spermicidal agents have an approximately 25% failure rate in preventing pregnancy and are not effective in preventing STIs. These agents kill sperm by destroying the protective surface of sperm and preventing metabolic activities necessary for survival. Barrier methods of contraception include the diaphragm, cervical cap, sponge, film, and condoms.

A licensed practical nurse (LPN) in a long-term care facility assigns the task of feeding a client with dysphagia to an unlicensed assistive personnel (UAP) who is in orientation. Which action should be taken by the LPN to assign this task safely? 1. Verify that the UAP has experience in feeding clients with dysphagia. 2. Ask the UAP if he/she has any questions about the correct procedure. 3. Observe the UAP during the feeding to ensure that the correct technique is used. 4. Confirm that the UAP has the knowledge needed to feed a client with dysphagia by testing.

3. Correct: The LPN should observe the UAP during the feeding to ensure that the correct technique is used. Actually observing the UAP's performance of the task is necessary to validate that correct technique is used.

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

3. Correct: The client has the right to the personal medical record. Generally, a period of time is required to get the record copied. The client may be charged for the copy. This assures the client that the request will receive attention.

The nurse is caring for a client who is severely depressed and has an extremely low energy level. The client answers questions by using one or two words, and makes no eye contact. Which intervention is most appropriate for this client? 1. Ask the client to go to the group session with you. 2. Remind the client to interact with the nurse today. 3. Sit with the client and make no demands. 4. Allow the client to decide when to talk with the nurse.

3. Correct: The client is severely depressed and does not wish to have one on one interaction. Sitting with the client without demands demonstrates that the client is worthy of your time. The silence may also encourage the client to talk with you.

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

3. Correct: The client's delusions can be very distressing. The nurse should empathize with the feelings of the client, but should not validate the belief itself. Empathy displays that the nurse is concerned, interested, and accepts the client but does not support the delusion.

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

3. Correct: The least appropriate client to assign the nurse from the adult unit would be the suspected sexual abuse. Caring for an abused child requires skill that must be developed from understanding the dynamics of abuse as well as working with a certain developmental level.

What task would be most appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 1. Ambulating a client who has syncopy. 2. Changing a colostomy bag on a client. 3. Serving the diet tray for a diabetic client. 4. Taking the initial vital signs on a client who is to receive blood.

3. Correct: The most appropriate task for a non-licensed person would be serving the diet tray for a client. This does not require experience for a particular skill nor does it require higher level skills that would require a licensed person to perform.

A nurse walks into the medication area of a long-term care facility and sees a colleague taking a pill from a resident's supply of narcotics. The nurse says, "Please don't say anything. I need my job and I have a migraine." What action should the nurse take? 1. Reassure the colleague that you won't tell this time. 2. Insist that the colleague get some help. 3. Report what was seen to the supervisor. 4. Send the colleague home.

3. Correct: The nurse should follow the procedure to return the narcotic, and then the nurse should report the observation to the supervisor. The nurse must serve as client advocate by reporting a nurse who may be impaired.

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

3. Correct: These foods are not high in tyramine. Tyramine is an amino acid that helps in the regulation of blood pressure. MAOIs block the enzyme monoamine oxidase which is responsible for breaking down excess tyramine in the body. Eating foods high in tyramine while on MAOIs can result in dangerously high levels of tyramine in the body. This can lead to a serious rise in blood pressure, creating an emergency situation. Tyramine is found in protein-containing foods and the levels increase as these foods age. Food such as strong or aged cheese, cured meats, smoked or processed meats, liver (especially aged liver), pickled or fermented foods, sauces, soybeans, dried or overripe fruits, meat tenderizers, brewer's yeast, alcoholic beverages and caffeine- such as in tea, cokes and coffee are considered to be high in tyramine and should be avoided in clients taking MAOIs.

The nurse just received an arterial blood gas (ABG) report that shows a borderline high PCO2 on a client who had chest surgery. What should be the priority nursing intervention? 1. Tell the client to breathe faster. 2. Medicate for pain and ambulate. 3. Have client use the incentive spirometer. 4. Prepare to administer bicarbonate to buffer.

3. Correct: This client had chest surgery and the pCO2 is high. What are you worried about? Hypoventilation. Yes, the client is probably hurting due to the incision and does not want to take deep breaths. In order to get rid of the excess CO2, the client needs to turn, cough, and deep breathe. Incentive spirometry can be provided to assist the client with this effort.

Which client is appropriate to be assigned in the room with a 6 year old prescribed chemotherapy? 1. Twenty-two month old diagnosed with respiratory syncytial virus (RSV). 2. Two year old with nephrotic syndrome. 3. Three year old admitted with febrile seizures. 4. Four year old who has a fractured tibia.

4. Correct. This child is not infectious. Place children within the same age group together whenever possible.

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

4. Correct: A clean needle that moves through blood-soiled gloves to stick the nurse is considered to be potentially contaminated and results in a blood-borne exposure. All other answers are considered a clean stick.

An unlicensed assistive personnel (UAP) has been assigned to take vital signs on several clients. Which instruction would be most important for the LPN/LVN to provide to the UAP? 1. "Notify me if the pulse oximetry reading drops below 95% in the client who has emphysema." 2. "The client in room 210 has dizziness and faintness when standing, so I need you to obtain a blood pressure reading with the client in the lying, sitting, and standing position." 3. "The client in room 212 has a pacemaker. Let me know if the apical heart rate is greater than 70 bpm." 4. "Let me know immediately if any client has a temperature of 101. 5 degrees F (38.6 degrees C) or higher."

4. Correct: A temperature of 101. 5 degrees F (38.6 degrees C) or higher is reported to the primary healthcare provider. The client is likely to need cultures and antibiotic therapy.

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

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

An infant has been prescribed Bryant's traction for a diagnosis of developmental dislocated hips (DDH). At what degree of hip flexion should the nurse maintain the infant's hip for proper traction alignment? 1. 15 2. 30 3. 45 4. 90

4. Correct: Bryant's traction is used for DDH. The child's body and the weights are used as tension to keep the end of the femur in the hip socket. Traction helps position the top of the femur into the hip socket correctly. This is accomplished with 90 degrees of hip flexion.

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

4. Correct: Clang association involves the choice of words governed by sounds, often taking the form of rhyming even though the words themselves don't have any logical reason to be grouped together.

Which snack selection should the nurse provide to a client receiving chemotherapy? 1. Fresh salad with cucumbers, carrots, and tomatoes. 2. Orange slices with yogurt. 3. Strawberries with whipped cream. 4. Milk shake with a packet of instant breakfast added.

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

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

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

The nurse is caring for a client who has been in Russell's traction for four days. Which finding would require immediate action by the nurse? 1. Absence of indentations in the popliteal space. 2. Hypoactive bowel sounds to all abdominal quadrants. 3. Bilateral pedal pulses with doppler. 4. Report of sharp pain to right upper anterior chest wall.

4. Correct: Report of sharp pain to the chest is one sign of pulmonary embolus and should be investigated immediately. A pulmonary embolism is the blockage of a major blood vessel in the lung caused by a blood clot. Pulmonary embolism can be life-threatening.

An elderly client comes to the clinic for a check-up. The client's daughter tells the nurse that her father's dementia symptoms become increasingly more difficult to handle in the evening. How would the nurse document this symptom? 1. Confabulation 2. Apraxia 3. Pseudodementia 4. Sundowning

4. Correct: Sundowning is a phenomenon where symptoms seem to worsen in the late afternoon and evening. Communication becomes more difficult, with increasing loss of language skills. Institutional care is usually required at this stage.

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

4. Correct: The client must sign the operative permit or any other legal document prior to taking preoperative drugs that can affect judgment and decision-making capacity.

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

4. Correct: The fracture would be most appropriate for an LPN/VN and is within the scope of practice. This LPN/VN would need minimal assistance from the RN. Possibly, the other clients could have intravenous fluid (IVF) needs and medications that would require skill from an RN.

A client who is occasionally confused states that the medication is the wrong color when the nurse hands it to the client. What action should the nurse take? 1. Encourage the client to take the medication. 2. Tell the client that the medication is correct. 3. Explain that generic medications may be different colors. 4. Double check the medication before administering.

4. Correct: The nurse cannot assume that the client is confused. Assessing orientation, LOC and asking client to state his/her name would help identify if the client is confused. The nurse must double check. An error may be prevented by doing this. Seeking clarification is the safest option.

An LPN/VN from the maternity unit is pulled to the medical-surgical unit for the first four hours of the shift. When the LPN/VN is receiving assignments from the charge nurse, which client assignment would be considered inappropriate? 1. Client with rheumatic fever 2. Client scheduled for an appendectomy 3. Client one day post cardiac catheterization 4. Client diagnosed with Methicillin-Resistant Staphylococcus Aureus

4. Correct: This client is contagious and should not be delegated to the maternity nurse. The nurse will be going back to the maternity unit after four hours and will be a potential agent for spreading the infection. Client safety could be compromised.

A client is seen in the clinic expressing feelings of hopelessness and despair after losing his wife two months ago. He tells the nurse, "I think I am ready to go meet her. Please don't tell anyone." How should the nurse respond? 1. "I can see that you miss your wife very much." 2. "Tell me about your wife." 3. "I will keep your secret if you promise me you won't do anything until we talk again." 4. "I can't keep a secret like that. Are you planning to harm yourself?"

4. Correct: This elderly client is contemplating suicide. Elderly men are at a high risk for succeeding at suicide because they tend to use lethal methods. The nurse has a responsibility to get the client help. The nurse is using the therapeutic communication technique of seeking clarification and validation.

What tips for administering medication to children should the nurse reinforce to parents? (SATA) 1. Demonstrate proper measuring techniques for liquid medications. 2. Put crushed medications into the child's favorite food. 3. Place liquid medication in an 8-ounce bottle of formula. 4. Call medication "candy" to encourage children to take the medicine. 5. Do not place medications in a container other than the original container.

1. & 5. Correct: This is a safety issue and the parents need to be able to accurately measure the child's medication. Never put medications in dishes, cups, bottles, or other household containers that children or other family members may be unaware of.

Which data will provide the nurse with the most information regarding a client's neurologic function? (SATA) 1. Level of consciousness 2. Doll's eyes reflex 3. Babinski reflex 4. Reaction to painful stimuli 5. Verbal ability

1. & 5. Correct: Yes, the most important and subtle changes are related to the client's level of consciousness, verbal ability, orientation, and ability to move to command.

Parents of school aged children are working toward a goal of healthy family TV viewing. Which parental statement indicates to the nurse an adequate understanding of appropriate use of TV in the family? 1. "I don't allow my kids to watch violent TV shows". 2. "Our children can watch anything that is on the kid network channel". 3. "I don't usually worry about the amount of time the kids watch TV on weekends". 4. "The kids can each choose one TV show per day without my input".

1. Correct: Violent TV shows are not recommended for school aged children. They may be disturbing and desensitize them to violence.

An adult client has just returned to the nursing care unit following a gastroscopy. Which updates to the client's plan of care should be initiated by the nurse? (SATA) 1. Vital sign checks every 15 min x 4 2. Supine position for 6 hours 3. NPO until return of gag reflex 4. Irrigate NG tube every 2 hours 5. Raise four side-rails

1., & 3. Correct: Vital signs, post procedure, are important to monitor for any post-procedure complications such as bleeding or any signs of respiratory compromise. VS are checked frequently for the first hour post procedure. Any client who has a scope inserted down the throat and has received numbing medication in the back of the throat to depress the gag reflex should be kept NPO until the gag reflex returns.

After a client returns from surgery, which actions should the nurse initiate to reduce the risk of pneumonia? (SATA) 1. Allow 2 hours of rest between deep breathing and coughing exercises. 2. Assist with splinting the incision when client coughs. 3. Have the client drink a glass of water before coughing. 4. Perform percussion and vibration every 2 hours. 5. Promote incentive spirometer use several times per hour while awake.

1., 2., & 5. Correct: They need to cough and deep breath at least every 2 hours. Deep breathing and coughing will expand the lungs and help expectorate secretions. Splinting helps with the ability to control pain and produce an effective cough. Incentive spirometry encourages deep inspiratory efforts, which are more effective in re-expanding alveoli than forceful expiratory efforts.

What behaviors would the nurse expect to observe in a client admitted to the psychiatric unit with a diagnosis of major depression? (SATA) 1. Withdrawn behavior 2. Sitting in room, lights out, drapes closed 3. Unkempt appearance 4. Overeating 5. Severe insomnia

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

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

15 mg: 1 mL = 20 mg: x mL 15x = 20 x= 1.33 = 1.3

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

2. Correct: Mucositis is pain and inflammation of the body's mucous membranes along the gastrointestinal tract. Ulcerations in the oral cavity can make it difficult to chew food or be intolerant to certain foods due to discomfort and pain. Intake may be inadequate as a result of this.

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

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

What characteristics would indicate to the nurse that a client is experiencing false labor? (SATA) 1. Cervical dilation noted. 2. Contractions decrease with sleep. 3. Bloody show noted. 4. Contraction intensity increases with walking. 5. Contractions felt in abdomen above umbilicus.

2., & 5. Correct: False labor or Braxton Hicks contractions are mild, irregular in frequency, and intermittent; decrease in frequency, duration, and intensity with walking or position changes; and often stop with sleep or comfort measures such as oral hydration or emptying of the bladder. False labor contractions are typically felt as a tightening or pulling sensation of the top of the uterus. In contrast, true labor contractions are more commonly felt in the lower back and gradually sweep around to the lower abdomen.

What should the nurse do when taking a telephone prescription from a primary healthcare provider? (SATA) 1. Document the prescription prior to the end of the shift. 2. Explain to the primary healthcare provider that nurses cannot take telephone prescriptions. 3. Repeat the prescription back to the primary healthcare provider prior to hanging up. 4. Transcribe the prescription in the client's chart. 5. Ask the primary healthcare provider to wait and write the prescription during rounds.

3. & 4. Correct: Whenever a verbal or telephone prescription is given, the nurse is to transcribe the prescription, and then read it back to the ordering primary healthcare provider during the time the prescription is given. If the prescription is received and repeated back to the primary healthcare provider without transcribing the prescription first, an error may occur.

The nurse is admitting an adolescent reporting severe depression and amenorrhea. What additional observations by the nurse would suggest the client may develop anorexia nervosa? (SATA) 1. Tight fitting clothes 2. Oily, elastic skin 3. Brittle, dry nails 4. Gingival infections 5. Low blood pressure

3. & 5. Correct: This client is reporting symptoms consistent with anorexia nervosa, a serious and potentially life-threatening eating disorder that develops secondary to the type of family or social stress experienced in adolescence. In addition to severe depression and amenorrhea, the nurse has identified brittle, dry nails and a low blood pressure secondary to weight loss as additional indications of anorexia nervosa.

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

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

A concerned parent is asking the nurse about activities that would be best for her child who has been diagnosed with asthma. In order to minimize the risk of exercise induced asthma, which activity would be best for the nurse to suggest? 1. Track 2. Basketball 3. Baseball 4. Soccer

3. Correct: Baseball is an activity that is considered "asthma friendly". It requires short, intermittent periods of exertion and is therefore tolerated better by children with asthma.

The nurse is caring for an oncology client with a WBC-5.5/mm3, Hgb-12g/dL, PLT- 40,000 /mm3. Which measure should be instituted? 1. Protective isolation 2. Oxygen therapy 3. Bleeding precautions 4. Strict intake and output

3. Correct: Yes. That is the only value that is not a normal level, and it is way too low, so this client is at risk for bleeding. Bleeding precautions are the appropriate intervention. A normal platelet count ranges from 150,000 to 450,000/mm3. Having more than 450,000 platelets is a condition called thrombocytosis; having less than 150,000 is known as thrombocytopenia.

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

3., 4., 6. Correct: The client who is five days post CVA is one of the most stable clients and could be assigned to the LPN/LVN. There is nothing in the option to indicate that this client is unstable. There is no indication that the eighty-four year old client with heart disease and dementia is unstable, so this client can be accepted by the LPN/LVN. The client with chronic emphysema will experience shortness of breath. There is nothing to indicate that this client is unstable.

postoperative surgical client has a prescription for monitoring of intake and output (I&O). The I&O sheet has been picked up by the unlicensed assistive personnel (UAP) for the 7AM-3PM shift. Calculate the client's output for the shift in mL. Intake Output IV fluid-1025 mL Urine - 1350 mL PRBC-250 mL NG tube - 75 mL Jackson Pratt - 22 mL

350 + 75 + 22 = 1447 mL

Which client assignments would be most appropriate for the LPN/VN to accept? (SATA) 1. 2 year old with asthma receiving IV medication. 2. 6 year old with new onset seizures. 3. 12 year old with colitis receiving TPN. 4. 2 month old with urinary tract infection. 5. 10 year old paraplegic needing assistance with bowel training.

4., & 5. Correct: These assignments would be appropriate for the LPN/VN. There is nothing in these options to indicate that the clients are unstable. The LPN/VN can provide care related to elimination needs.

Which diagnosis does the nurse expect in a client with a (+) Brudzinski's sign? 1. Meningitis 2. Peritonsillar abscess 3. Pharyngitis 4. Rhinosinusitis

1. Correct: Severe neck stiffness causes a client's hips and knees to flex when the neck is flexed. This is a (+) Brudzinski's sign which is suggestive of meningitis.

Which task by the nurse should be performed first? 1. Suctioning the tracheostomy of an anxious client 2. Changing a colostomy bag that is leaking 3. Collecting admission data on a client that has been on the floor for 45 minutes 4. Administering pain medication for a client that is 8 hours post op

1. Correct: Suctioning the tracheostomy should take priority. This client is anxious, which is a sign of hypoxia, and they need immediate action.

A client is admitted to the surgical unit with cholelithiasis and a history of psychosis and a known allergy to phenothiazines. Which prescription should the nurse discuss with the primary healthcare provider? Prescriptions: Clear liquid diet Gallbladder ultrasound today IV of LR with KCL 20 mEq at 125 ml/hr Thioridazine 50 mg PO TID ​Ciprofloxacin 200 mg IVPB every 12 hours Haloperidol 5 mg by mouth twice daily Ondansetron 4 mg IM as needed for nausea or vomiting 1. Thioridazine 50 mg PO tid 2. Ciprofloxacin 200 mg IVPB every 12 hours 3. Haloperidol 5 mg PO bid 4. Ondansetron 4 mg IM prn nausea or vomiting

1. Correct: The client is allergic to phenothiazines. Thioridazine is a phenothiazine and should not be given to this client.

While reviewing the prescriptions written by a primary healthcare provider, the nurse notes that ibuprofen 30 mg by mouth every 6 hours is prescribed for a child weighing 6 kg. The drug information book states that the appropriate dosage range is 20-30 mg/kg/24 hours. What action should the nurse take? 1. Administer the ibuprofen at 30 mg by mouth every 6 hours. 2. Contact the nursing supervisor regarding the prescription. 3. Ask the pharmacist to calculate the appropriate dose. 4. Notify the primary healthcare provider.

1. Correct: The maximum dose in 24 hours would be 30 x 6 = 180 mg. 30 mg every 6 hours is a safe dose.

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

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

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

1., 2., 3., & 4. Correct: Washing the face frequently (at least twice a day) with mild soap or detergent and warm water will remove oil, dirt, and bacteria which increase inflammatory reactions and resulting acne. Oily creams and oil based cosmetics can block the ducts of the sebaceous gland ducts and the hair follicles, making the acne worse. These should be avoided. Squeezing or picking at lesions will increase potential for infection and scarring.

The women's health unit is short one staff member and will receive a LPN/VN from the medical-surgical unit. Which clients should the LPN/VN accept from the charge nurse? (SATA) 1. Total abdominal hysterectomy (TAH). 2. Client post C-section to be discharged home. 3. Breast Reduction. 4. Vaginal delivery of fetal demise. 5. 28 week gestation of bed rest. 6. Bladder suspension with anterior and posterior repair.

1., 3. and 6. Correct: When a nurse is pulled to another unit, always assign them like a brand new nurse. A client with a TAH, breast reduction, or bladder suspension require basic post-operative care. These are within the scope of knowledge of a brand new LPN/VN with medical-surgical knowledge.

The nurse is providing care to a 5 year old client who has been experiencing moderate pain. Which intervention is appropriate for the nurse to use with this client? 1. Encourage the client to talk about the pain. 2. Provide distraction by asking the client to sing with the nurse. 3. Suggest that the client try to relax. 4. Tell the client that the pain can be self controlled

2. Correct: Distraction is a good technique to use with the toddler/preschooler. Other distractions might be to read a book, watch TV with the client, or look at pictures.

A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R 36. The client is extremely anxious and crying uncontrollably. Based on this assessment, the nurse should anticipate that this client is likely in which acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

2. Correct: Hyperventilation due to anxiety, pain, shock, severe infection, fever, or liver failure can lead to respiratory alkalosis. With each of these, the client loses too much CO2. The reduction of CO2 creates an excessive loss of acid, resulting in an alkalotic state. Since the problem is respiratory, it is respiratory alkalosis.

A client recently prescribed propranolol returns to the outpatient clinic for follow-up. Which statement by the client should be reported immediately to the primary healthcare provider? 1. "My resting pulse was 60 this morning." 2. "I feel a little short of breath when walking." 3. "I have lost 5 pounds in the last 2 weeks." 4. "My blood pressure (BP) was lower this visit than last time."

2. Correct: Propranolol is a non-selective beta blocker, so it blocks sites in the heart and in the lungs. The shortness of breath could be the result of the adverse reactions of bronchospams or heart failure. This statement requires immediate investigation by the primary healthcare provider.

The client at a clinic has voiced suicidal thoughts and has access to firearms at home. Which action by the nurse is priority? 1. Empathize with the client and listen to feelings. 2. Inform the supervisor of client's statements. 3. Chart the thinking pattern and make a follow up appointment. 4. Ask the client to return to the clinic tomorrow for further evaluation.

2. Correct: The LPN should report the client's statements, which indicate a developing crisis, to the supervisor. The family should be notified. Suicidal thinking is one condition that necessitates breach of confidentiality. The client has identified a plan and has access to firearms; therefore, the family should remove them from the house. Client safety is a priority. This client will likely be directly admitted to the hospital.

A nurse is caring for a client who delivered a baby vaginally four hours ago. What signs and symptoms of postpartum hemorrhage should the nurse report to the primary healthcare provider? (SATA) 1. Two blood clots the size of a dime. 2. Perineal pad saturation in 10 minutes. 3. Constant trickling of bright red blood from vagina. 4. Urinary output of 20 mL per hour. 5. Firm fundus

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

The nurse is participating in an education program for a group of clients on how to decrease the risk of developing recurrent renal calculi. What topics should be included when the nurse reinforces the teaching? (SATA) 1. High-purine foods to consume 2. Diuretic use to prevent urinary stasis 3. Strain urine with each void 4. Maintain a daily water intake of at least 2 liters 5. Foods low in calcium

2., 4., & 5. Correct: Diuretics are often used to prevent urinary stasis and further calculus formation. Daily fluid intake should be 2-3 liters per day to ensure good renal function. Most stones are calcium stones, so decrease calcium in the diet to reduce the chance of calcium stones.

While collecting data on an elderly client diagnosed with advancing Alzheimer's disease, the client's spouse begins to sob and states, "After all these years, we won't be together anymore." What would be the best response by the nurse? 1. "You can come to visit anytime you want to." 2. "Would you like to see the room and facilities?" 3. "Let's find a quiet place to sit and talk awhile." 4. "You did the best you could in this situation."

3. Correct. The nurse recognizes that the client's spouse is emotionally distraught at this moment, and is most in need of the nurse's focus at this time. Major life events have affected this family unit, including the client's terminal diagnosis and separation to a new living environment. This spouse is understandably overwhelmed by the changes occurring and, while the nurse will need to gather data, family needs must be met. Focusing on the spouse's emotional needs and allowing time to verbalize feelings could positively affect the client's adaptation to the situation.

A client in a manic state is on the inpatient psychiatric unit. The client has a need for adequate sleep and rest due to the fact that the client has been awake for 72 hours. Which intervention should the nurse initiate for the client? 1. Encourage the client to participate in an exercise class after dinner. 2. Offer the client a cup of coffee prior to going to bed. 3. Provide a warm bath and snack before the client goes to bed. 4. Send the client to watch the "unit movie" each evening.

3. Correct: A warm bath and snack may promote sleep. The client who is manic may become exhausted due to lack of sleep.

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

3. Correct: Gloves should be removed and hands washed before leaving each client's room. Gloves quickly become contaminated and then become a potential vehicle for the transfer of organisms between clients.

A client in the manic phase of bipolar disorder is constantly walking around the day room and refuses to sit down to eat the spaghetti and meatballs sent by the kitchen. Which food should the nurse request from dietary? 1. Carrots and apples 2. Donuts 3. Pepperoni pizza sticks 4. Strawberry pastry

3. Correct: High protein, high calorie, nutritious finger foods are required when the client will not sit down to eat. This client needs food they can eat "on the go" because they are burning more calories in this phase of bipolar disorder.

A client is admitted with an acute episode of diverticulitis. What symptom would the nurse promptly report to the primary healthcare provider? 1. Mid-abdominal pain radiating to the shoulder 2. Nausea and vomiting periodically for several hours 3. Abdominal rigidity with pain in the left lower quadrant 4. Elimination pattern of constipation alternating with diarrhea

3. Correct: Pain in the lower left quadrant with abdominal rigidity indicates the client is experiencing a perforated diverticulum and is a medical emergency. Abdominal rigidity indicates either perforation or internal bleeding. Both of these symptoms are considered an "acute abdomen" and are emergencies.

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

3. Correct: Placing a turn sheet under the client before moving will prevent friction and shearing forces which may lead to an abrasion or skin tear. Pressure ulcers are more likely to develop in tissues where shear force injury has occurred.

The nurse is caring for a client who is unresponsive during a postictal state. Which position is correct for this client? 1. Orthopneic 2. Dorsal recumbent 3. Sims' 4. Reverse trendelenburg

3. Correct: Sims' position is a semi-prone position where the client is halfway between lateral and prone positions. Often used for enemas or other examinations of the perianal area. Sims' position is used for unconscious clients because it facilitates drainage from the mouth and prevents aspiration.

A client was admitted to the medical unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's BP is 198/94. What would be the best action for the nurse to take? 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm in 15 minutes. 3. Administer the 0900 furosemide and enalapril now. 4. Check the client for pain.

3. Correct: The nurse should recognize the need for measures to reduce the blood pressure. Administering the client's blood pressure medicine is aimed at correcting the problem. It is appropriate to administer the medications at this time in relation to the time that the next dose is due.

Following surgery, a client refuses to ambulate as prescribed. What action should the nurse take? 1. Notify the primary health care provider of client's refusal to ambulate. 2. Offer the client pain medication. 3. Explain complications associated with bed rest. 4. Perform passive range of motion exercises.

3. Correct: The nurse should tell the client about complications that can be prevented with ambulation, such as constipation, pneumonia, or deep vein thrombosis (DVT).

A client with cirrhosis is being treated with bumetanide 1 mg daily for the management of ascites. What would the nurse identify as an effect of this medication? 1. Hyperbilirubinemia 2. Hypercalcemia 3. Hypoaldosteronism 4. Hypokalemia

4. Correct: Bumetanide is a K+ depleting diuretic. Potassium is lost primarily through the kidneys; therefore, when the urine output increases with the use of a diuretic, more potassium can be lost and the client is at risk for hypokalemia.

The nurse is caring for a 5 year old client who is 12 hours post tonsillectomy. The client is pain free and has advanced to a soft diet. What is the priority nursing intervention? 1. Apply warm compresses to the throat. 2. Encourage gargling to reduce discomfort. 3. Position the child supine. 4. Monitor for frequent clearing of the throat.

4. Correct: Continuous swallowing and frequent clearing of the throat are signs of bleeding.

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

4. Correct: Here the nurse is speaking only for the nurse. The nurse cannot legitimately speak for anyone else. The nurse must model the process of not speaking for anyone else. The response also lets the client know that the nurse cares about the way the client feels.

A client admitted with a diagnosis of end stage kidney disease (ESKD) has been prescribed a diet containing no more than 1 gram of phosphate per day. Which food item, if found on the client's meal tray should be removed by the nurse? 1. Skinless chicken breast 2. Green beans 3. Asparagus 4. Ice cream

4. Correct: Ice cream, a milk product is high in phosphate. This is not appropriate for a diet limited in phosphate. This item would need to be removed.

Which observation by the nurse would demonstrate normal development of an infant during a well child clinic visit? 1. Eight month old infant who requires support to maintain a sitting position. 2. Twelve month old infant who can only say 2 words 3. Four month old infant who is fearful and cries when the nurse approaches. 4. Eleven month old infant who can only stand by holding onto the walls.

4. Correct: It is normal for 11 month old infants to "cruise" by holding onto furniture and walls. Children have until 22 months to walk independently.