Question Trainer 1 Review
1) CORRECT- It is important to interview the client alone. In the presence of the family, the client may not disclose the abuse. 2) Watching the family's reaction is not a reliable method to assess whether or not elder abuse has occurred. 3) A referral for a home visit is not a priority. The priority is assessment of the client. 4) It is not the nurse's responsibility to notify the adult protective agency. The priority is assessment of the client.
An older adult client is admitted with bilateral fractures of the arms. The client is brought to the emergency department (ED) by a family member. Which action by the nurse is appropriate in determining if the client has been a victim of physical abuse? 1. Have the family member stay in the waiting area while the client is assessed.2. Ask the client how the injury occurred and observe the family member's reaction.3. Make a referral for a home assessment visit by the visiting nurse.4. Notify an elder protective services agency about the possible abuse.
1) Lacto-vegetarians do not eat fish. 2) CORRECT - Lacto-vegetarians will drink milk. 3) Lacto-vegetarians will not eat eggs. 4) CORRECT - Lacto-vegetarians will eat cheese. 5) CORRECT - Lacto-vegetarians will eat yogurt.
The client states to the nurse, "I am a lacto-vegetarian." Which food will the nurse expect the client to eat? (Select all that apply.) 1. Fish.2. Milk.3. Eggs.4. Cheese.5. Yogurt.
1) SSRI's take 2 to 4 weeks to attain therapeutic levels. There is no indication in the question that the client is suicidal. 2) CORRECT- Expected side effects of SSRIs include drowsiness and dizziness. The client should be placed on fall precautions. 3) It takes 2 to 4 weeks to attain therapeutic levels of an SSRI; therefore, it is not uncommon for depressive symptoms to continue during this time frame. The side effects may occur with the first dose and the priority action is to take action to protect the client from harm. 4) There is no evidence that functional capacity is affected.
The nurse is providing care to a client who is starting a selective serotonin reuptake inhibitor (SSRI). Which action is the most important for the nurse to initiate? 1. Perform suicide watch protocol with checks every 15 minutes.2. Initiate fall risk protocol.3. Contact the health care provider due to continued depressive symptoms.4. Perform a daily functional assessment.
1) Libel is defined as malicious or untrue writing by a person that is brought to the attention of others. 2) CORRECT- Slander is defined as malicious or untrue spoken words by a person that is brought to the attention of others. 3) Negligence is defined as the act of doing (or not doing) something that a reasonably prudent nurse would have done. 4) Battery is defined as unlawful touching of another person without informed consent.
The nurse manager is advised of a situation on the unit in which one nurse told other staff members that another nurse had been fired for diverting narcotics. The nurse manager is later called into court because the nurse who was fired is seeking legal action against the nurse who discussed the situation with staff members. Which charge is the basis of the lawsuit? 1. Libel. 2. Slander. 3. Negligence. 4. Battery.
1) Declining the request should not be done without reviewing the dress code policy. 2) Making the accommodation should not be done without reviewing the dress code policy. 3) The organization's policy should be reviewed prior to advocating for change, because the accommodation may already be included in the policy. 4) CORRECT - Reviewing the dress code policy should take place on a regular basis, from a cultural standpoint, to accommodate the various traditional dress needs of employee groups. In addition, the accommodation for wearing the requested clothing may already be covered in the dress code.
The nurse who is a practicing Muslim requests to wear a hijab while working. Which action will the nurse manager take next? 1. Decline the request.2. Make the accommodation.3. Advocate for modification of the organization's dress code.4. Review the organization's dress code policy.
1) Pain level can be assessed after the health care provider is notified. 2) Determining whether the cast is wet or dry is not the priority at this time. 3) Measuring the blood pressure is not going to help determine the reason for the client's foot to feel numb. 4) CORRECT — Compartment syndrome begins with edema and increased pain. It progresses with decreased perfusion, causing a change in skin color and weak pulses. Numbness is a later sign that could indicate tissue necrosis. This is an emergency that should be reported to the health care provider.
A client with a newly casted lower leg reports to the nurse that the foot feels numb. Which action will the nurse take first? 1. Assess for pain.2. Monitor the cast for dampness.3. Measure the client's blood pressure.4. Notify the health care provider.
1) CORRECT - A pulse rate of 115 beats/minute indicates tachycardia, which could occur with insufficient blood volume. 2) CORRECT - Low blood pressure is an indication of insufficient blood volume. 3) A hemoglobin of 13 g/dL is within the normal range for a female client. 4) CORRECT - A normal hematocrit level for females is 36% to 47%. The client's level of 28% indicates low blood volume. 5) A normal red blood cell range for females is 4.4 X 106 cells/µL (4.2-5.9 X 1012) cells/L. The client's count of 4 X 106/µL (4.4 x 1012 cells/L) is within normal limits.
A female client received 2 units of packed red blood cells (PRBCs) for gastrointestinal bleeding. Which finding indicates to the nurse that the client may need an additional transfusion? (Select all that apply.) 1. Pulse rate 115 beats/minute.2. Blood pressure 82/40 mm Hg.3. Hemoglobin 13 g/dL (130 g/dL).4. Hematocrit 28%.5. Red blood cell count 4 X 106 cells/µL (4.4 X 1012 cells/L).
1) Ondansetron is used for nausea. This client does not exhibit signs of nausea. 2) CORRECT - Atropine is an anticholinergic that can reduce secretions. Dyspnea should improve and rales should dissipate. 3) Dexamethasone is not indicated for secretions. 4) Haloperidol is not indicated for secretions.
A terminally ill client that received intravenous morphine 20 minutes ago develops dyspnea and bilateral rales. Which medication will the nurse plan to administer next? 1. Ondansetron intravenous.2. Atropine sublingual.3. Dexamethasone intravenous.4. Haloperidol sublingual.
1) Contact precautions requires visitors to wear a gown before entering the room of a client with Clostridium difficile. 2) CORRECT - Alcohol does not kill Clostridium difficile spores. The use of soap and water is more effective than alcohol-based hand rubs. 3) While in the client's room, the visitor should wear clean gloves. 4) All personal protective equipment must be discarded before the visitor exits the client room.
The nurse observes a visitor in the room of a client diagnosed with Clostridium difficile. For which action by the visitor does the nurse intervene? 1. Applies an isolation gown before entering the room. 2. Uses alcohol hand rub after leaving the client's room. 3. Wears a pair of clean gloves while in the client's room. 4. Removes all protective equipment before leaving room.
1) Deep, rapid respirations are the body's response to metabolic acidosis. 2) Altered white blood cell count is not a specific sign of metabolic imbalance. 3) CORRECT - Deep, rapid respirations are the body's way to compensate for metabolic acidosis via the respiratory system, which tries to eliminate the buffered acids by increasing alveolar ventilation. 4) An altered platelet count is not a sign of a metabolic imbalance.
The nurse provides care to an infant with dehydration and metabolic acidosis. Which finding will the nurse expect to observe? 1. Slow, shallow respirations.2. Decreased white blood cell count.3. Tachypnea.4. Decreased platelet count.
1) Unemancipated minors with specific medical conditions, such as a sexually transmitted infection (STI), may consent to medical treatment. Information and treatment can be provided without notification of, or consent from, the parent(s). 2) The nurse does not know if this is true. This response does not address the immediate concern. 3) This question is important, but it does not specifically address the client's concern about informing the parents. 4) CORRECT - The nurse needs to obtain informed consent for treatment from the unemancipated minor. The nurse is not obligated to notify the parents.
A 16-year-old client visits the community health clinic. The client tells the nurse, "I think I got an infection from having sex with my boyfriend. I can't tell my parents. They will kill me!" Which is the best response by the nurse? 1. "Since you are a minor, I will have to notify your parents."2. "Your parents will appreciate your maturity in seeking help."3. "Does your boyfriend understand that he will need treatment?"4. "Your parents do not need to know, but will you give me consent for treatment?"
1) Caput succedaneum is the coning of the head from the birth canal. This is not a risk factor. 2) High blood glucose does not increase the chance of hyperbilirubinemia. 3) Petechiae can co-occur with the diagnosis that caused the hyperbilirubinemia, but does not indicate an increased risk. 4) CORRECT - Cephalhematoma a risk factor for hyperbilirubinemia. It can occur after cephalohematoma birth injuries because the baby's body needs to replace lost red blood cells.
The nurse assesses a newborn. Which finding alerts the nurse that the newborn is at risk for hyperbilirubinemia? 1. Caput succedaneum.2. Hyperglycemia.3. Petechiae.4. Cephalhematoma.
1) CORRECT — Gloves should be removed before the protective gown is removed. 2) CORRECT — Glove cuffs are pulled up over the gown cuffs. Gloves reduce the possibility of transmission of microorganisms between the nurse and the client. 3) CORRECT — Perform hand hygiene before gloving and immediately after removing the gloves because no glove is 100% protective. 4) The needle should be recapped after withdrawing medication from a vial to keep it sterile. 5) Gloves are not needed when measuring the blood pressure of a client who has tested positive for HIV.
The nurse is discussing infection control guidelines with a group of student nurses. Which information is most important for the nurse to include in the teaching? (Select all that apply.) 1. "Gloves should be removed before the protective gown is removed."2. "Glove cuffs are pulled up over the gown cuffs."3. "Perform hand hygiene before gloving and immediately after removing the gloves."4. "The needle should not be recapped after withdrawing medication from a vial."5. "Gloves should be worn when measuring the blood pressure of a client who has tested positive for the human immunodeficiency virus (HIV)."
1) The nurse should have the client sign a consent form for a blood transfusion. 2) The blood should be administered with Y-tubing and a filter. 3) CORRECT - Dextrose should not be used with a blood transfusion, since this will cause clotting and cell breakdown. 4) The expiration date should be checked on the transfusion prior to administering.
The nurse mentors a novice nurse who prepares a unit of packed red blood cells (PRBCs) for a client. Which observation indicates that the novice nurse needs additional direction? 1. Obtaining a consent form. 2. Selecting Y-tubing with a filter. 3. Hanging an intravenous solution of dextrose. 4. Checking blood transfusion for expiration date.
1) Respiratory rate is not used to determine the development of Cushing triad. 2) Pulse oximeter percentage is not used to determine the development of Cushing triad. 3) CORRECT - One criterion for the development of Cushing triad is bradycardia. A heart rate of 52 beats/min indicates bradycardia. 4) Body temperature is not used to determine the development of Cushing triad. 5) CORRECT - An elevated blood pressure with a widening pulse pressure are criteria for the development of Cushing triad.
The nurse suspects that a client with a head injury is developing Cushing triad. Which finding causes the nurse to make this clinical determination? (Select all that apply.) 1. Respiratory rate 20 breaths/min.2. Pulse oximeter 92%.3. Pulse 52 beats/min and irregular.4. Temperature 98.4ºF (36.9ºC).5. Blood pressure 180/58 mm Hg.
1) Sevelamer should not be chewed. 2) Sevelamer does not need to be taken with a full glass of water. 3) Sevelamer does not have a cross-allergy with shellfish. 4) CORRECT - Sevelamer is a phosphate binder and should be taken with meals.
The nurse notes that a client is prescribed sevelamer. Which action will the nurse take when providing the client with a dose of the medication? 1. Remind to chew the medication.2. Ask to drink a full glass of water.3. Inquire about an allergy to shellfish.4. Provide with a meal.
1) A result of 115 mEq/L is below the normal range for serum sodium. 2) A result of 122 mEq/L is below the normal range for serum sodium. 3) A result of 131 mEq/L is below the normal range for serum sodium. 4) CORRECT — A result of 141 mEq/L is within in normal range of 136 to 145 mEq/L.
While preparing a client for surgery, the nurse reviews the serum sodium level. Which result does the nurse identify as falling within the normal range for serum sodium? 1. 115 mEq/L. 2. 122 mEq/L. 3. 131 mEq/L. 4. 141 mEq/L.
1) The nurse should not report on behalf of a capable adult, unless that individual asks the nurse to do so. 2) Asking how the fall occurred does not achieve the goal of determining whether the client is abused. 3) CORRECT - The goal is to get the client away from the potential abuser in order to ask the client face-to-face if the client is being abused. If the answer is yes, then the nurse can offer to help. 4) Asking if the client has a head injury does not achieve the goal of assessing whether the client is abused.
A client reports receiving injuries from falling down the stairs, yet avoids looking at the nurse when asked about a left eye bruise. Further questions are answered only after glancing at the spouse and with the words yes or no. Which action will the nurse take first? 1. Report the spouse to the nursing supervisor for abuse. 2. Ask the client how the fall down the stairs occurred.3. Ask the client for a urine specimen to be collected in the presence of the nurse.4. Ask the client if the head was also injured in the fall.
1) This is not an appropriate action for the choking victim. The nurse should should assure the emergency response team (ERS) is activated first. 2) The is an appropriate action when client is unconscious. The nurse should ensure the ERS is activated first. 3) CORRECT - ERS should be activated immediately. 4) This is unnecessary in this situation. The nurse should tell someone to activate ERS first.
A nurse is having dinner in a restaurant when another patron begins to choke. The patron's hands are at the throat and there is no discernible cough. Which action should the nurse take first? 1. Initiate back blows between the scapulae of the choking patron.2. Look, listen, and feel for airflow from the patron's nose and mouth.3. Instruct another patron to activate the emergency response system.4. Ask if anyone else in the restaurant knows CPR.
1) CORRECT - To ensure fire safety, nurses need to know the location of all fire exits along with the evacuation plan. 2) CORRECT - To ensure fire safety, nurses need to know where the fire extinguishers are located. If the fire extinguisher needs to be activated, nurses must use the mnemonic PASS (P = Pull the extinguisher's pin, A = Aim at base of fire, S = Squeeze the handle, and S = Sweep side to side). 3) Nurses need to remember the mnemonic RACE for fire safety. The nurse needs to first rescue and remove clients who are in immediate danger of the fire. The second step is to activate the fire alarm. 4) CORRECT - To ensure fire safety, nurses must close all doors and windows to help contain the fire. 5) CORRECT - To ensure fire safety, someone needs to be responsible for shutting off oxygen sources. Therefore, part of the safety plan is educating all nurses and staff regarding whom should perform this task.
In a hospital setting, which step does the nurse take during a fire drill to ensure safety of all clients? (Select all that apply.) 1. Knowing the location of all fire exits and the evacuation plan.2. Determining the location of fire extinguishers. 3. Recognizing that activation of the fire alarm is the first step to fire safety. 4. Closing all doors and windows.5. Identifying who is responsible for shutting off oxygen sources.
1) Lisinopril, which is an angiotensin-converting-enzyme (ACE) inhibitor, increases the risk for hyperkalemia. 2) Cyclosporine, which is an immunosuppressant medication, increases the risk for hyperkalemia. 3) Propranolol, which is a beta-blocker, may cause hyperkalemia. 4) CORRECT- Prednisone, which is a corticosteroid, increases the risk for hypokalemia. Administration of this medication may worsen the patient's existing hypokalemia (normal serum potassium is 3.5 to 5.0 mEq/L).
The client's serum potassium level is 3.0 mEq/L. After reviewing the client's medication administration record (MAR), the nurse immediately notifies the health care provider (HCP) that the client is taking which medication? 1. Lisinopril.2. Cyclosporine.3. Propranolol.4. Prednisone.
1) CORRECT - The priority action of the charge nurse is to alert those in the chain of command so they can call in additional resources and implement the disaster plan. 2) Arranging for more stretchers in the hallway may be needed, but it is not the priority action. 3) If there is enough time, some preparation may be wise, but it is not the priority action. 4) While it may be appropriate to request that some of the victims be sent to other facilities, it is not the priority action.
The emergency department (ED) charge nurse is alerted to a nearby shopping center shooting with 20 victims expected to arrive within 5 minutes. Which action will the charge nurse take next? 1. Alert the nursing supervisor and the ED manager.2. Arrange for additional stretchers in the hallway to accommodate the victims.3. Begin setting up intravenous fluids, tubing, blood tubing, and pumps.4. Request that the ambulance divert less critical clients to other facilities.
1) CORRECT — Teaching about physical signs of impending death will help allay the family's fears and anxiety. 2) CORRECT — Managing adverse signs and symptoms allows maximum comfort of the client. 3) CORRECT — Assessing family coping mechanisms allows the provision of client and family-centered care. 4) Spirituality/spiritual practices may bring comfort to the client and family. 5) Abandoning the family is not appropriate. They are a part of end-of-life care.
The family sits at the bedside of a client nearing the end-of-life. Which action is appropriate for the nurse to implement? (Select all that apply.) 1. Teach family members about physical signs of impending death.2. Encourage the management of adverse signs and symptoms.3. Assess family coping mechanisms to handle impending loss.4. Avoid spirituality as nurse's beliefs may not be congruent with the client's.5. Leave the family alone as there is no more need for direct nursing care.
1) This platelet count is within the normal range of 150,000 to 400,000/mm3 (150 to 400 × -109/L). A platelet count <100,000/mm3 (100 × 109/L) would cause the nurse to question the prescription as this is a contraindication for t-PA therapy. 2) CORRECT — Gastrointestinal or urinary bleeding in the previous 21 days is a contraindication for t-PA therapy; therefore, the nurse questions this prescription. 3) CORRECT — Intravenous t-PA can be administered within 3 hours of symptom onset. This is expanded to 4.5 hours in some centers. An interarterial t-PA infusion can be administered for up to 6 hours after onset of stroke symptoms. The nurse questions the prescription based on this data. 4) CORRECT — Prior intracranial hemorrhage, neoplasm, atrioventricular (AV) malformation, or aneurysm are all contraindications for t-PA therapy; therefore, the nurse questions the prescription based on this data. 5) Intracranial surgery, stroke, and serious head injury in previous 3, not 6, months are contraindications for t-PA therapy.
The health care provider prescribes tissue plasminogen activator (t-PA) for a client diagnosed with an ischemic stroke. Which criteria would cause the nurse to question this prescription for the client? (Select all that apply.) 1. Platelet count 180,000/mm3 (180 × -109/L).2. Gastrointestinal bleeding 7 days ago.3. Symptom onset 7 hours ago.4. Prior intracranial hemorrhage.5. Intracranial surgery 6 months ago.
1) A postoperative client should not be in a room with the client who has an infection as the postoperative client is at an increased risk for infection. 2) CORRECT — Neither client is infected. Pancreatitis is an inflammatory process of the pancreas and not an infectious disease. 3) Clients who are diagnosed with two different infectious organisms should not be placed in the same room. 4) A client who is neutropenic should be in a private room.
The nurse admits several clients during the day shift. Which room assignment is most appropriate for the nurse to make? 1. Assign the client who is returning from an appendectomy to a room with a client who had an incision and drainage of a leg wound earlier today.2. Assign the client who is returning from a total knee replacement to a room with a client diagnosed with pancreatitis.3. Assign the client diagnosed with streptococcal pneumonia to a room with a client diagnosed with staphylococcal pneumonia.4. Assign the client diagnosed with gastritis to a room with a client who is neutropenic.
1) In preterm neonates of less than 34 weeks gestation, the ear has little cartilage and remains folded over or returns slowly when folded. In a full- or post-term neonate, the ear returns to the original position immediately. 2) CORRECT — A post-term neonate has deeply cracked, dry, thick skin. A full-term newborn has some peeling and cracking of the skin, especially in areas with creases. 3) CORRECT — A post-term neonate has no vernix. There is little vernix on the body of a full-term newborn except small amounts in the skin creases. There is a thick covering of vernix in preterm neonates. 4) CORRECT — A post-term neonate has deep plantar creases. A preterm newborn has few creases on the foot. 5) Lanugo appears at 20 weeks gestation, increases until 28 weeks, and then begins to disappear. Most lanugo is shed by 32 to 36 weeks. A small amount may remain over the upper back and shoulders, on the ears, or on the sides of the forehead.
The nurse assesses a newborn to determine gestational age. Which finding does the nurse document as a characteristic of a post-term neonate? (Select all that apply.) 1. Slow recoil of the pinna.2. Skin that is cracked and peeling.3. Absent vernix.4. Deep plantar creases.5. Lanugo present on extremities.
1) A respiratory rate of 38 breaths per minute are within the normal range of 30 to 60 breaths per minute. 2) The nurse will report apneic periods of >20 seconds to the health care provider. 3) CORRECT - Grunting at 20 minutes of age is a sign of respiratory distress and will be reported to the health care provider. 4) CORRECT - Nasal flaring when an infant is supine is a sign of respiratory distress and will be reported to the health care provider. 5) It is normal for the abdomen and chest to rise together for each breath.
The nurse assesses the respiratory status of 6 newborns. Which finding does the nurse report to the health care provider? (Select all that apply.) 1. Respirations 38 breaths per minute at 30 minutes of age.2. Six-second periods of apnea at 1 hour of age.3. Grunting at 20 minutes of age.4. Nasal flaring when the infant is supine.5. Abdomen and chest rise together for each breath.
1) CORRECT - The nurse reports respiratory distress including nasal flaring, retractions, cyanosis, grunting, or seesawing to the HCP. 2) Acrocyanosis is a common, normal variation for up to 24 hours, due to poor peripheral circulation of the newborn. This is especially evident if the newborn is exposed to cold. 3) CORRECT - The nurse reports tachypnea. A normal respiratory rate ranges from 30 to 60 breaths per minute. 4) Apneic periods < 20 seconds are a normal finding for a newborn. 5) A respiratory rate of 40 breaths per minute is within the normal range of 30 to 60 breaths per minute for a newborn.
The nurse assesses the respiratory status of a 12-hour-old newborn. Which finding does the nurse report to the health care provider? (Select all that apply.) 1. Nasal flaring.2. Acrocyanosis.3. Tachypnea.4. Ten second periods of apnea.5. Respiratory rate of 40 breaths per minute.
1) The statement about putting the client on oxygen while the team decides what to do next demonstrates the informing technique, which involves demonstrating skills or giving information. 2) Stating a concern about the client's condition is a sharing observation technique used in the TeamSTEPPS process. 3) CORRECT - Closed-loop communication is a technique used to avoid misunderstandings. When the sender gives a message, the receiver repeats this back. 4) Saying that the nurse's break starts soon questions the nurse's clinical judgement. It may not be appropriate for the nurse to disappear for a break while the client is in distress.
The nurse assists the rapid response team (RRT) care for a client in respiratory distress. Which statement by the nurse demonstrates closed-loop communication? 1. "I'm going to put this client on oxygen while you decide on what to do next."2. "I am concerned that the client's blood pressure is much lower than before."3. "You want an arterial blood gas drawn STAT, is that right?"4. "My break starts soon. My colleague will assist you now."
1) CORRECT - Carbonation, chocolate, caffeine, and greasy or spicy foods can all increase symptoms associated with a hiatal hernia. These symptoms are commonly associated with gastroesophageal reflux. 2) An abdominal binder will increase abdominal pressure and increases symptoms associated with the hiatal hernia. 3) CORRECT - The client should not recline for a period after eating a meal because the contents tend to reflux or cause increased pressure on the lower esophageal sphincter increasing symptoms. This position can cause the hernia to slide and worsen. 4) Increasing the amount of liquid in the stomach just before laying down to sleep will increase symptoms and should be avoided. 5) CORRECT - Elevating the head of the bed decreases the motion of the hernia which will decrease symptoms.
The nurse cares for a client scheduled for surgical repair of a hiatal hernia next month. Which intervention should the nurse suggest that the client implement? (Select all that apply.) 1. Avoid chocolate and carbonated drinks.2. Wear an abdominal binder during the day.3. Stay in an upright position after meals.4. Increase fluid intake in the evening.5. Elevate the head of the bed six inches.
1) CORRECT - A blood pressure greater than 140/90 mm Hg indicates a need for testing. 2) CORRECT - Testing is considered for those who are over 45 years old and overweight. 3) CORRECT - A sedentary lifestyle is a risk factor for type 2 diabetes. 4) Smoking is a risk factors for cardiovascular diseases, but not for type 2 diabetes. 5) CORRECT - Those with first-degree relatives with diabetes have a higher risk for developing type 2 diabetes.
The nurse conducts diabetes screening education. Which factors prompt the nurse to refer the client for type 2 diabetes mellitus (DM) testing? (Select all that apply.) 1. Having a history of hypertension.2. Being 45 years of age or older with a BMI greater than 25.3. Being physically inactive.4. Smoking 1 pack of cigarettes per day.5. Having a first-degree relative with diabetes.
1) Education is a task the nurse should complete and should not be delegated to the NAP. 2) CORRECT — Assisting a client to a high-Fowler position when in bed is an appropriate task the nurse can delegate to the NAP. 3) CORRECT — Encouraging a client to not talk during a nebulizer treatment is an appropriate task the nurse can delegate to the NAP. 4) CORRECT — Reminding the client to use the incentive spirometer every hour while awake is an appropriate task the nurse can delegate to the NAP. 5) CORRECT — Encouraging the client and family to wash their hands frequently is an appropriate task the nurse can delegate to the NAP.
The nurse creates a care plan for a client diagnosed with bilateral lower lobe pneumonia. Which intervention is appropriate for the nurse to delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Instructing the client on the importance of increasing fluid intake.2. Assisting the client to a high-Fowler position when in bed.3. Encouraging the client to not talk when receiving a nebulizer treatment.4. Reminding the client to use the incentive spirometer every hour when awake.5. Encouraging the client and family to wash their hands frequently.
1) CORRECT — Informed consent is permission granted by a client after discussing the exact details of the treatment with the health care provider who will perform the surgery or procedure. 2) CORRECT — By witnessing a client's signing of an informed consent, the nurse verifies that the client is mentally competent and that the signature is that of the client. 3) It is not the nurse's responsibility to explain the benefits and risk of the procedures that require an informed consent. The health care provider needs to do that. 4) General consent forms giving permission for treatment in a hospital are signed by a client before being admitted. An informed consent would not be required for a chest X-ray. 5) CORRECT — The nurse, as a client advocate, is responsible for ensuring that the client has received adequate information regarding the proposed procedure.
The nurse develops a brochure on informed consent. Which information is appropriate for the nurse to include in the brochure? (Select all that apply.) 1. An informed consent should not be obtained until the client has discussed the exact details of the surgery or procedure.2. Witnessing an informed consent means that the nurse verifies that the client is mentally competent.3. The nurse needs to explain the benefits and risks of the procedures that require an informed consent.4. Even if a client has signed a general admission consent, an informed consent is required for the client to have a chest X-ray.5. Acting as a client advocate, the nurse is responsible for ensuring that the client has received adequate information regarding the proposed procedure.
1) There is no indication that the client will need suctioning. 2) There is no indication that the client should be on seizure precautions. 3) CORRECT— Keeping the bed in the lowest position prevents falls and would be appropriate for this client. 4) There is no indication that this client needs to be on neutropenia precautions. 5) CORRECT — The client with Parkinson disease ambulates with a shuffling gait. Non-skid socks would be appropriate to prevent falls.
The nurse discharges a client diagnosed with Parkinson disease to live at home with the family. Which teaching will the nurse provide as part of this client's discharge? (Select all that apply.) 1. Provide intermittent oral suctioning for aspiration precautions.2. Arrange for sides of bed to be padded for seizure precautions.3. Keep bed at lowest position.4. Wear surgical masks for neutropenia precautions.5. Use non-skid socks for fall precautions.
1) CORRECT - The signs and symptoms of cystitis include dysuria, frequency, urgency, and suprapubic tenderness. An ascending infection may lead to pyelonephritis. This phone message is a priority for nurse to follow up. 2) Fetal movements are first felt by the mother at 16 to 20 weeks' gestation as a faint fluttering in the lower abdomen. This phone message is not a priority. 3) Leg cramps result from the pressure of the uterus on blood vessels, which impairs circulation to the legs, causing muscle strain and fatigue. This phone message is not a priority. 4) Shortness of breath later in pregnancy is caused by the uterus rising into the abdomen and pressing on the diaphragm. This phone message is not a priority.
The nurse in an antepartum clinic has several phone messages from clients. Which client does the nurse call first? 1. The client who is 9 weeks pregnant and reports urinary frequency and painful urination.2. The client who is 18 weeks pregnant and is concerned that she cannot feel her baby move.3. The client who is 28 weeks pregnant and reports having had leg cramps last night.4. The client who is 36 weeks pregnant and reports shortness of breath when walking up stairs.
1) When using crutches, the client needs to maintain a straight posture to help maintain balance and prevent muscle strain. This finding indicates that the client needs additional teaching by the nurse on how to use crutches. 2) When using crutches, the handle bars, not the axillary pads, support the body weight. Body weight should never be placed on the axillae for this could cause nerve damage. This finding indicates that the client needs additional teaching by the nurse on how to use crutches. 3) CORRECT - Resting crutches 6 inches in front and lateral of the feet is considered the tripod position. This position helps maintain balance when using crutches. This finding indicates that the client understands how to use crutches appropriately. 4) When using crutches, there needs to be a 30-degree flexion in the elbows when grabbing the handle bars. This finding indicates that the client needs additional teaching by the nurse on how to use crutches.
The nurse is evaluating client understanding regarding the use of crutches. Which finding indicates to the nurse that the client understands how to use crutches appropriately? 1. Maintains a posture that is leaning slightly forward. 2. Places weight of body on axillary pads.3. Rests crutches 6 inches in front and lateral of the feet. 4. Keeps arms straight when grasping handle bars.
1) Needing a splint applied is a task that is less of a priority than the client with lung disease requesting ambulation. This task should be completed third. 2) A client with diabetes and a stable blood sugar requesting a snack is more stable than the client with lung disease requesting ambulation. This task would be completed second. 3) A client with diarrhea needing the commode emptied would be a task that is not a priority and can wait until last. 4) CORRECT - The client with emphysema has breathing difficulties and wants to ambulate. This client needs to be monitored closely when ambulating and should be the highest priority.
The nurse is proving care for several clients. Which client need will the nurse address first? 1. Client with a stroke needing a hand splint reapplied.2. Client with diabetes and a fasting blood glucose of 78 mg/dL requesting a snack.3. Client with diarrhea needing the bedside commode emptied.4. Client with emphysema requesting assistance with ambulation.
1) CORRECT — The client with AIDS is immunocompromised. Children who have just received a live vaccine and children who have not been vaccinated pose a risk. 2) CORRECT — The use of a barrier method during sexual activity is the only way to prevent transmission of the virus to the partner. 3) Avoiding contact sports is unnecessary unless the specific type of sport causes frequent bleeding injuries. If the client feels well enough to participate, engaging in sports may also increase social interaction and well-being. 4) CORRECT — Drug paraphernalia such as needles, syringes, and straws can transfer the virus that causes AIDS to people who share these devices with infected individuals. 5) It is advisable to restrict partners, but the use of condoms during sexual activity is the primary way to prevent transmission to others and the acquisition of an additional sexually transmitted infection.
The nurse manager creates a discharge teaching form for clients with acquired immunodeficiency syndrome (AIDS). Which statement will the manager include on this form? (Select all that apply.) 1. Avoid children who have just gotten a live vaccine.2. A condom is necessary during sexual activity.3. Contact sports, such as football, must be avoided.4. Drug paraphernalia must not be shared with others.5. Sexual activity must be restricted to a single partner.
1) CORRECT - A misconception about evidence-based practice is that it is another name for standardized care. 2) Evidence-based practice matches client care needs with the best interventions to achieve care goals. 3) CORRECT - Evidence-based practice is not conducting research, but rather using the best evidence substantiated by research for client care. 4) Software applications are available to help locate evidence-based information. 5) Research conducted lends support to why certain interventions are appropriate or applicable for client care needs.
The nurse manager reviews the importance of using best evidence when planning client care during a nursing staff meeting. Which nursing staff response indicates additional information is required regarding evidence-based practice? (Select all that apply.) 1. "I'm glad that standardized care plans are gone."2. "Care plans now will be customized and useful."3. "I always liked research and now we can do it with our clients."4. "A software program to help search for information will be helpful."5. "Now we know that interventions for care will work for our clients."
1) CORRECT - Inflammation of the bronchial tubes results in an increased production and accumulation of secretions. 2) CORRECT - Inflammation of bronchial tissues and the related increase in mucus results in early onset of a cough to clear the airway. 3) CORRECT - Chronic bronchitis does not typically result in a large weight loss. 4) There is usually minimal mucus in pulmonary emphysema, whereas there is a large amount of mucus in chronic bronchitis because of the irritation of the lung tissues. 5) CORRECT - Slight shortness of breath is consistent with chronic bronchitis, whereas marked dyspnea is more characteristic of emphysema.
The nurse notes that a client has a history of chronic bronchitis. Which assessment finding supports this diagnosis? (Select all that apply.) 1. Large amount of purulent mucus.2. Early onset cough.3. Minimal weight loss.4. Scant mucus.5. Mild episodes of dyspnea.
1) Swollen and pale nasal mucosa is associated with allergies. 2) CORRECT — Ulcerations along the nasal septum occur from chronic irritation that can be caused by substance use. 3) Red and edematous nasal mucosa is associated with an infection. 4) Blood-tinged crusting would be associated with nose bleeds.
The nurse observes ulcerations along a client's nasal septum. Which additional information will the nurse need to obtain from this client? 1. Allergies.2. Substance use.3. Recent infections.4. Frequency of nosebleeds.
1) CORRECT — The nurse should consider an adolescent client who has abdominal bleeding and confusion to require immediate care to preserve life. Therefore, the nurse should recommend that this client receive treatment first. 2) The nurse should consider that a school-age child who has lacerations on the face and scalp can wait more than 60 minutes for treatment. The nurse should recommend that a different client receives treatment first. 3) The nurse should consider an older adult client who has a chest wound and is apneic to have injuries that are most likely fatal. Therefore, the nurse should recommend that a different client receive treatment first. 4) The nurse should consider an adult client who has an open fracture of the humerus with present radial pulses can wait 30 to 60 minutes for treatment. Therefore, the nurse should recommend that a different client receive treatment first.
The nurse performs triage at a mass casualty incident. Which client will the nurse recommend receive treatment first? 1. Adolescent client with abdominal bleeding and confusion.2. School-aged child with lacerations on the face and scalp.3. Older adult client with a chest wound who is apneic.4. Adult client with an open fracture of the humerus with present radial pulses.
1) A WBC of 10,000/mm3 (10 × 109/L) is normal and does not require the nurse to notify the HCP. 2) CORRECT - Creatinine clearance of 41 mL/min signals poor kidney function. Normal creatinine clearance is 107 to 139 mL/min for men and 87 to 107 mL/min for women with a 24-hour urine collection (depending on the source, ranges may vary slightly). Creatinine clearance values decrease progressively per decade of life for adults older than 40 years because of age-related declines in glomerular filtration rate. Since the contrast used in cardiac catheterization is potentially nephrotoxic, the nurse will notify the HCP. 3) A fingerstick glucose of 222 mg/dL (12.32 mmol/L) is elevated but is not a contraindication for cardiac catheterization; therefore, there is no reason for the nurse to notify the HCP. 4) An A1c of 7% (0.07 proportion of total hemoglobin) does not require the nurse to notify the HCP. The goal for most people with diabetes mellitus is 7% or less.
The nurse prepares a client diagnosed with diabetes mellitus for a cardiac catheterization. Which lab result would cause the nurse to notify the health care provider (HCP)? 1. White blood cell (WBC) of 10,000/mm3 (10 × 109/L).2. Creatinine clearance of 41 mL/min.3. Fingerstick glucose of 222 mg/dL (12.32 mmol/L).4. Glycated hemoglobin A1c of 7% (0.07 proportion of total hemoglobin).
1) The antecubital area can bend and lead to extravasation with the possible loss of function to surrounding tissues from the vesicant medication. 2) The wrist bends and can lead to extravasation with the possible loss of function to surrounding tissues from the vesicant medication. 3) The hand bends and can lead to extravasation with the possible loss of function to surrounding tissues from the vesicant medication. 4) CORRECT— The forearm is the safest peripheral intravenous site for chemotherapy infusion because it does not involve a movable joint.
The nurse prepares to administer an intravenous (IV) vesicant chemotherapy to a client. Which is the correct area to insert an IV catheter for this medication? 1. Antecubital.2. Wrist.3. Hand.4. Forearm.
1) Rectal tubes should be removed after 20 minutes. Prolonged stimulation of the anal sphincter may result in a loss of the neuromuscular response and cause pressure necrosis of the mucosa. 2) CORRECT — The tube should be inserted into the rectum, past the external and internal anal sphincters, approximately 2 to 4 inches. 3) The left lateral recumbent position is used because it facilitates insertion of the tube following the normal curve of the rectum and sigmoid colon. 4) A water-based lubricant is used to lubricate the tube prior to insertion.
The nurse prepares to insert a rectal tube in a client experiencing severe abdominal pain from flatus. Which approach does the nurse use when inserting this device? 1. Tape the tube in place for 30 minutes.2. Insert the tube 2 to 4 inches past both of the anal sphincters.3. Place the client in the right lateral recumbent position.4. Lubricate the tube with an oil-based lubricant.
1) CORRECT - Medication reconciliation should be completed at every health care provider appointment. 2) Medication reconciliation should occur before discharge. 3) CORRECT - Medication reconciliation should be done at the time of discharge to ensure that the medications are correctly identified for the client. 4) CORRECT - Medication reconciliation should occur upon admission or entry into a new medical unit. 5) CORRECT - Medication reconciliation should occur when there is any change in level of care.
The nurse provides care to a newly admitted client. At which time will the nurse conduct a medication reconciliation? (Select all that apply.) 1. At every clinic appointment.2. At the pharmacy.3. Upon discharge to home.4. Upon entry into the unit.5. Upon transfer to a skilled unit.
1) The client's airway should be opened before delivering breaths with a handheld resuscitation bag. 2) Auscultating breath sounds at this point will not provide additional useful information. 3) CORRECT— Clients undergoing prolonged anesthesia are typically unconscious when entering the PACU. Due to their relaxed state, the client's lower jaw and tongue fall back and obstruct the airway, causing hypopharyngeal obstruction. The nurse opens the client's airway by tilting the client's head back and pushing the lower jaw forward. 4) The client's airway should be opened before increasing supplemental oxygen.
The nurse provides care for a client admitted to the postanesthesia care unit (PACU) after a thoracotomy that required prolonged anesthesia. The client develops noisy, irregular respirations and the oxygen saturation level drops. Which action does the nurse implement first? 1. Deliver breaths with a handheld resuscitation bag and mask.2. Auscultate the client's breath sounds.3. Tilt the client's head back and push forward on lower jaw.4. Increase the supplemental oxygen, as prescribed.
1) CORRECT — Setting up supplies is within the scope of practice of NAPs. 2) Selecting the right dressing is done by the nurse, based on assessment of the wound. 3) Measuring the wound is an assessment that the nurse does. 4) CORRECT — Repositioning the client independently as directed by the nurse is within the scope of practice of NAPs. 5) CORRECT — Assisting clients with food and fluid intake is within the scope of practice of NAPs.
The nurse provides care for a client diagnosed with a pressure injury wound on the sacrum. Which client care activity is appropriate to delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Set up supplies for use in the dressing change.2. Choose the right dressing for wound treatment.3. Measure the wound size and depth and notify nurse.4. Reposition the client at least every 2 hours.5. Assist the client with adequate food and fluid intake.
1) Insulin should only be drawn up in an insulin syringe. A 1 mL syringe is not appropriate for insulin. 2) A 1 mL U-100 (unit) syringe is too big for the dose prescribed to this client. 3) CORRECT - A 0.5 mL U-100 (unit) syringe is the appropriate size for the client's dose, and is calibrated in units for better accuracy. The nurse uses this syringe to draw up the insulin to administer to the client. 4) Insulin should only be drawn up in an insulin syringe. A 3 mL syringe is not appropriate for insulin.
The nurse provides care for a client diagnosed with diabetes mellitus (DM). The nurse prepares to administer 33 units of insulin to the client. Which syringe is the best choice for the nurse to use to draw up the insulin? 1. 1 mL syringe.2. 1 mL U-100 (unit) syringe.3. 0.5 mL U-100 (unit) syringe.4. 3 mL syringe.
2. Encourage the client to do pursed-lip breathing 1) The client should receive low-flow oxygen (less than 3 liters per minute) to prevent carbon dioxide narcosis. 2) CORRECT — This prevents the collapse of the alveoli and helps the client control the depth and rate of breathing. 3) The confusion most likely is related to decreased oxygenation, not an electrolyte imbalance. 4) The confusion most likely is related to decreased oxygenation. Taking the blood pressure is not warranted.
The nurse provides care for a client diagnosed with emphysema. The client becomes anxious and confused. What is the first action the nurse should take? 1. Increase the client's oxygen flow rate to 4 liters per minute. 2. Encourage the client to do pursed-lip breathing. 3. Assess the client's sodium level. 4. Take the client's blood pressure.
1) The client is demonstrating manifestations of acute osteomyelitis. Antibiotics will be prescribed; however, bed rest is not identified as a routine part of treatment for the disorder. 2) Surgery is usually required for chronic osteomyelitis; however, the client is demonstrating manifestations of acute osteomyelitis. Antibiotics will be needed for more than a few weeks for a bone infection. 3) CORRECT- The client with acute osteomyelitis will be prescribed antibiotics. These medications can be started in an acute care facility and continued at home after discharge. 4) An acute bone infection will not improve with rest and warm compresses. Pain medication is required since the area does cause pain. Antibiotics are also required.
The nurse provides care for a client experiencing a fever who also reports bone pain, redness, and swelling. The client asks the nurse which treatment will likely be prescribed by the health care provider (HCP). Which response from the nurse is the most accurate? 1. "Usually a few days of bed rest and antibiotics are needed."2. "You will need surgery and then antibiotics for a few weeks."3. "Antibiotics will be prescribed for several weeks, which you can take at home."4. "If the area improves with rest and warm compresses, you might just need pain medication."
1) Malignant tumors are poorly differentiated. Benign tumors are more differentiated, meaning they more closely resemble the cells of the tissue from which they arose. 2) Benign tumors are not able to metastasize. 3) Not all tumors, benign or malignant, grow aggressively; some are indolent, or slow growing. 4) CORRECT - Benign tumors can cause tissue destruction by the size and location in the body.
The nurse provides care for a client newly diagnosed with a benign brain tumor. The nurse teaches the client about the diagnosis. Which property of benign tumors should the nurse include in the teaching? 1. They are poorly differentiated.2. They metastasize to other organs.3. They grow at an aggressive rate.4. They can cause tissue destruction.
1) Asepsis is all that is usually necessary for clients with a splenectomy. 2) Both clients may receive antibiotics, but it would not be a result of the nurse's assignment. 3) CORRECT — It is unsafe to risk transferring the pneumococcal infection to the at-risk immune system of the splenectomy client. 4) If the assignment cannot be changed, strict asepsis must be maintained. The first action of the nurse would be to ask that the client with the infection be reassigned.
The nurse provides care for a client who had a splenectomy 2 days ago. The nurse is also assigned a client diagnosed with pneumococcal pneumonia. Which action should the nurse take first? 1. Place the splenectomy client in reverse isolation.2. Ensure that both clients receive broad-spectrum antibiotics.3. Request the charge nurse alter the client care assignment.4. Maintain strict aseptic technique while providing client care.
1) CORRECT— An oil retention enema is likely to soften the stool so the client can expel the impaction. 2) An impaction that has built up over a few days needs to be softened before removal. Also, the nurse needs to determine if the facility allows digital removal of an impaction. 3) An impaction that has built up over a few days is difficult for the client to expel without softening it first. 4) An oral stool softener will not correct the impaction. Quicker action is needed.
The nurse provides care for a client who reports not having a stool for 4 days. The nurse checks the client's rectum and finds a ball of hard feces about 4 inches above the rectum. Which action does the nurse take next? 1. Administer an oil retention enema.2. Digitally remove the stool.3. Have the client sit on the toilet to attempt to defecate.4. Administer an oral stool softener.
1) The rapid heart rate is not consistent with atrioventricular block. 2) Decreased kidney perfusion is an effect of low cardiac output rather than a cause of it. 3) CORRECT — During tachycardia, diminished ventricular filling occurs due to lack of filling time. This leads to low stroke volume and decreased cardiac output. 4) Afterload is primarily reflected by blood pressure rather than heart rate.
The nurse provides care for a client with a heart rate of 145 beats per minute. Which statement explains the risk for decreased cardiac output in this client? 1. Atrioventricular block.2. Decreased kidney perfusion.3. Decreased diastolic filling time.4. Increased afterload.
1) CORRECT — Bradycardia should be treated when client is symptomatic. Well-conditioned clients may experience bradycardia without symptoms and this bradycardia should not be treated. 2) Client symptoms are the primary criteria for treating bradycardia, not the numerical heart rate. 3) The client's advanced directive status should not definitely rule out treatment of bradycardia. The client's overall condition, prognosis, and wishes should be considered. 4) Client symptoms are the primary criteria for treating bradycardia, rather than functional status alterations.
The nurse provides care for a client with bradycardia. Which statement accurately reflects a best practice guideline in caring for this client? 1. If the client is symptomatic, treat the bradycardia.2. If the heart rate is below 50, treat the bradycardia.3. If the client has an advanced directive, do not treat the bradycardia.4. If there is functional impairment, treat the bradycardia.
1) Therapeutic effects of atorvastatin include a decrease in triglycerides. In a fasting lipid profile, the normal triglyceride level is less than 150 mg/dL. An increased triglyceride level is not a desired effect of atorvastatin therapy. 2) CORRECT- In a fasting lipid profile, normal total cholesterol of less than 200 mg/dL is desirable and, for the patient who takes atorvastatin, suggests that treatment is effective. Atorvastatin is an antihyperlipidemic medication that works by inhibiting HMG-CoA reductase, which is an enzyme involved in cholesterol synthesis. Therapeutic effects of atorvastatin include decreased LDL concentration, decreased triglyceride levels, increased HDL concentration, and decreased total cholesterol level. 3) Therapeutic effects of atorvastatin include decreased LDL concentration. In a fasting lipid profile, desired LDL concentration is less than 100 mg/dL. For very high-risk patients, the desired LDL concentration is less than 70 mg/dL. An elevated LDL concentration is not a desired effect of atorvastatin therapy. 4) Therapeutic effects of atorvastatin include increased HDL concentration. In a fasting lipid profile, desired HDL concentration is greater than 40 mg/dL for males and greater than 50 mg/dL for females. A decreased HDL concentration is not a desired effect of atorvastatin therapy.
The nurse provides care for a male client who is prescribed atorvastatin. Which laboratory value in the client's fasting lipid profile indicates that the treatment is effective? 1. Triglycerides 300 mg/dL.2. Total cholesterol 160 mg/dL.3. Low-density lipoprotein (LDL) 220 mg/dL.4. High-density lipoprotein (HDL) 25 mg/dL.
1) Infants begin to process pain in utero. 2) Infants respond to pain with behavioral cues such as crying and withdrawing limbs. 3) CORRECT — Infants have the same sensitivity to pain as older children. 4) Behavioral pain scales effectively assess the level of pain in an infant. 5) CORRECT — Absorption of medications is quicker in an infant than an adult.
The nurse provides care for an infant who has a fractured femur. Which statement regarding pain in an infant is accurate? (Select all that apply.) 1. Infants cannot feel pain.2. Infants cannot express pain.3. Infants have the same sensitivity to pain as older children.4. Pain scales do not work well with infants.5. Absorption of pain medication is faster in an infant than an adult.
1) Hyponatremia and hypochloremia occur due to vomiting and the use of laxatives and/or diuretics. 2) CORRECT - Tooth erosion occurs due to vomiting and erosion of enamel. 3) CORRECT - Parotid gland swelling occurs secondary to increased serum amylase levels. 4) Gastric dilation occurs secondary to binge eating. The client may report abdominal pain. Esophageal tears may also be present secondary to self-induced vomiting. 5) CORRECT - Hypokalemia occurs secondary to vomiting and the use of laxatives and/or diuretics.
The nurse provides care to a client diagnosed with bulimia nervosa. Which sign will the nurse expect to observe while providing care to this client? (Select all that apply.) 1. Hypernatremia.2. Tooth erosion.3. Parotid gland swelling.4. Gastric narrowing.5. Hypokalemia.
1) Hunger is a side effect of prednisone. 2) CORRECT — Potassium depletion is a side effect of prednisone. 3) Weight gain is expected due to sodium and water retention. 4) CORRECT — Elevated blood glucose level is a side effect of prednisone. 5) CORRECT — Hypertension is a side effect of prednisone.
The nurse provides care to a client prescribed long-term prednisone for the treatment of chronic obstructive pulmonary disease (COPD). Which side effect of prednisone does the nurse expect to observe? (Select all that apply.) 1. Loss of appetite.2. K+ 3.1 mEq/L (3.1 mmol/L).3. Weight loss.4. Blood sugar 180 mg/dL (9.99 mmol/L).5. BP 140/90 mmHg.
1) There is no indication that the client needs more time to decide. 2) Religious beliefs are enduring. The nurses needs to respect the client's beliefs. 3) CORRECT - All competent clients have the right to make an informed decision. 4) Refusal based on religious beliefs does not indicate a need for a psychiatric evaluation.
The nurse provides care to a client who refuses a blood transfusion because of religious beliefs. Which statement guides the nurse's action in the care of this client? 1. Allow more time for the client to decide.2. Religious beliefs can be changed with proper explanation.3. Competent adults have the right to make health decisions.4. A psychiatric consult may be needed to assess the client's capacity to decide.
1) The client may take a few steps if ordered, but it is too early for ambulating in the hall. 2) CORRECT - Using an overhead trapeze prevents hazards of immobility by permitting movement in bed and strengthening the upper extremities in preparation for ambulation. 3) Sitting in a chair would require too great hip flexion initially. 4) Sitting in a chair for meals would require too great hip flexion initially.
The nurse provides care to an older adult client recovering from surgery to repair a fractured hip. Which nursing intervention will best facilitate the resumption of activities for this client in the first few days after surgery? 1. Ambulating four times per day in the hall.2. Encouraging the use of the overhead trapeze.3. Assisting to sit in the chair twice a day.4. Encouraging to eat in the cafeteria with family.
1) PCP is caused by Pneumocystis jirovecii and is an opportunistic infection commonly affecting those with extremely poor immune systems, such as those with acquired immunodeficiency syndrome (AIDS). This organism does not pose a hazard requiring transmission precautions. 2) CORRECT — Active chicken pox, or varicella, requires airborne transmission precautions, including a fit-tested N95 respirator, until the lesions are dried or crusted. 3) Pertussis, or whooping cough, requires droplet transmission precautions, including the use of a surgical mask. 4) Norovirus requires contact transmission precautions, which may include a face shield if fluid contact is anticipated.
The nurse provides care to four clients. For which client illness will the nurse use an N95 disposable respirator? 1. Pneumocystis pneumonia (PCP) with fever.2. Varicella lesions with drainage.3. Bordetella pertussis with cough.4. Norovirus with projectile emesis.
1) A 3% saline solution contains sodium; therefore, not indicated for a client experiencing hypernatremia. 2) CORRECT — This client is experiencing hypernatremia. The normal range for serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L). The nurse anticipates a prescription for a sodium-free intravenous fluid such as D5W, which dilutes excess serum sodium. 3) A 0.9% saline solution contains sodium; therefore, not indicated for a client experiencing hypernatremia. 4) A lactated ringer solution contains sodium; therefore, not indicated for a client experiencing hypernatremia.
The nurse provides cares for a client with a sodium level of 156 mEq/L (156 mmol/L). Which health care provider prescription does the nurse anticipate? 1. A 3% saline solution.2. A 5% dextrose solution.3. A 0.9% saline solution.4. A lactated ringer solution.
1) Opioids can be used for more severe pain. They are not the first-line pain meds in osteoarthritis. 2) CORRECT — The primary pain med of choice in osteoarthritis is acetaminophen. 3) If acetaminophen does not relieve pain in osteoarthritis, NSAIDs are the next class of medications to use. 4) Cyclobenzaprine is a skeletal muscle relaxant. It is not the first-line pain med in osteoarthritis. It is used cautiously in older adults as it can cause confusion.
The nurse provides pain management teaching to an older adult client diagnosed with osteoarthritis (OA). Which medication does the nurse discuss as the initial treatment of choice for OA pain? 1. Morphine.2. Acetaminophen.3. Ibuprofen.4. Cyclobenzaprine.
1) CORRECT — A client should walk, swim, or bike at least three times per week. Exercise stimulates bowel motility and moves stool through the colon. 2) A client should avoid caffeinated coffee, tea, and cola. Caffeine stimulates fluid loss through urination, which is then lost from the bowel. 3) A client should drink 3 quarts of fluids per day to add liquid to the stool to relieve constipation. 4) A client should consume 20 to 30 grams fiber (soluble and bulk forming) per day. Fiber promotes evacuation by softening hard stools and adding bulk to the stool.
The nurse provides teaching to a client diagnosed with constipation. Which statement by a client to the nurse demonstrates that the teaching is effective? 1. "I will exercise three times per week."2. "I will drink 1 quart of fluid per day."3. "I will drink five caffeinated beverages."4. "I will consume 10 grams of fiber per day."
1) CORRECT - The nurse should first record the prescription in the client's medical record. 2) CORRECT- After writing down the prescription in the client's medical record, the nurse should read back the prescription to verify the accuracy of the prescription. 3) CORRECT - After writing down the prescription in the client's medical record and reading back the prescription to verify its accuracy, the nurse should record the date and time the prescription was issued. 4) The nurse should record the name of the health care provider who gave the verbal prescription, but it is not necessary to document the health care provider's prescriber number. 5) After writing down the prescription in the client's medical record and reading back the prescription to verify its accuracy, the nurse should record the date and time the prescription was issued. Then, record the name of the health care provider who gave the prescription and the nurse's own name and title. The nurse's license number should not be included.
The nurse receives a verbal prescription from a health care provider during a client emergency. Which action does the nurse take to ensure client safety? (Select all that apply.) 1. Record the prescription in the client's medical record.2. Read back the prescription to verify the accuracy of the prescription.3. Date and time the prescription that was issued during the emergency.4. Record the health care provider's prescriber number.5. Document the nurse's own name and license number.
1) Premature ventricular contractions frequently occur in the first few hours after a myocardial infarction. 2) Approximately 40% of clients develop mild post-procedure headaches after a lumbar puncture. These are believed to be caused by puncture of the dura during the procedure or with withdrawal of the needle, resulting in leakage of cerebrospinal fluid. Headaches may begin within hours of the procedure. Some do not begin until more than 24 hours later. This is not an emergency. 3) CORRECT - It would be a priority for the nurse to follow up if the client has difficulty breathing, dizziness, fainting, chest pain, and prolonged hiccupping after pacemaker insertion. Dizziness could indicate that the pacemaker is not functioning correctly and would be the priority assessment. 4) After total hip replacement surgery the client should not bend the hips more than 90 degrees. A semi-Fowler position is acceptable.
The nurse receives report on assigned clients. Which client will the nurse assess first? 1. Client who had a myocardial infarction 3 hours ago and is experiencing two to three premature ventricular contractions per minute.2. Client who had a lumbar puncture 2 hours ago and is reporting a headache rated as an 8 on a pain rating scale of 0 to 10.3. Client who had a permanent pacemaker inserted 12 hours ago and is reporting dizziness.4. Client who had a total hip replacement 8 hours ago and is in a semi-Fowler position.
1) A client can use guided imagery to visualize images and focus on relaxing to reduce pain. 2) CORRECT - A client can use yoga to learn how to perform exercises that will improve circulation, promote relaxation, and alleviate pain. 3) A client can use biofeedback to control physiological responses of the body, such as pain, using electronic equipment to evaluate specific responses. 4) A client can use music or other forms of sound to induce distraction and relaxation, thus reducing pain.
The nurse teaches a client about how yoga can control pain. Which client statement indicates to the nurse that the client understands the teaching? 1. "I will learn how to visualize images that can help me relax."2. "I will learn how to perform exercises to improve my circulation."3. "I will learn to control my physiological responses to pain."4. "I will use sound to help relieve my distress."
1) CORRECT — The suppository should be inserted a minimum of 2 inches for the medication to be effective. 2) The client should recline for 5 to 10 minutes with the hips elevated after inserting the suppository. 3) The client should wear a perineal pad to protect the clothing from drainage or staining. 4) The applicator for the suppository should be cleansed with soap and water prior to reuse.
The nurse teaches a client about prescribed vaginal suppositories for use at home. Which client statement indicates a need for further instructions? 1. "I should insert the suppository about a half inch into my vagina."2. "I should plan to lie on my back with my hips elevated for 5 to 10 minutes after inserting the suppository."3. "I should wear a perineal pad if I have some of the melted medication come out."4. "If I reuse an applicator, I should wash it with soap and water before I use it again."
1) CORRECT - The nurse should offer an estimated time of arrival for planning purposes and then report for duty, if able. 2) The nurse has a professional duty to help enact the emergency response plan by reporting for duty. 3) This may be the nurse's initial instinct, but the nurse is really responsible for reporting to the institution so that client's can be cared for in an orderly manner. 4) Responding that the nurse will report later is vague and unhelpful to those staff actively trying to manage the crisis.
The off-duty staff nurse is vacationing 2 hours from the hospital. The nurse is notified that a disaster plan is in effect after a widespread natural disaster. The nurse is instructed to report to the hospital immediately. Which response by the nurse is appropriate? 1. "I should arrive within 3 hours."2. "I am on vacation and do not have to come in."3. "I will help people near me first."4. "I will report to my unit later today."
1) A non-ST elevation MI does not cause heart blocks. 2) A septal wall MI does not put client at risk for heart blocks. 3) CORRECT — The SA node is supplied by the right coronary artery, is located in the inferior wall, and is the type of infarct to SA node that leads to heart blocks and the related bradyarrhythmia. 4) A subendocardial wall MI does not put client at risk for heart blocks.
Which client does the nurse monitor for a heart block after a myocardial infarction (MI)? 1. A client with a non-ST elevation MI.2. A client with a septal wall MI.3. A client with an inferior wall MI.4. A client with a subendocardial wall MI.
1) Dorsiflexion of the foot prevents foot drop and the formation of venous stasis ulcers; however, this measure does not prevent the development of a pressure injury. 2) A diet high in calories, protein, and fluids will decrease the possibility of formation of a pressure injury. There is no need to limit caffeinated fluids. 3) When a client moves up in bed or strains on defecation, a Valsalva maneuver occurs. During a Valsalva maneuver, the client holds the breath and strains. This maneuver increases intrathoracic pressure, which decreases venous return and cardiac output. It is not recommended or beneficial for a client to perform this maneuver and will not prevent the development of a pressure injury. 4) CORRECT — Using a turning or lift sheets, or other devices to turn or transfer clients, eliminates shearing forces that can cause pressure injury formation. 5) CORRECT — Avoid vigorous massage over bony prominences as it may damage the skin, which increases the risk for a pressure injury.
Which safety measure is appropriate for the nurse to use to prevent the development of a pressure injury when providing care to clients? (Select all that apply.) 1. Encourage dorsiflexion exercises of the foot.2. Limit the client's intake of caffeinated fluids.3. Encourage the client to hold the breath and try to exhale when moving up in bed.4. Use a turning or lift sheets or devices to turn or transfer clients.5. Avoid a strong massage over bony prominences.
1) Elevating the head of the bed by this amount does not impact the presence or absence of bowel sounds. 2) Auscultating breath sounds does not impact the presence or absence of bowel sounds. 3) CORRECT- Changing position can apply pressure to the abdomen. If bowel sounds are auscultated after the position change, they may be falsely generated. Examining another body area can be done while waiting for the abdominal organs to relax prior to auscultating the bowel sounds. 4) A difference of 20 mm Hg systolic measurement between arms would not influence the presence or absence of bowel sounds.
While conducting a physical examination, the nurse assesses motor function and then returns to auscultate bowel sounds. Which finding or occurrence is a reason for the nurse to delay listening to bowel sounds at that time? 1. The head of the bed is elevated 30 degrees. 2. Breath sounds are auscultated.3. The client rolls over onto their side.4. The systolic blood pressure differs by 20 mm Hg between the arms.
1) Cataracts cause vision to appear cloudy. 2) Glaucoma causes a gradual loss of peripheral vision. 3) With a detached retina, there is a sudden loss of partial or complete vision in one eye. 4) CORRECT - Manifestations of macular degeneration include a change in central vision that is described as blurry or distorted.
While performing an eye assessment, a client asks the nurse what could be the reason for vision to be blurry when looking "straight ahead." For which health problem will the nurser perform an additional assessment? 1. Cataracts.2. Glaucoma.3. Detached retina.4. Macular degeneration.
