Review Questions

The nurse educator is talking to a group of students regarding anorexia nervosa. Which statement by the students indicates an understanding of the condition? A. "Clients with anorexia nervosa are usually perfectionists and overachievers." B. "Clients with anorexia nervosa display a binge-purge syndrome." C. "Clients with anorexia nervosa have poor dental conditions." D. "Clients with anorexia nervosa have stomach ulcers and rectal bleeding."

A. "Clients with anorexia nervosa are usually perfectionists and overachievers." -clients with anorexia nervosa have the desire to please others. They need to be accurate or perfect to cope with their stress. -B, C, and D are incorrect. These statements apply to clients with bulimia nervosa, not anorexia.

The nurse is teaching a client about newly prescribed insulin glargine. The nurse recognizes the need for further instruction when the client makes the following statement? Select all that apply. A. "I will take this insulin right before my meals." B. "I should roll this vial of insulin before removing it with the syringe." C. "This insulin will help control my glucose for 24 hours." D. "I can only inject this insulin into my abdomen." E. "I'm glad to know I can mix this with my regular insulin."

A. "I will take this insulin right before my meals." B. "I should roll this vial of insulin before removing it with the syringe." D. "I can only inject this insulin into my abdomen." E. "I'm glad to know I can mix this with my regular insulin." -These statements are incorrect and require follow-up. Insulin glargine is a long-acting insulin that has no peak effect. Thus, it is not taken with meals. It is dosed once a day to provide glucose control for 24 hours. Insulin glargine is not a suspension; thus, it does not need to be rolled like NPH. This insulin is not mixed with any other insulin. Insulin glargine does not have to only be injected into the abdomen.

You are attending to a male client who is postoperative day one following mitral valve replacement. He is getting ready to ambulate for the first time. His heart rate is 102 beats/minute and the stroke volume based on the echocardiogram is 72 mL. Which of the following represents his cardiac output (CO)? A. 7.344 L/min B. 30 L/min C. 55% D. 73.444 mL/min

A. 7.344 L/min -Cardiac Output (CO). CO = Heart Rate (HR) x Stroke Volume (SV). Heart rate -Cardiac output is usually reported in liters/min; the average is about 5 L/min but varies greatly depending on the size of the patient. A decreased cardiac output (low-output failure) is seen in congestive heart failure. A high cardiac output state refers to resting cardiac output more significant than 8 L/min. An increased cardiac output (high-output failure) may be seen in hyperthyroidism, thiamine deficiency, and severe uncorrected anemia.

The nurse is assessing a neonate with Hirschsprung's disease. Which of the following would be an expected finding? A. Abdominal distention B. Urinary retention C. Hematemesis D. Palpable abdominal mass

A. Abdominal distention -Hirschsprung's disease is a congenital gastrointestinal disorder where the distal colon does not have functional ganglionic cells; therefore, the client does not have effective peristalsis. Neonatal manifestations of Hirschsprung's disease include failure to pass meconium, constipation, abdominal distention, and poor feeding.

The nurse is preparing a patient for scheduled total knee arthroplasty (TKA). Which action by the nurse would be most important to reduce this patient's risk for experiencing emergence excitement after this procedure? A. Ask the patient about any concerns regarding the procedure. B. Monitor for changes in the patient's respiratory status. C. Reassure the patient that this is a simple, minor procedure. D. Ask the patient about any recent alcohol and drug use.

A. Ask the patient about any concerns regarding the procedure. -Patients who are anxious prior to anesthesia are at higher risk of experiencing postoperative emergence excitement or delirium. The nurse should focus on actions that aim to reduce the patient's anxiety to reduce this patient's risk of emergence excitement. The nurse should provide reassurance, explain the purpose of procedure, and allow the patient to express concerns/ask questions. -Patients with a history of recent drug or alcohol use may be at increased risk of post-operative emergence excitement, but this action would only identify the risk factor, not actively reduce the patient's risk of experiencing this problem.

Among Erickson's Stages of Development, which of the following stages of development would the nurse expect a 2-year-old patient to be in? A. Autonomy vs. Shame and Doubt B. Industry vs. Inferiority C. Trust vs. Mistrust D. Initiative vs. Guilt

A. Autonomy vs. Shame and Doubt -Autonomy vs. Shame and Doubt is the typical stage of development for early childhood, which lasts from ages 2 to 3 years, so this is what the nurse would expect for a 2-year-old patient. In Autonomy vs. Shame and Doubt, children seek to develop a sense of personal control over physical skills and knowledge of independence. When they are successful, for example, with a task like toilet training, they feel independent, and it leads to a sense of autonomy. When they are not successful, they think they are a failure which then results in shame and self-doubt

A nurse is caring for a woman that just had a normal delivery an hour ago. The nurse understands that the patient is still at risk for uterine atony at this stage. All of the following interventions should be included in the care plan of the patient for detection of uterine atony, except: A. Checking for saturated perineal pads every shift B. Palpating the fundus at frequent intervals C. Weighing perineal pads once they are changed, noting the time it was changed and the saturation D. Checking vital signs frequently for signs of shock

A. Checking for saturated perineal pads every shift -Checking perineal pads every shift is an incorrect practice and therefore the correct answer to this question. The nurse should assess the perineal pad of the immediate post-partum woman every 30-minutes, not every turn. Perineal pads getting soaked with blood within 30 minutes should be a cause of concern for the nurse for this is a sign of continuous bleeding through the uterus due to uterine atony. -Weighing used perineal pads once they are changed is correct practice. The nurse should weigh the perineal pads after they are soaked to accurately assess the amount of blood lost by the patient through the perineum. One gram in weight is equivalent to 1 mL in plasma. Taking note of the time that the pads were changed would signify the frequency of pad changes, which is also essential in the assessment.

A 16-year-old adolescent client is brought to the emergency department following an injury at a skating rink. The client's left knee is bruised and swollen. Upon interview, the nurse finds out that the client has hemophilia A. Which medication would be most appropriate for this client? A. Codeine phosphate B. Aspirin C. Ibuprofen D. Oxycodone terephthalate and acetyl-salicylate

A. Codeine phosphate -Codeine phosphate is an analgesic medication with no aspirin components and is used for moderate to severe pain. -clients with hemophilia should avoid nonsteroidal anti-inflammatory drugs (NSAIDs), as these medications inhibit proper platelet functioning. Ibuprofen is an NSAID and should therefore be avoided in clients with hemophilia.

Which of the following is considered the gold standard for determining fluid balance? A. Daily weights B. Strict intake and output measurements C. Urine osmolarity testing D. Basal metabolic panel results

A. Daily weights -Daily weights are considered the gold standard for monitoring fluid balance. Monitoring for changes in normal pressure is the most direct and useful way to compare changes in fluid status and evaluate needed interventions.

You are performing a thorough assessment of a client to determine all responses to stress. Which of the following are examples of cognitive responses to stress? Select all that apply. A. Difficulty concentrating B. Poor judgment C. Depression D. Forgetfulness E. Lethargy F. Aggressiveness

A. Difficulty concentrating B. Poor judgment D. Forgetfulness These are examples of cognitive responses to stress. Psychological responses are both emotional and cognitive. They include feelings, thoughts, and behaviors. Emotional responses usually involve anxiety, fear, anger, and depression; whereas, cognitive responses affect thought processes. -Depression and lethargy are emotional responses to stress. -Aggression is a behavioral response to stress.

The nurse is working with a client who suffered a blunt injury to the chest wall. Which of the following assessment findings would indicate the presence of a pneumothorax? A. Diminished breath sounds B. A barrel chest C. Lower than normal respiratory rate D. A sucking noise at the site of the injury

A. Diminished breath sounds -Since this is a closed chest injury, the most common sign of pneumothorax (PTX) will be diminished breath sounds. -With most cases of pneumothorax, the patient will become tachypneic rather than have a lower than usual respiratory rate. A sucking noise is noted in an open chest injury.

Which action taken by the school nurse will have the most impact on the incidence of infectious disease in the school? A. Ensure that students are immunized according to national guidelines. B. Provide written information about infection control to all patients. C. Make soap and water readily available in the classrooms. D. Teach students how to cover their mouths when coughing.

A. Ensure that students are immunized according to national guidelines. -While these are helpful, receiving proper and timely immunizations has a great impact.

The nurse is assessing a client with infective endocarditis (IE). Which of the following would be an expected finding? Select all that apply. A. Fever B. Night sweats C. Osler nodes D. Cardiac murmur E. Syncope F. Weight loss

A. Fever B. Night sweats C. Osler nodes D. Cardiac murmur F. Weight loss -Infective endocarditis (IE) is a serious condition that, if untreated, may lead to heart failure. Infectious symptoms are the hallmark of this condition, including fever, night sweats, chills, weight loss, headache, and malaise. Other physical manifestations that may be assessed with IE include a cardiac murmur, Janeway lesions (flat, reddened maculae on hands and feet), Roth spots (hemorrhagic lesions that appear as round or oval spots on the retina), and Osler nodes (on palms of hands and soles of feet).

The nurse is caring for a client with atrial fibrillation who takes prescribed warfarin. Which alternative therapies should the nurse advise this patient to avoid? Select all that apply. A. Ginger root B. Aloe vera C. Garlic D. Ginko biloba E. Saw palmetto

A. Ginger root C. Garlic D. Ginko biloba E. Saw palmetto -The client taking prescribed warfarin should avoid alternative therapies that may potentiate the anticoagulant effects and increase bleeding risk. Alternative therapies such as Ginkgo Biloba, ginger root, garlic, and saw palmetto increase the bleeding risk in a client taking warfarin. The client should be advised against taking these medications.

Which of the following neurological assessments would be considered abnormal in a newborn? Select all that apply. A. High pitched cry B. Pupils are 2mm, equal, round, and react briskly to light. C. Lethargy D. Sleeping between each feeding

A. High pitched cry C. Lethargy -A high, pitched cry is an irregular finding in a newborn. It can be a sign of withdrawal in neonatal abstinence syndrome, or a sign of increased ICP if there is birth trauma. For the level of consciousness, lethargy is not a normal finding. We expect the newborn to be alert. Lethargic, obtunded, stuporous, or comatose are all abnormal findings.

Religious and cultural rituals/practices often surround death. Which of the following populations prefer cremations rather than burying the remains of the deceased person? A. Hindus B. Islam C. Mormons D. Eastern orthodox

A. Hindus -The Hindus prefer cremations rather than burying the remains of the deceased person. The ashes are then typically spread over the holy river. Cremations are viewed as discouraged or forbidden among those who practice Islam, Mormonism, and the Eastern Orthodox religion.

The nurse is assessing a client with pheochromocytoma. Which of the following would be an expected finding? Select all that apply. A. Hyperglycemia B. Hypertension C. Ataxia D. Oliguria E. Headache

A. Hyperglycemia B. Hypertension E. Headache -Pheochromocytoma is a condition caused by a tumor that sits on the adrenal medulla. This causes a surge in catecholamine discharge resulting in headaches, palpitations, marked hypertension, and hyperglycemia. Treatment includes antihypertensives and removal of the tumor. The client should be educated to avoid sources of caffeine, smoking, and stressful situations, as this would further increase blood pressure.

The nurse provides discharge education to the parents of a six-year-old who underwent a tonsillectomy. The nurse should recommend which dietary items to this client during their recovery? Select all that apply. A. Ice chips B. Orange slices C. Potato chips D. Applesauce E. Tomato soup

A. Ice chips D. Applesauce -Food items that are soft, not hot, non-acidic, and do not have jagged edges are permitted to consume following a tonsillectomy. -Soup that is room temperature is permitted. However, tomato soup would be disallowed because it is acidic.

A nasogastric tube has been inserted into a client with bowel obstruction for gastric decompression. The nurse should set the suction on which setting? A. Intermittent suction at 70 mmHg B. Intermittent suction at 100 mmHg C. Continuous suction at 100 mmHg D. Continuous suction at 70 mmHg

A. Intermittent suction at 70 mmHg -Gastric decompression should always be intermittent and at low suction pressure. A suction pressure below 80 mmHg is considered low suction. -Continuous and high suction pressure for gastric decompression should be avoided as this predisposes the gastric mucosa to injury and ulceration.

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing ovarian cancer? Select all that apply. A. Nulliparity B. Advancing age C. Family history D. Herpes simplex virus (HSV) E. Early menarche

A. Nulliparity B. Advancing age C. Family history E. Early menarche -Risk factors for ovarian cancer include nulliparity, advancing age, family history, and early menarche.

The nurse is caring for a client with hypokalemia scheduled to receive the prescribed 20 mEq of intravenous (IV) potassium. Which client assessment requires notification of the primary healthcare provider (PHCP)? A. Oliguria B. Abdominal distention C. Muscle weakness D. Weak peripheral pulses

A. Oliguria -Oliguria is a contraindication to the administration of IV potassium. Parenteral potassium is highly concentrated, and this may cause life-threatening hyperkalemia. -The manifestations of hypokalemia include abdominal distention, hypoactive bowel sounds, muscle weakness, weak peripheral pulses, and confusion. ECG changes associated with hypokalemia include ST-segment depression and an increase in the amplitude of the U wave.

While working in the emergency department, you are assessing a 3-month-old infant who was brought in by parents for poor feeding, irritability, and vomiting. Upon auscultating the heart sounds, you note a machine-like murmur. Which conditions does the nurse suspect? Select all that apply. A. Patent Ductus Arteriosus (PDA) B. Congestive Heart Failure (CHF) C. Aortic Stenosis D. Ventricular Septal Defect (VSD)

A. Patent Ductus Arteriosus (PDA) B. Congestive Heart Failure (CHF) -The objective here is to identify that a patent ductus arteriosus can lead to congestive heart failure and must be suspected in an infant presenting with the symptoms mentioned in the question. The nurse does suspect a patent ductus arteriosus (PDA) (Choice A), due to the presence of a machine-like murmur, a hallmark sign of a PDA. The nurse also suspects congestive heart failure (CHF) due to the classic presenting symptoms in the infant: poor feeding, irritability, and vomiting. -A large VSD can cause congestive heart failure in an infant but this would result in a pan-systolic murmur, not a machine-like murmur, so the nurse does not suspect this.

The nurse is caring for a client involuntarily admitted to the behavioral health unit. The client has been mailed a package. The nurse should perform which action? A. Provide the client with the package B. Open the package to review its content C. Provide the package upon discharge D. Determine if the sender is the client's next of kin

A. Provide the client with the package -Under the patient bill of rights, the client has a right to confidentiality and privacy. The nurse should not open postal packages prior to giving them to the client. If the nurse is concerned that the client could be mailed something harmful, the nurse should request that they open the package up in front of them. -Mail tampering is a crime, and the nurse is obligated to provide the client with dignity, privacy, and respect. This includes timely delivery of their mail.

The nurse is discussing infection control with a group of nursing students. Which conditions require contact precautions? Select all that apply. A. Respiratory syncytial virus B. Psoriasis C. Pediculosis D. Rubella E. Scabies F. Clostridium difficle

A. Respiratory syncytial virus C. Pediculosis E. Scabies F. Clostridium difficle -Conditions requiring contact precautions include RSV, pediculosis, Clostridium difficle, and scabies. Pediculosis refers to infestation with head lice. Clostridium difficle is a spore-forming bacteria that causes diarrhea. RSV may be transmitted by the droplet route but is primarily spread by direct contact with infectious respiratory secretions. Droplet precautions are not routinely warranted but are appropriate if the infecting agent is not known.

The nurse should understand the regulations of nursing practice as put forth by the Nurse Practice Act. Which of the following statements are correct? Select all that apply. A. Some other issues covered by the Nurse Practice Act include grounds for disciplinary action—licensure requirements and the rights of the nurse licensee if disciplinary action is taken. B. The Nurse Practice Act defines the scope of nursing practice. C. Nurses do not have the responsibility to know the provisions of the act for the state or province in which they work. D. The Nurse Practice Act is a series of statutes enacted by the federal government to regulate the practice of nursing.

A. Some other issues covered by the Nurse Practice Act include grounds for disciplinary action—licensure requirements and the rights of the nurse licensee if disciplinary action is taken. B. The Nurse Practice Act defines the scope of nursing practice. -Nurse practice acts (NPAs) contain a provision that creates and empowers a state board of nursing to regulate the practice of nursing in that state. All 50 states, the District of Columbia, and the four U.S. territories have established boards of nursing. Although NPAs can vary from state to state, they all have standard components because states use the ANA guidelines in developing their regulations. -Nurse practice acts are created by the state, not the federal government.

The primary healthcare provider (PHCP) prescribes the client's chest tube discontinuation. The nurse should place which supply item at the bedside for this procedure? A. Suture removal kit B. Bag valve mask (BVM) C. Nasal cannula oxygen D. Wall suction with tubing

A. Suture removal kit -If the PHCP prescribes a chest tube to be discontinued, nursing should have pertinent supplies such as a suture removal kit, occlusive gauze, dry sterile gauze, tape, biohazard bag and a clamp. A suture removal kit is necessary because the chest tube is sutured into place. -Wall suction and tubing are not necessary to remove a chest tube. This may be necessary to operate the chest tube - but not for its removal.

The nurse is caring for a client who is recovering from surgery. Which assessment data would suggest that the client's pain is not well controlled? Select all that apply. A. Tachypnea B. Bradycardia C. Nausea D. Mydriasis E. Increased blood glucose

A. Tachypnea C. Nausea D. Mydriasis E. Increased blood glucose -A client experiencing acute pain will have activation of the sympathetic nervous system

The nurse is evaluating the progress of a completely paraplegic female client with a C6-C7 spinal cord injury. Which indicator signifies that the client is improving in physical therapy? A. The client can control the motorized wheelchair. B. The client states she wants to stand up with assistance. C. The client says she wants to move her toes. D. The client says she regained her bladder control.

A. The client can control the motorized wheelchair. -A C6-C7 spinal cord injury (SCI) can still retain some ability to extend shoulder, arms, and fingers with compromised dexterity in the hands and fingers. The client showing that she can maneuver a wheelchair indicates that she has progressed in therapy. -The client who loses control of their bladder may regain function again sometime after injury. However, this is not dependent on physical therapy and does not indicate a positive response to physical therapy.

Your client is at the end of life and experiences guilt for past transgressions. After a number of independent and dependent nursing functions, what is an expected outcome for this client? A. The client will articulate the nature of humans in terms of fallibility. B. The client will go to confession to ask for forgiveness. C. The client will perform relaxation techniques to dissolve guilt. D. The client will not express any more feelings at the end of life.

A. The client will articulate the nature of humans in terms of fallibility. -An expected outcome for this client could be that the client will articulate the nature of humans in terms of fallibility. The purpose of guilt is to allow the person to know that they have done something wrong, and it also permits the person, at the end of life, to make final amends to those that they have hurt. -Although relaxation techniques may be used by the person to decrease their anxiety related to guilt, relaxation techniques do not dissolve guilt.

The nurse manager is completing an annual performance apprasial/evaluation on a staff nurse. Which elements should the nurse manager include when completing the evaluation? Select all that apply. A. The nurses' bar-code medication administration scan rate B. The number of times the nurse has been absent or tardy C. The nurse achieving a national certification D. The nurses' performance compared to other staff nurses E. The number of medication errors the nurse has self-reported.

A. The nurses' bar-code medication administration scan rate B. The number of times the nurse has been absent or tardy C. The nurse achieving a national certification -The performance appraisal/evaluation goal is to provide a broad review of the employee's performance with minimal evaluator bias. The more objective the evaluation, the less the bias. Objective metrics such as bar-code medication administration rate, attendance, and national certifications are logical elements to include in the appraisal. -Using self-reports of a medication error against the nurses' performance would likely discourage future reporting.

For a nonstress test to be considered reactive, several factors have to be present. Which of the following are components of a reactive nonstress test? Select all that apply. A. The test occurs over a 20-minute period B. There are 2 or more accelerations C. Accelerations are 15 beats/minute lasting 15 seconds D. Moderate variability is present

A. The test occurs over a 20-minute period B. There are 2 or more accelerations C. Accelerations are 15 beats/minute lasting 15 seconds -Although moderate variability is a reassuring sign, variability is not a component of a nonstress test and is therefore not a part of it's reading.

The nurse is reviewing the assignment for the shift and will be caring for the following clients. Which client is at risk for hypokalemia? A client with A. hyperemesis gravidarum. B. end-stage renal failure. C. diabetic ketoacidosis. D. third-degree burns.

A. hyperemesis gravidarum. -The intense vomiting is why this condition puts the patient at risk for hypokalemia. The hypokalemia associated with hyperemesis gravidarum is related to the metabolic alkalosis the client experiences due to the vomiting. -A client with third-degree burns will be at risk for hyperkalemia, not hypokalemia. Burns destroy tissue and lyse cells, causing large amounts of intracellular potassium to be released into the vascular space, causing hyperkalemia.

A 16-year old patient injures her ankle on the soccer field. She is taken to the emergency department by ambulance. In the ambulance, she starts hyperventilating. Upon arrival to the waiting room, an arterial blood gas is drawn. What values will most likely appear on the results? A. pH: 7.55, CO2: 22, HCO3: 24 B. pH: 7.35, CO2: 39, HCO3: 26 C. pH: 7.32, CO2: 47, HCO3: 25 D. pH: 7.55, CO2: 42, HCO3: 34

A. pH: 7.55, CO2: 22, HCO3: 24 -Hyperventilating can cause respiratory alkalosis. This is because there the body is blowing off too much CO2. CO2 is an acid, so when the body is loosing too much of it, the client can become alkalotic. -Choice D is incorrect. These values represent metabolic alkalosis, which would not be expected in the patient who is hyperventilating. Because it is a change in CO2 causing the pH to shift, the cause of the imbalance is respiratory, not metabolic.

The nurse receives a prescription for sevelamer. The nurse plans on administering this medication A. with the client's meals. B. immediately before hemodialysis. C. with a prescribed proton pump inhibitor (PPI). D. right before the client goes to bed.

A. with the client's meals. -Sevelamer is a phosphate binder indicated in the treatment of hyperphosphatemia associated with chronic kidney disease. This medication is purported to decrease serum phosphorus levels by binding to food. Thus, this medication is given with meals. Combined with a low phosphorus diet, the goal of this medication is to decrease serum phosphate levels.

The nurse is performing medication administration for four clients. Which client and medication should be administered first? A: client one with prednisone for asthma exacerbation B: client two with acetaminophen for fever C: client three with mag oxide for chronic alcoholism D: client four with glargine insulin for DM

A: client one with prednisone for asthma exacerbation -This medication is prescribed for a client with an asthma exacerbation which is an acute problem. Additionally, this acute problem deals with the client's breathing problem (asthma), prioritizing a fever, diabetes, and chronic alcoholism. -The client with a fever prescribed acetaminophen will require treatment but does not prioritize the acute respiratory ailment of an asthma exacerbation.

The nurse is teaching a client about the newly prescribed medication, sevelamer. Which statement, if made by the client, would indicate a correct understanding of the teaching? A. "This medication will help lower my calcium level." B. "I should take this medication with my meal." C. "I may experience bad diarrhea with this medication." D. "My blood pressure may increase while I take this medication."

B. "I should take this medication with my meal." -Hyperphosphatemia and hypocalcemia are common laboratory abnormalities found in CKD. Phosphorus and calcium have a reciprocal relationship; therefore, lowering phosphorus levels through phosphate binders is a standard treatment for CKD. The nurse should ensure these medications are given with meals and advise the client to mitigate the common effect of constipation through stool softeners and laxatives.

The nurse has provided education to a client with atrial fibrillation. Which of the following statements by the client would require a follow-up? Select all that apply. A. "I have an increased risk for a stroke." B. "I should weigh myself daily at the same time." C. "I may be prescribed medications such as amiodarone." D. "I should wear a mask when I am in public." E. "I should follow-up with my primary healthcare provider (PHCP) if I develop shortness of breath."

B. "I should weigh myself daily at the same time." D. "I should wear a mask when I am in public." -The client does not need to weigh themselves daily as that would be applicable for CHF and not for atrial fibrillation. Considering daily weight checks in CHF is useful to detect excess fluid retention, which may precede symptoms such as shortness of breath. Wearing a mask in public is unnecessary as an infection is not the concern here -A client with atrial fibrillation is at risk for an ischemic stroke because of the formation of clots in the atrial appendage. Treatment for atrial fibrillation range from medications (diltiazem, amiodarone) to cardiac ablation. Finally, the client needs to notify the PHCP if they develop dyspnea because this could be an indication of atrial fibrillation with a rapid ventricular response (RVR), which requires immediate medical attention.

A 7-year-old child is brought to the emergency department because of a fall. A fractured arm was confirmed and a plaster cast was applied. The nurse is providing instructions to the child's mother regarding the cast. Which statement by the mother necessitates further instructions from the nurse? A. "As the cast dries, it can feel a bit warm." B. "I'll just put some powder or lotion on the edges of the cast in case my child complains of an itch." C. "I can use shoe polish to clean the external surface of the cast." D. "I can use a blow dryer on the cool setting to dry the cast in case it gets wet."

B. "I'll just put some powder or lotion on the edges of the cast in case my child complains of an itch." -The patient is not allowed to put lotion or powder inside the cast or very close to it as it may be sticky and cause skin irritation. This statement requires follow-up and further instructions by the nurse

The newly registered nurse is caring for a preschool child in the pediatric ward under the supervision of a nurse educator. Which statement by the new RN indicates to the nurse educator that she knows how to care for a preschooler? A. "We can convince the preschooler to cooperate with us by providing a thorough explanation of the procedure." B. "We need to ensure that the child doesn't feel threatened about being mutilated during nursing care." C. "We can make him more cooperative by involving him in competitive games." D. "The preschooler should not wait to have his needs met."

B. "We need to ensure that the child doesn't feel threatened about being mutilated during nursing care." -The preschooler has many fears at this stage. One concern is the fear of mutilation. The nurse should take care to prevent painful experiences in the child. -The preschooler is now able to tolerate more extended periods of delayed gratification. There is no need to gratify him instantly.

The nurse is assigned the case manager role. She understands that case management uses which of the following methods of patient care delivery and documentation? A. A problem-oriented documentation system. B. A critical pathway documentation system. C. A source-oriented documentation system. D. A variance-oriented documentation system.

B. A critical pathway documentation system. -Case management refers to the process of organizing the patient care throughout an episode of illness so that certain clinical and financial outcomes are achieved within an assigned time frame. Case management uses a critical pathway documentation system as a form of patient care delivery and documentation. Critical pathways are time-oriented multidisciplinary plans of care that are established and approved by the interdisciplinary team. Variances are deviations from the expected course that are documented within the critical pathway system.

The RN is the only RN in the assisted care facility on a busy evening shift. Of the following tasks, the ones that can be safely delegated to an experienced LPN/LVN include: Select all that apply. A. Completing an admission assessment on a new patient B. Administering PO medications to patients on the unit C. Removal of a urinary catheter D. Completing a dressing change

B. Administering PO medications to patients on the unit C. Removal of a urinary catheter D. Completing a dressing change -In general, LPN/LVN training allows those nurses to do those tasks that have the most predictable outcomes. That includes administering oral meds, removal of urinary catheters, dressing changes, and other similar jobs.

The nurse is caring for a client with incontinence-associated dermatitis. The nurse should take which action? Select all that apply. A. Cleanse the affected area with isopropyl alcohol B. Apply zinc oxide to the affected area C. Use an incontinence pad instead of a brief D. Applying an extra incontinence brief to encapsulate the moisture E. Apply a transparent dressing to the affected area

B. Apply zinc oxide to the affected area C. Use an incontinence pad instead of a brief -The nurse should immediately cleanse the area after urine and bowel incontinence with a solution that has a pH between 4.0 and 6.8. The solution should not have any alcohol or fragrances that could irritate the dermatitis. Once the affected area is cleansed, zinc oxide should be applied because of its moisture-wicking effects. Incontinence pads are recommended over a brief because it allows aeration of the site and the prevention of encapsulating moisture against the client's skin. -Transparent dressings are not helpful because they trap moisture directly in the skin and prevent aeration of the skin.

The nurse is teaching a leadership and management course and is discussing client referrals. Which of the following statements describes the purpose of referrals? A. Allows the nurse to demonstrate their leadership abilities B. Care is appropriately routed to an individual or discipline C. Ensures that care is unilateral and cost effective D. Focuses on empowering the client's decision making

B. Care is appropriately routed to an individual or discipline -The primary purpose of referrals is to ensure the completeness and appropriateness of the client's care. A registered nurse completes a referral to ensure that an appropriate individual or discipline meets the client's needs. -While referrals may be cost effective, they are collaborative not unilateral.

Which of the following educational points are correct when teaching a patient about iron supplementation? Select all that apply. A. Take the iron supplement 30 minutes after a meal. B. Drink a glass of orange juice with your iron supplement. C. Report any black stools to your doctor. D. Drink the iron suspension with a straw.

B. Drink a glass of orange juice with your iron supplement. D. Drink the iron suspension with a straw. -Orange juice is high in vitamin C, which will help increase the absorption of iron. Also, this will make taking the supplement easier on the stomach and many say it helps with the bad taste. If the healthcare provider orders an oral suspension iron supplementation, you should teach your patient to drink it through a straw to avoid staining their teeth. Alternatively, if you are administering the medication to a young child who cannot drink through a straw, you can pull it up in a syringe and squirt it into the back of their mouth behind their teeth.

Which term is used to describe the comparative potency and strength of an opioid analgesic when compared to parenteral morphine? A. Morphine equivalency B. Equianalgesia C. Morphine equivalent D. The morphine factor

B. Equianalgesia -Equianalgesia is the term that is used to describe the comparative potency and strength of an opioid analgesic when compared to parenteral morphine. The equianalgesic of an opioid, when compared to parenteral morphine, is mathematically calculated. -Morphine equivalency relates to the equivalency of an opioid analgesic when compared to parenteral morphine. The morphine factor is the term that elements in the power of parenteral morphine.

The nurse reviews the assessment data for a child with acute glomerulonephritis (AGN). Which of the following would be an expected finding? A. Urine specific gravity of 1.004. B. Hematuria C. Urinary incontinence D. Hypotension

B. Hematuria The urine characteristics in a client with AGN include hematuria, proteinuria, and high urine-specific gravity. Additionally, urine output may also decrease in the early stages of AGN. Urinary incontinence is not a feature of AGN neither is hypotension. Hypertension is more likely because of the fluid retention that the client experiences.

The nurse is taking care of a client two days post lobectomy. He is complaining of difficulty breathing. He is restless, lethargic, and has bilateral crackles. What is the nurse's most appropriate initial intervention? A. Check the client's oxygen saturation. B. Notify the rapid response team (RRT). C. Place the client in Trendelenburg position. D. Check the client's surgical dressing.

B. Notify the rapid response team (RRT). -The client is in obvious respiratory distress. The nurse needs help with initiating life-saving procedures such as endotracheal intubation. The nurse need not call a "Code Blue" since the client is still breathing. However, a Rapid Response Team (RRT) can be called for help. Since the client is in obvious respiratory distress, no additional assessment is needed prior to calling the RRT. -The client is in obvious respiratory distress, even without the oxygen saturation reading. The nurse should initiate a nursing intervention to help the client. RRT needs to be contacted right away. Please note, "When in distress do not assess!"

The nurse is caring for a client with heart failure. Which medication should the nurse clarify with the primary healthcare provider (PHCP)? A. Lisinopril B. Prednisone C. Hydralazine D. Carvedilol

B. Prednisone -Prednisone is a corticosteroid that causes sodium retention, thereby increasing fluid volume. This is detrimental to a client with heart failure. The increased fluid volume may exacerbate heart failure symptoms.

You are working in a Family Practice office. A patient comes into the office with right facial drooping. The physician makes a diagnosis of Bell's palsy. You know that the primary treatment for this disease is likely to include: Select all that apply. A. Surgery B. Prednisone C. Antibiotic D. Antivirals

B. Prednisone D. Antivirals -Prednisone or another corticosteroid is likely to be prescribed. The anti-inflammatory action of these medications may help to reduce the swelling of the facial nerve and lessen the impingement that is causing the facial drooping. Antivirals are controversial, but some studies show that the combination of antivirals with corticosteroids may be helpful in patients with severe facial drooping. Both of these medications should be given as soon as possible after the symptoms start. Physical therapy to massage facial muscles can help to minimize permanent damage.

The nurse is preparing to teach a client who was recently diagnosed with Meniere's disease. To help the client reduce the incidence of attacks, the nurse should recommend that the client do which of the following? A. Irrigate their ear with sterile water. B. Reduce dietary sodium intake. C. Not use earbuds or headphones. D. Speak with limited inflections.

B. Reduce dietary sodium intake. -Meniere's disease is characterized by excessive endolymphatic fluid. This causes three main features of vertigo, tinnitus, and sensorineural hearing loss. Nursing care aims to provide education that should focus on diet medication (low salt, limiting caffeine and alcohol) and adherence to pharmacotherapy, including antiemetics, diuretics, antihistamines, and glucocorticoids.

The nurse is preparing the discharge of a patient with heart failure. The nurse double checks his prescription and notes that the patient has been prescribed digoxin and lasix. Which of the following laboratory tests must the patient have monitored because of the medications prescribed? A. Stool for occult blood B. Serum electrolytes C. Urinalysis D. Glycosylated hemoglobin

B. Serum electrolytes -When taken together, digoxin and lasix increase renal perfusion leading to potassium loss. The patient should be instructed to monitor his serum electrolyte levels, notably his serum potassium. -Glycosylated hemoglobin is a test to determine blood sugar control in people with diabetes. This is entirely unrelated to digoxin and lasix.

The nurse is caring for a cancer patient who is receiving chemotherapy. The patient is experiencing weight loss as a result of intermittent nausea. The nurse should implement which of the following nursing interventions to help with the patient's nausea? Select all that apply. A. Suggest using hot sauce and strong herbs for bland foods. B. Serve small meals every 2-3 hours. C. Provide meals that are best eaten at room temperature. D. Encourage the patient to brush their teeth in the afternoon rather than in the morning. E. Serve high-fat and protein dense foods.

B. Serve small meals every 2-3 hours. C. Provide meals that are best eaten at room temperature. D. Encourage the patient to brush their teeth in the afternoon rather than in the morning. -Serving small meals every 2-3 hours may help keep nausea at bay. Food eaten at room temperature and delaying teeth brushing till the afternoon may also improve nausea. -High-fat foods are especially nauseating for those experiencing nausea.

The nurse is completing an assessment on a 6-year-old client with asthma. Which of the following assessment findings is of most concern to the nurse? A. Expiratory wheezing B. Silent chest C. Cough D. Head bobbing

B. Silent chest -Silent chest is the assessment finding of most concern. This refers to the inability to auscultate any lung sounds. There is complete obstruction of the patient's airway and therefore the inability to move air. When complete obstruction occurs, this is a medical emergency. This assessment finding is of most concern because the client has lost their airway. -Expiratory wheezing is an expected finding when a client is having an asthma exacerbation. Although it is a significant finding, it is not the finding of most concern in this question, because the client still has a patent airway.

The nurse is assessing a client who is requiring bilateral wrist restraints. Which assessment data is necessary for the nurse to obtain? Select all that apply. A. Previous restraint use B. Skin integrity C. Behavioral status D. Vital signs E. Urinary continence

B. Skin integrity C. Behavioral status D. Vital signs -Urinary continence is not pertinent to restraining a client because toileting is offered at certain intervals based on the restraint and facility protocol.

A client with episodes of vertigo who has a fractured leg has been ordered crutches and not to bear weight on the affected extremity. The most appropriate crutch-walking gait the nurse should teach the client is the A. Two-point gait B. Three-point gait C. Four-point gait D. Swing-through gait

B. Three-point gait -The three-point gait is most appropriate because the client is of non-weight bearing status on the affected leg. In a three-point gait, the client bears weight on both crutches and then the unaffected leg. This gait is also appropriate because it is slower than the swing-through gait, which requires more balance and is faster. -The two-point gait requires at least partial weight bearing on each foot. This gait would be inappropriate because the client is instructed to have non-weight bearing status on the affected leg. -The four-point, gait gives stability to the client but requires weight-bearing on both legs. This gait would be inappropriate because the client has non-weight bearing status ordered to the affected extremity. -If the client has complete paralysis of the hips and legs, the swing-to gait or swing-through gait is utilized.

The nurse notes that the physician has entered a do not resuscitate [DNR] order. However, there is no advanced directive by the patient present on the patient's chart. Which is the appropriate nursing action? A. Notify the physician about the need for a living will to validate this order. B. Verify that the physician consulted with the patient and/or family. C. Accept the order as written, no other documentation is needed. D. Notify the nurse supervisor and risk management about the DNR order.

B. Verify that the physician consulted with the patient and/or family. -Documentation that the physician has consulted with the patient and family is required before a do not resuscitate order is entered on the patient's chart. -It is not necessary to have a living will on the patient's chart, but there must be documentation that the issue was discussed with the patient/family.

The image below depicts which post-operative surgical complication? A. Wound Evisceration B. Wound Dehiscence C. Diabetic Ulcer D. Tertiary Healing

B. Wound Dehiscence -This image shows wound dehiscence. Wound dehiscence is a partial or total separation of previously approximated wound edges due to a failure of proper wound healing, sometimes described as "splitting open of the wound." The abdominal muscle layer is intact in wound dehiscence, preventing the internal organs from protruding out. Typically, this occurs five to eight days following surgery when healing is still in the early phases.

The nurse overhears unlicensed assistive personnel (UAP) telling a client that they will have to get a feeding tube if they do not start eating more at mealtimes. The nurse recognizes that the UAP has Select all that apply. A. committed battery. B. emotionally abused the client. C. committed assault. D. been negligent. E. demonstrated libel.

B. emotionally abused the client. C. committed assault. -The UAP has committed assault, and they have also emotionally abused the client. Charge-like emotional abuse occurs when someone causes another person, like a client, to feel fearful and threatened. Assault is conduct that makes an individual fearful and apprehensive. -libel is not demonstrated because libel is the written defamation of character.

The nurse is preparing to administer the prescribed mannitol. The nurse plans to administer the infusion using A. microdrip intravenous tubing. B. filtered intravenous tubing. C. vented intravenous tubing. D. non-vented intravenous tubing.

B. filtered intravenous tubing. -Mannitol is an osmotic diuretic indicated for cerebral edema. Mannitol may crystallize when exposed to low temperatures. Because of this, mannitol is always administered intravenously through intravenous tubing with a filter.

The nurse is reviewing a new prescription for amphotericin b. The nurse understands that this medication treats A. autoimmune infections. B. fungal infections. C. viral infections. D. bacterial infections.

B. fungal infections. -Amphotericin B is a powerful antifungal indicated in treating systemic fungal infections. This medication requires pre-medication with isotonic saline, diphenhydramine, and acetaminophen to help decrease the symptoms of fever, chills, and rigors associated with the infusion.

The nurse is educating clients that are attending a prenatal class. Which of the following statements should the nurse include? A. "Chorionic Villous Sampling (CVS) may detect neural tube defects." B. "Maternal serum alpha-fetal protein (MSAFP) may determine gender." C. "Amniocentesis may be used to assess for chromosomal abnormalities." D. "A biophysical profile (BPP) assesses six variables such as fetal glucose."

C. "Amniocentesis may be used to assess for chromosomal abnormalities." -Amniocentesis is a widely used antepartum test that may determine the gender of a fetus, the presence of neural tube defects, chromosomal abnormalities, and fetal lung maturity. This test may also be used therapeutically for polyhydramnios as it may remove some excessive amniotic fluid volumes.

The school nurse is talking to a group of mothers regarding poison prevention and management. Which statement by the mothers indicates a need for further teaching? A. "I need to properly label the containers of poisonous liquids." B. "I need to make my child vomit in the instance he ingests gasoline." C. "I can give my child milk or some water to dilute the poison while I rush him to the hospital." D. "All poisonous materials should be stored away from children."

C. "I can give my child milk or some water to dilute the poison while I rush him to the hospital." -Induction of vomiting when a victim has ingested hydrocarbons is contraindicated. Vomiting may lead to inhalation of the poison, worsening the situation -Diluting the poison can buy some time in getting the child/victim some needed help.

The nurse is giving discharge instructions regarding methods that can prevent dumping syndrome for a client that had undergone a pyloroplasty. Which statement from the client indicates a need for further teaching by the nurse? A. "This means I have to give up milk and cookies for my snack." B. "I need to minimize eating pasta, rice, and bread." C. "I have to stay upright after eating my meals." D. "I need to get used to eating smaller, more frequent meals."

C. "I have to stay upright after eating my meals." -To prevent rapid gastric emptying, the client needs to lie down after meals. Staying upright promotes gastric emptying due to gravity. -To prevent dumping syndrome, the client needs to avoid sugar, salt, and milk as these promote gastric emptying. The client is instructed to eat a high protein, high fat, low carbohydrate diet. Pasta, rice, and bread are high carbohydrate foods that the client needs to eliminate from her diet.

What is the priority nursing intervention for a newly admitted client with the possible nursing diagnosis of self-care deficit: bathing and hygiene? A. Helping the client with their self-care needs in terms of bathing and hygiene. B. Asking a family member to assist the client with their bathing and hygiene self-care needs. C. A thorough assessment of the client in terms of their self-care strengths and weaknesses. D. A thorough assessment of the client in terms of their bathing and hygiene preferences.

C. A thorough assessment of the client in terms of their self-care strengths and weaknesses. -The priority nursing intervention for a newly admitted client with the possible nursing diagnosis of "self-care deficit: bathing and hygiene" is to perform the priority first phase of the nursing process. Your priority nursing intervention is to perform a thorough assessment of the client in terms of their bathing and hygiene self-care strengths and weaknesses so that you can determine if the client has or does not have a possible self-care deficit in terms of bathing and hygiene. -Although you would perform a thorough assessment of the client in terms of their bathing and hygiene preferences, this is not the priority. There is something else that you would do first.

What is the process with which members of another culture adopt the culture of the host, predominant culture? A. Immigration B. Emigration C. Acculturation D. Assimilation

C. Acculturation -Acculturation is the process with which members of another culture adopt the culture of the host, predominant religion. This adaptation allows the members of the non-dominant culture to survive and thrive in the new environment. Although acculturation and assimilation are similar, adaptation is the process with which a person develops a new cultural identity, rather than assimilating and adopting a new culture while retaining their own.

The nurse cares for a client immediately following a percutaneous coronary intervention (PCI). Upon sheath removal, the client develops bradycardia and hypotension. Which intervention would be the nurse's priority? A. Assess bilateral pedal pulses B. Apply sandbag to the puncture site C. Administer prescribed bolus of intravenous (IV) fluids D. Elevate the head of the bed

C. Administer prescribed bolus of intravenous (IV) fluids -The client presents with signs of vasovagal response. A vasovagal response may occur due to pain and baroreceptor stimulation from manual pressure during femoral sheath removal. Decreased heart rate (bradycardia) and reduced blood pressure (hypotension) are typical of a vasovagal (para-sympathetic) response. The nurse's priority would be to address the hypotension by administering a bolus of intravenous isotonic fluids and lowering the head end of the bed (elevating lower extremities > 30 degrees). If bradycardia persists, atropine is used. -Applying a sandbag for pressure to the puncture site would not be indicated without signs of active bleeding and would be expected to exacerbate the vasovagal response.

The nurse observes a client with dementia not recognizing their family member. The nurse understands that this client is demonstrating signs of which of the following? A. Apraxia B. Agraphia C. Agnosia D. Aphasia

C. Agnosia -Agnosia is a clinical feature associated with dementia. Agnosia is the inability to identify familiar objects or people, even a spouse. -Apraxia is a clinical feature of dementia, and apraxia is the inability to perform familiar and purposeful tasks. Agraphia is a term describing when a client has difficulty writing. Aphasia is the difficulty finding the correct word, then is reduced to a few words, and finally is reduced to babbling or mutism.

The nurse is caring for a client receiving prescribed sumatriptan. Which client report would indicate that the client is experiencing an adverse response? A. Nervousness B. Warm sensation C. Angina D. Tingling sensation

C. Angina -Sumatriptan is a medication indicated to abort migraine headaches. Angina is a concerning finding and requires follow-up by the nurse. Vasoconstriction may occur with this medication, and thus, the client with a medical history of coronary artery disease, uncontrolled hypertension, and a previous stroke should not take this medication. -These are common (and expected) reactions to this medication. Thus, the nurse should educate the client to expect these sensations; the more they take the drug, the less they will experience these manifestations.

While assessing a laboring mother during a contraction, the nurse notes a decrease in fetal heart rate from 150 to 120 bpm. The heart rate slows for about 10 seconds and increases back to 150 bpm as the contraction ends. Which of the following correctly classifies this observation? A. Late deceleration B. Moderate variability C. Early deceleration D. Marked variability

C. Early deceleration -Early decelerations occur when the fetal heart rate decreases at the same time as a contraction. In this question, the nurse noted a decrease from 150 to 120 bpm with the contraction and then a return to baseline. This occurs due to the pressure of the head of the fetus on the pelvis or soft tissue, and no intervention is required by the nurse after an early deceleration.

Your adolescent client has been admitted to the adolescent psychiatric mental health unit. What is the first thing that you should do for this client? A. Assess their current psychosocial functioning. B. Generate a nursing diagnosis. C. Establish trust with the client. D. Allow the client to ventilate their feelings.

C. Establish trust with the client. -The first thing that you should do is establish the client's trust. Trust is the early stage of the therapeutic nurse-client relationship. After the trust is established, the nurse should encourage, facilitate, and allow the client to ventilate their feelings. This ventilation of feelings is used for and enfolded into the assessment of the client as well as their current psychosocial functioning; this is often used to generate a nursing diagnosis that is specific to the client's needs.

Which of the following correctly describes the physical growth pattern from infancy into early childhood? A. Growth occurs from the distal to the proximal parts of the body B. Growth occurs from the proximal to the distal parts of the body C. Growth occurs in a head-to-toe progression D. Growth initially occurs most rapidly in the extremities

C. Growth occurs in a head-to-toe progression -The cephalocaudal principle (also known as cephalocaudal development) refers to a general pattern of growth and development followed from infancy into toddlerhood and even early childhood whereby development follows a head-to-toe progression.

The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question? A. Furosemide for a client with hyperparathyroidism B. Methimazole for a client with hyperthyroidism C. Hydrocortisone for a client with diabetes insipidus D. Prazosin for a client with pheochromocytoma

C. Hydrocortisone for a client with diabetes insipidus -Treatment for diabetes insipidus includes medications such as desmopressin, thiazide diuretics, and anti-inflammatories. Hydrocortisone is a short-acting corticosteroid and is indicated in the treatment of adrenal insufficiency. This requires follow-up because DI is not treated with hydrocortisone. -Hyperparathyroidism causes hypercalcemia, and the treatment for hyperparathyroidism is a combination of 0.9% saline infusion followed by furosemide. Hyperthyroidism requires antithyroid medications such as methimazole or propylthiouracil. The classic manifestation of pheochromocytoma is hypertension, and treatment of this condition involves antihypertensive such as prazosin, an alpha-adrenergic blocker.

A patient presents with weight loss and diarrhea with frothy, fatty, foul-smelling, yellow-gray stools. Which of the following malabsorption issues would not be a possible cause? A. Pancreatitis B. Celiac disease C. Lactose intolerance D. Tropical sprue

C. Lactose intolerance -Weight loss and diarrhea are general signs and symptoms of most malabsorption disorders and are not specific enough symptoms to differentiate these disorders. Therefore, the critical symptom is the frothy, fatty, foul yellow-gray stools (steatorrhea). Steatorrhea may occur in all of the other answer choices listed but is not seen in lactose intolerance. -Tropical sprue refers to bacterial proliferation that is common in tropical regions and causes chronic/progressive damage to jejunal and ileal tissues. Steatorrhea may occur as a result of the damage to these tissues and malabsorption.

You are providing education to an HIV+ mother about what she will need to do for her baby after he is born. Which of the following teaching points are appropriate? Select all that apply. A. Follow exclusive breastfeeding to ensure your infant receives proper nutrition. B. Ensure your infant receives all vaccines on time. C. Monitor your infant closely for signs of HIV for at least 18 months. D. Keep track of your baby's weight gain and notify the pediatrician if he doesn't gain weight as expected.

C. Monitor your infant closely for signs of HIV for at least 18 months. D. Keep track of your baby's weight gain and notify the pediatrician if he doesn't gain weight as expected. -Infants born to an HIV+ mother are usually asymptomatic at birth and do not begin demonstrating signs of immunodeficiency until 2-3 months of life. The mother's antibodies persist for 18 months, so continuing to watch the child closely will be very important. If they start to exhibit signs such as persistent diarrhea, poor feeding, or weight loss, they should see their pediatrician immediately. This is a critical education point for HIV+ mothers. Weight loss is a classic sign of HIV and may not start to show until 2-3 months of life. -No live vaccinations should be administered to an infant until it is confirmed they are HIV negative. This includes MMR (measles, mumps, rubella), smallpox, chickenpox, rotavirus, and yellow fever vaccines. All other vaccines can be administered on schedule.

You are caring for a patient with a new order for nitroglycerin ointment one inch applied to the skin twice a day to prevent angina. To use nitroglycerin correctly, you know to: A. Apply it only to the upper chest B. Rub the ointment into the skin until it disappears C. Rotate the application sites D. Cover the application site with a gauze dressing

C. Rotate the application sites -To apply nitroglycerin correctly, be sure to rotate the application sites with each application to avoid irritation from the medication. The medication comes with a supply of paper applicators with a small ruler on the paper for proper measurement of the drug. Apply the appropriate amount of ointment on the paper and apply the cream to an area of the skin. -Do not rub the cream on the skin until it disappears. Tape the paper into place, and do not cover it with gauze. The cream is usually applied to the chest, back, upper arms, or other torso parts.

Which of the following medication classes are considered quick-relief or rescue medications for a child having an acute asthma attack? Select all that apply. A. Corticosteroids B. Leukotriene modifiers C. Short-acting beta-2 agonists D. Anticholinergics

C. Short-acting beta-2 agonists D. Anticholinergics -Short-acting beta-2 agonists are "rescue" medications used for bronchodilation in an acute asthma attack. Examples include albuterol and salbutamol. A "rescue" medication is the one that can provide relief even after bronchospasm is triggered. Anticholinergics are rescue medications used for the relief of acute bronchospasm. Examples include ipratropium and tiotropium. -Corticosteroids are long term control medications used to reduce inflammation. They are not immediately useful as "rescue" medications but are useful in long term management of persistent asthma.

The nurse is assessing a cardiac rhythm strip with the characteristics shown below. -PR interval: 0.16secs QRS interval: 0.06 secs Rhythm: Regular Rate: 105 The nurse should plan to document this rhythm as which of the following? A. Ventricular fibrillation B. Complete (3rd degree) heart block C. Sinus tachycardia D. Sinus bradycardia

C. Sinus tachycardia -The normal PR interval is 0.12 - 0.20 seconds. The normal QRS interval represents the time for ventricular depolarization. The normal is 0.04 - 0.12 seconds.

When caring for a patient who has impaired hearing, the nurse knows that the best way to approach them is to do which of the following? A. Speak loudly B. Speak quickly C. Speak at a normal volume D. Speak into the impaired ear

C. Speak at a normal volume -The nurse should speak directly to the client and at an average volume. If this method does not work, the nurse should try to express what is being said differently. -Speaking loudly may startle the patient as the nurse approaches.

A client has been prescribed alendronate (Fosamax) 5 mg daily for her osteoporosis. Which teaching would the nurse include to avoid side effects? A. The client should rotate injection sites during administration of medication. B. The client should monitor liver function tests frequently. C. The client should take the medication early in the morning and not lay down until breakfast. D. The client should report any vaginal bleeding.

C. The client should take the medication early in the morning and not lay down until breakfast. -Alendronate is a bisphosphonate that may cause a side effect of esophagitis when the tablet is not completely swallowed. The client should take the drug early in the morning, 30 minutes before eating, and should remain upright during the 30 minutes before eating. -Alendronate is given orally, not through injections.

Your client is a 50-year-old man who sustained an air embolism after the placement of a central venous catheter. You realize the patient was not properly positioned during the procedure. Which of the following could have prevented this incident from happening? A. Supine B. Prone C. Trendelenburg D. Fowlers position

C. Trendelenburg -In this position, the body is supine, or flat on the back, on a 15-30 degree incline with the feet elevated above the head. This position is used to prevent air embolism during central venous cannulation. When placing and removing central venous catheters, the CVP should be raised (to decrease the pressure gradient) by placing the patient in the Trendelenburg position. It should also be ensured that patients are adequately hydrated to prevent hypovolemia and to increase CVP. The Trendelenburg position is also used to increase the venous blood return to the heart when a client is affected with hypotension, hypovolemia, or shock.

The nurse is educating staff on infection control. Which of the following statements by the nurse would indicate a correct understanding of infection control guidelines for influenza? Select all that apply. A. Limiting visitation to 30 minutes per day. B. Keeping the door to the client's room closed. C. Wearing a surgical mask when providing care. D. Placing the client in a room at the end of the hall. E. Cleaning common surfaces with 70% isopropyl alcohol.

C. Wearing a surgical mask when providing care. E. Cleaning common surfaces with 70% isopropyl alcohol. -Infected droplets primarily spread influenza. Wearing a surgical mask when providing care is essential. Finally, cleaning common surfaces with a cleaning agent of at least 70% isopropyl alcohol is important as the influenza virus may survive on these surfaces. -Keeping the client's door closed is reserved for the client on airborne precautions.

The nurse working on a medical-surgical unit has just received a change-of-shift report. The nurse should initially assess the client who is A. receiving treatment for chronic pulmonary emphysema with PaCO2 of 50 mm Hg. B. admitted with pulmonary tuberculosis (TB) and refuses their prescribed isoniazid. C. infected with Clostridium difficile, and is reporting dizziness. D. being treated for acute pyelonephritis and has a temperature of 101.8⁰ F (38.7⁰ C).

C. infected with Clostridium difficile, and is reporting dizziness. -Dizziness is not expected with a C. diff infection. This could be regarded as a complication because the dizziness is likely associated with severe dehydration caused by diarrhea. The nurse needs to follow up with this client because of the potential for further clinical deterioration. -These clients do not require immediate follow-up because a client with pulmonary emphysema would have hypercapnia. Thus, an increase in PaCO2 would be expected.

The nurse supervises a student nurse prepare a client for a magnetic resonance imaging (MRI) test. Which of the following actions by the student nurse would require follow-up by the nurse? The student A. asks the client if they have claustrophobia. B. instructs the client to apply earplugs before the exam. C. moves the nitroglycerin patch from the torso to the back. D. tells the client that they will not have any exposure to radiation.

C. moves the nitroglycerin patch from the torso to the back. -Nitroglycerin transdermal patches should be temporarily removed during the procedure because they may burn the client. The transdermal patch may contain aluminum which is contraindicated for an MRI. Moving the patch would not be helpful as it should be totally removed during the procedure.

The nurse observes a client perform isometric exercises. It would indicate effective understanding if the client A. exercises both extremities simultaneously. B. knows their heart rate should be monitored while exercising. C. practices forced resistance against stable objects. D. swings their limbs through the full range of motion.

C. practices forced resistance against stable objects. -Isometric exercises involve applying pressure against a stable object, like pressing the hands together or pushing an extremity against a wall.

The nurse is educating the client regarding oral contraceptives. All of the following statements by the nurse are true, except: A. "Oral contraceptives are drugs containing combined doses of estrogen and progesterone that stop ovulation." B. "Oral contraceptives increase your risk for thrombophlebitis and hypertension." C. "They are almost 99% effective when taken consistently." D. "They prevent sperm from entering the cervical os."

D. "They prevent sperm from entering the cervical os." -This nurse's statement is incorrect, therefore the correct answer to the question. Oral contraceptives work by stopping the process of ovulation, preventing implantation, and inhibiting sperm travel. -Oral contraceptives increase platelets and clotting factors that increase the woman's risk for thrombophlebitis.

Which of the following clients is at the highest risk for complications related to folate deficiency? A. An 80-year-old man living in a nursing home B. A 4-year-old boy who is developmentally delayed C. A 16-year-old girl who just started her menstrual cycle D. A 25-year-old woman who is attempting to get pregnant

D. A 25-year-old woman who is attempting to get pregnant -Evidence shows that adequate intake of folate before conception and in the first trimester of pregnancy reduces the incidence of neural tube defects. Since folate is not stored in the body in large amounts, your blood levels will get low after only a few weeks of eating a diet low in folate. Folate is found in green leafy vegetables and liver. Groups of people considered at-risk for folate deficiency include women who are pregnant, women who wish to become pregnant, alcoholics, liver disease and dialysis patients, as well as breast-feeding mothers. -All individuals can have deficiencies in folate, however, the client at the highest risk of complications among those listed is the 25-year-old woman who is attempting to conceive.

The nurse is assisting a client of the Orthodox Jewish faith while serving lunch. A kosher meal has been delivered to the client. What is the next appropriate action to perform with this client? A. Substitute plastic utensils with metal utensils B. Unwrapping the eating utensils for the client C. Carefully transferring the food from a styrofoam tray to a ceramic plate D. Allow the client to unwrap the utensils and prepare his own meal

D. Allow the client to unwrap the utensils and prepare his own meal -A person of the Orthodox faith should be able to unwrap the utensils and prepare his meal. -The nurse should not assist or touch the kosher meal in any way.

The most serious adverse effect of tricyclic antidepressant (TCA) overdose is: A. Seizures B. Hyperpyrexia C. Metabolic acidosis D. Cardiac arrhythmias

D. Cardiac arrhythmias -The excessive ingestion of tricyclic antidepressants (TCAs) results in life-threatening wide QRS complex tachycardia. -TCA overdose can induce seizures, but they are typically not life-threatening. TCAs do not cause metabolic acidosis. TCAs do not cause an elevation in body temperature.

The nurse is caring for a client with end-stage renal disease who receives prescribed sevelamer. Which of the following findings would indicate a therapeutic response? A. Decreased serum calcium levels B. Increased hemoglobin and hematocrit C. Decreased serum potassium levels D. Decreased serum phosphorus levels

D. Decreased serum phosphorus levels -Sevelamer is a phosphate binder indicated in the treatment of hyperphosphatemia associated with chronic kidney disease. This medication is purported to decrease serum phosphorus levels by binding to food. Thus, this medication is given with meals. Combined with a low phosphorus diet, the goal of this medication is to decrease serum phosphate levels.

What statement about contractures secondary to immobility is accurate? A. Contractures cannot be prevented because of muscular spasticity. B. Contractures cannot be prevented because of muscular tension. C. Extension contractures are the most commonly occurring contracture. D. Flexion contractures are the most commonly occurring contracture.

D. Flexion contractures are the most commonly occurring contracture. -Fortunately, contractures can be prevented with full joint mobility and range of motion exercises.

A patient was admitted to the ER due to low serum calcium levels. Upon further examination, he demonstrates carpopedal spasms and reports numbness in his lips and hands. An ECG was taken and revealed a prolonged QT interval. Upon assessment of the client, the nurse should suspect which condition? A. Hyperthyroidism B. Hypothyroidism C. Hyperparathyroidism D. Hypoparathyroidism

D. Hypoparathyroidism -Symptoms of hypoparathyroidism mirror that of hypocalcemia. It manifests as numbness and tingling of the lips and hands, tetany, carpopedal spasms (Trousseau's sign), Chvostek's sign, and muscle/abdominal cramps. ECG analysis may reveal a prolonged QT interval and T-wave abnormalities. Because of low serum calcium, serum phosphorus levels may also be increased. -Hypothyroidism results in a general metabolic depression of almost all body systems.Patients with hyperthyroidism display a generalized metabolic excitement in almost all their body systems.

A client is brought to the emergency department after a severe car accident. They need immediate surgery if their life is to be preserved. However, they are unconscious and unable to consent to the operation. Which of the following is the best action? A. Ask a friend who was with the client to sign the consent form. B. Attempt calling a family member to obtain consent. C. Call the on-staff nursing supervisor and request a court order for the surgery. D. Immediately transport the client to the operating department without obtaining consent.

D. Immediately transport the client to the operating department without obtaining consent. -When delaying treatment to a client would result in severe injury or death, consent is not needed. The only other circumstance where treatment of adults does not require approval is if the client declines treatment. -Attempting to contact a family member may be impossible in this situation and will likely delay treatment.

A client who is 28 weeks pregnant is admitted to the gynecology ward for labor induction due to fetal demise. Which of the following substances will be used for the effacement of the client's cervix? A. Normal saline solution B. Oxytocin IV C. Amniotomy D. Laminaria

D. Laminaria -For second-trimester abortions, cervical dilation with the removal of the fetus and placenta is generally performed. To begin this process, dilation is initiated with the insertion of laminaria into the cervix 12 to 24 hours before the procedure into the cervical canal to absorb the cervical secretion. Additionally, laminaria expands and aids in the effacement and dilatation of the cervix. -Oxytocin induces uterine contractions but is not utilized for the effacement of the client's cervix. -An amniotomy is the intentional rupture of the amniotic sac by an obstetrical provider performed during labor to aid in the descent of the fetal head. However, in fetal demise, it does not help in effacing the cervix.

The nurse reviews a client's medical history and identifies a diagnosis of presbycusis. The nurse should integrate which intervention in the care plan? A. Have educational materials in large print B. Provide an eye patch to the affected eye C. Request food be seasoned with herbs D. Move closer to the better-hearing ear

D. Move closer to the better-hearing ear -Presbycusis is a type of sensorineural hearing loss associated with aging. Sensorineural hearing loss is often permanent. Interventions for a client with this type of hearing loss include speaking in the ear less affected, speak clearly and slowly, avoid shouting, and ensure that the environment is well lit while conversing.

An RN is in charge of the unit with an LPN. Which situation indicates proper delegation of tasks by the RN? A. The RN delegates to the LPN to check the circulation of the child with a forearm cast. B. The LPN is tasked to feed a one-year old that just had a cleft palate repair. C. The LPN demonstrates urinary catheterization to the mother of a child with neurogenic bladder. D. The RN checks if the LPN completed all delegated tasks.

D. The RN checks if the LPN completed all delegated tasks. -It is the responsibility of the nurse to evaluate and check if the delegated tasks to the LPN have been performed. -The LPN cannot assess a client -The child has just undergone a cleft palate repair. There is a risk for the child to damage his incision site and aspirate if he/she is fed by untrained personnel. -Demonstrating a procedure to the mother is similar to educating or teaching the client. The LPN is not allowed to perform teaching/education.

Which of the following outcome statements would be most appropriate for a newly hospitalized client experiencing an impairment of the second cranial nerve (CN II)? A. The client will not experience sensory overload in the hospital. B. The client will list ways to effectively decrease their blood pressure. C. The client will participate in physical therapy to improve balance. D. The client will remain free of falls while hospitalized.

D. The client will remain free of falls while hospitalized. -The optic nerve is the second cranial nerve (CN II) responsible for transmitting visual information. Compromise of the CN II results in visual field defects and/or visual loss. As a result, the client's vision will be impaired, and fall risk will increase. "The client will remain free of falls while hospitalized" is an appropriate outcome statement for a newly hospitalized client experiencing a CN II impairment, as the client's current visual impairment places the client at high risk of falls, the client's safety is a priority under Maslow's hierarchy of needs, and this nursing diagnosis includes a clear, measurable outcome.

What are the expected fundal assessment findings for a woman who delivered a set of twins one hour ago via Cesarean section? The fundus is hard, midline, and 1-2 fingerbreadths above the umbilicus. B. The fundus need not be assessed because of the C-section. C. The fundus is to the right of the umbilicus and soft. D. The fundus is hard, midline, and at the level of the umbilicus.

D. The fundus is hard, midline, and at the level of the umbilicus. -Regardless of the mode of delivery, this is the normal postpartum fundus at one to two hours. Immediately after delivery and expulsion of the placenta, the uterus is about the size of a grapefruit and is located midline in the abdomen, halfway between the umbilicus and the symphysis pubis. Over the next several hours, the fundus will rise on the midline of the stomach to the level of or slightly above the umbilicus. Subsequently, the height of the fundus decreases by at least 1 cm or one fingerbreadth daily as the uterus goes through the process of involution. By the 10th day, the fundus is usually not palpable. -The fundus should not be to the right of the midline or soft within a few hours after delivery. Right or leftward deviation indicates bladder distension.

While working in the Neonatal Intensive Care Unit (NICU), you are notified that a "small for gestational age" infant is being brought to the unit. Being a NICU nurse, you understand that this means which of the following? A. The infant's weight is less than 2500 grams. B. The infant's weight is below the 20th percentile. C. The infant's weight is less than 1500 grams. D. The infant's weight is below the 10th percentile.

D. The infant's weight is below the 10th percentile. -The term "Small for Gestational Age (SGA)" is used when the infants are smaller than normal for the number of weeks of pregnancy (gestational age). When an infant's weight is below the 10th percentile for the gestational age, it is considered small for gestational age -Not all "Low Birth Weight" babies are SGA. Infants may be of low birth weight but may still fall above the 10th percentile for gestational age.

The nurse is caring for a 4-day post-abdominal surgery client. The nurse notes a temperature of 37 °C, no complaints of pain at the incision site, dry wound dressing, and hypoactive bowel sounds on all quadrants. Which conclusion can the nurse make based on all the assessment data? A. The client's wound is getting infected. B. The nurse should implement pain relief measures. C. There are no present problems for the client. D. The nurse should perform an additional GI assessment.

D. The nurse should perform an additional GI assessment. -The client had abdominal surgery and has hypoactive bowel sounds. The nurse needs to do a further assessment to determine if there are any impending GI problems for the client and if any treatments need to be initiated.

During a 12-hour shift on a medical-surgical unit, nurses are assigned a specific task applicable to all clients within the unit. On this shift, one nurse is assigned to perform wound care and dressing changes for those clients requiring these services, one nurse is assigned to dispense medications to all clients, and one nurse is assigned to monitor the vital signs and assist with all other nursing care. Which nursing delivery system does this example exemplify?

Functional nursing -involves assigning each nurse with a specific task to perform for the shift. More specifically, a functional nursing delivery system ("functional nursing"), also known as task nursing, focuses on the distribution of work based on the performance of tasks and procedures, where the target of the action is not the client but rather the task. This is a task-focused method of nursing.