SIMCLEX
While reviewing home medications with a client that has Marfan Syndrome, which medication would the nurse expect the client to be taking? A) Ace Inhibitors B) Anti-Marfan medication C) Vasopressers D) Anticoagulation medication
A A) Ace Inhibitors Clients with Marfan Syndrome are at risk for an enlarged aorta and need to take blood pressure lowering medications to prevent further enlarging the aorta. They can take Ace inhibitors, Beta blockers, and/or calcium channel blockers. B) Anti-Marfan medication This is not a specific class of drugs. C) Vasopressers Vasopressors would increase blood pressure, which would be the opposite of the desired effect for these clients. D) Anticoagulation medication Anticoagulants are not necessary for Marfan Syndrome, they do not have issues with clotting. The goal is to lower blood pressure.
A client with severe, uncontrolled hypertension is being evaluated for chronic kidney disease. The provider checks the glomerular filtration rate and determines that it is 22 mL/min. Which stage of chronic kidney disease does this GFR place the client? A) Stage IV B) Stage I C) Stage II D) Stage III
A A) Stage IV The glomerular filtration rate (GFR) is a measure of kidney function that determines how well the kidney is able to filter waste products. A normal GFR is approximately 125 mL/minute. A client who has a GFR of 22 mL/min would be categorized as having severe kidney disease and would be classified at stage IV. B) Stage I Stage I GFR is >90 mL/minute. C) Stage II Stage II GFR is 60-89 mL/min. D) Stage III Stage III is 30-59 mL/min. Stage IV is 15-29 mL/min. Stage V is <15 mL/min.
A client arrives to the emergency room suffering from a crush injury. The client presents with symptoms of compartment syndrome. Which of the following symptoms is the most common sign that would lead the nurse suspect compartment syndrome? A) Unproportionate pain B) Paresthesia C) Pulselessness D) Paralysis
A A) Unproportionate pain Pain that is not in proportion to the injury is the most common sign of compartment syndrome and the most consistent sign of compartment syndrome. Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells. B) Paresthesia Paresthesia may be present, but it is not the most common sign. C) Pulselessness This does occur but is a late sign and is the least reliable sign of compartment syndrome because pulselessness can be present with so many other conditions. D) Paralysis Paralysis is not the most common sign of compartment syndrome and it may not be evident despite deep tissue death.
The nurse caring for a child with gastroenteritis and mild dehydration knows that it is important to use an oral rehydration solution for rehydration in order to prevent which of the following? Select all that apply. A) Hypoglycemia B) Hyponatremia C) Hypokalemia D) Malnutrition E) Aspiration
A,B&C A) Hypoglycemia Oral rehydration solution contains glucose and children with gastroenteritis may become hypoglycemic if they are unable to keep any food down. B) Hyponatremia Rehydrating with water instead of an oral rehydration solution will over dilute the sodium in the body resulting in hyponatremia. Oral rehydration solutions contain sodium to help prevent this. C) Hypokalemia A child who is vomiting and having loose stools is at risk for being hypokalemic. Oral rehydration solutions contain potassium to help prevent this. D) Malnutrition Oral rehydration solutions are not designed to address malnutrition as they do not contain enough calories to help prevent this. E) Aspiration Oral rehydration solutions will not prevent aspiration.
A nurse works in a hospital that has developed a culture of safety as described by the Joint Commission. Which elements would be included as part of developing this type of environment? Select all that apply. A) Safety is everyone's first priority B) Behaviors that undermine the culture of safety are addressed in a non-punitive way C) Staff are committed to promptly changing unsafe conditions D) Workers report each other's mistakes to best learn from them E) The building's security systems are available throughout the day
A,B&C A) Safety is everyone's first priority B) Behaviors that undermine the culture of safety are addressed in a non-punitive way. To develop a culture of safety, the hospital would ensure that safety is a priority and educate others about the importance of upholding safe practices in a non-punitive environment. When staff members don't feel afraid to report their own errors, it results in an increased reporting of errors, and a better chance to address and fix them. This greatly increases safety in an organization. C) Staff are committed to promptly changing unsafe conditions D) Workers report each other's mistakes to best learn from them. The goal of a non-punitive safety culture is for a staff member to report their own mistakes. E) The building's security systems are available throughout the day The security system is not related to the safety culture as described by the Joint Commission. Rather than physical building security,
The nurse is educating a client with Meniere's disease who is recommended to follow the Hydrops diet. Which of the following are guidelines included in this diet? Select all that apply. A) Even food intake through the day B) Limiting alcohol intake C) Avoiding foods with MSG D) Avoid high salt content D) Double fiber intake
A,B,C&D A) Even food intake through the day B) Limiting alcohol intake C) Avoiding foods with MSG D) Avoid high salt content D) Double fiber intake
The nurse is talking with new parents about newborn reflexes. The mother wants to know when they should expect their baby to lose the tonic neck reflex. Which of the following is an appropriate answer for the nurse to give? A) 5-6 months B) 6-7 months C) 8-12 months D) 2 years
B A) 5-6 months B) 6-7 months The tonic neck reflex, or fencing reflex, involves the infant turning the head to one side while the arm on that side extends and the opposite arm flexes. Babies lose their tonic neck reflex at about 6-7 months. C) 8-12 months D) 2 years
A 67-year-old client tells the nurse that he used to run marathons, but no longer has the stamina to run as far. Which of the following changes in exercise tolerance are associated with the aging process? Select all that apply. A) Increased total body water B) Decreased lean muscle mass C)Increased oxidative capacity D) Decreased testosterone secretion E) Increased bone loss
B, D&E B) Decreased lean muscle mass As a person ages, stamina and ability to exercise is decreased. The normal aging process results in decreased muscle mass, decreased hormone secretion, and increased bone loss that can negatively impact a person's ability to exercise. D) Decreased testosterone secretion This contributes to decreased ability to exercise with age. E) Increased bone loss This contributes to decreased ability to exercise with age.
Which has been shown to be a benefit of minimally invasive cardiac surgery? Select all that apply. A) Decreased risk of hyperglycemia B) Smaller scars C) Decreased risk of infection D) Decreased length of stay E) Fewer anesthesia drugs to administer
BCD A) Decreased risk of hyperglycemia A client undergoing a minimally invasive cardiac surgery will still be under a considerable amount of bodily stress as with other surgeries, and glucose levels can change as a result of this stress. B) Smaller scars C) ecreased length of stay A client recovering from MICS typically has a decreased length of stay when compared to standard cardiac surgery. D) Decreased length of stay A client recovering from MICS typically has a decreased length of stay when compared to standard cardiac surgery. E)
A nurse is caring for a 5-year-old child who has been diagnosed with bronchiectasis. Based on the nurse's understanding of this condition, the nurse knows to expect signs and symptoms of which of the following? A) Chronic cough that produces green sputum B) Wheezing and a barrel chest C) Sharp chest pain with each breath D) Absence of respiratory effort
A A) Chronic cough that produces green sputum Bronchiectasis is a lung condition that causes permanent dilation of the bronchi, resulting in breathing difficulties and pooling of sputum in the bronchial tree that can progressively worsen. The nurse should assess for signs and symptoms of a productive cough with thick or green sputum. Occasionally, the client may also cough up blood. As the disease progresses, sputum production tends to increase. B) Wheezing and a barrel chest Rather than describing bronchiectasis, this answer describes symptoms of chronic obstructive pulmonary disease (COPD). C) Sharp chest pain with each breath This describes symptoms of a pulmonary embolism. D) Absence of respiratory effort This describes apnea, not bronchiectasis.
A client recently had surgery on the lower back and the provider has left orders for the nurse to remove the sutures. The nurse notes that the client has retention sutures in place in the incision. Which of the following interventions by the nurse is most appropriate? A) Contact the provider B) Pull up on the stitch and cut on the same side as the knot C) Push down in the center of the stitch before cutting the suture next to the skin D) Leave the sutures in place to dissolve
A A) Contact the provider A provider, when closing a wound, may use various types of sutures. In some instances, the nurse may remove the sutures or staples as the provider orders. Retention sutures are a type of suture that are often placed to relieve tension on the primary suture line that holds the wound closed. Retention sutures are non-absorbable and are nearly always removed by the surgeon and not the nurse. If the nurse receives an order to remove them, there should be a call made to clarify with the provider first. B) Pull up on the stitch and cut on the same side as the knot C) Push down in the center of the stitch before cutting the suture next to the skin D) Leave the sutures in place to dissolve
A client is admitted to the hospital after falling at home. The nurse case manager reviews the client's information and meets with the client to discuss healthcare needs. Which of the following describes what the nurse case manager would perform during the planning stage of the case management process? A) Finding the least restrictive level of care for the client B) Informing the interdisciplinary team about the client's background C) Contacting a pastor to meet with the client D) Collecting outcomes data about the client
A A) Finding the least restrictive level of care for the client The planning stage of the case management process is somewhat similar to the planning stage of the nursing process, in that the nurse has intentions for the client's care. When planning for client care services, the nurse case manager should find the least restrictive level of care for the client that would still allow the most independence possible for the health condition. B) Informing the interdisciplinary team about the client's background This is not related to the planning stage of the case management process. C) Contacting a pastor to meet with the client This is not related to the planning stage of the case management process. D) Collecting outcomes data about the client This is not related to the planning stage of the case management process.
The nurse obtains a set of vital signs on a client with asthma. Results are: respirations 22, pulse 95, oxygen saturation 84% on 6 liters nasal cannula, blood pressure 130/85. Which of the following actions should the nurse perform next? A) Increase the client's oxygen to 7 liters and call respiratory therapy B) Instruct the client to perform pursed-lip breathing and re-check the oxygen saturation C) Reduce stimulation in the room and ask the client to take slow, deep breaths D) Administer PRN blood pressure medication and re-check vital signs after 30 minutes.
A A) Increase the client's oxygen and call respiratory therapy The respiratory therapist should be informed when a client's oxygen needs increase above 6 liters. B) Instruct the client to perform pursed-lip breathing and re-check the oxygen saturation This client may or may not be experiencing shortness of breath. C) Reduce stimulation in the room and ask the client to take slow, deep breaths The scenario is not clear on whether there is increased stimulation in the room. D) Administer PRN blood pressure medication and re-check vital signs after 30 minutes. The client's blood pressure is pre-hypertensive, but this is not the main concern of the nurse.
A nurse is caring for an immobile client who is African American. The nurse is assessing the client's skin for signs of breakdown and is having difficulty determining if the client has developed a stage I pressure ulcer. Which best describes the nurse's action to determine skin breakdown in a client with dark skin tones? A) Look at the affected area for signs of induration B) Assess capillary refill at the level below the suspected area of injury C) Assess the peripheral extremities for rash or raised areas D) Look for areas that appear gray or yellow in color
A A) Look at the affected area for signs of induration The initial signs of redness and nonblanchable skin are not necessarily noted in this population. Instead, the nurse should look for areas that are blue-black in color, appear shiny, or demonstrate induration (hardness). B) Assess capillary refill at the level below the suspected area of injury The nurse must assess the suspected area, not the area surrounding the suspected area. C) Assess the peripheral extremities for rash or raised areas The area at risk for a pressure ulcer injury is where the nurse must focus on the assessment, rather than peripheral extremities. D) Look for areas that appear gray or yellow in color In the client with darker skin tones, the nurse should look for blue-black color and other signs, such as induration and shine.
A nurse is preparing to discharge a client with bronchitis to home from the hospital. The nurse has the client demonstrate that he understands how to use his inhaler appropriately. After successfully demonstrating use of the inhaler, the nurse says, "You seem pretty confident about using that inhaler." This is an example of which type of therapeutic communication? A) Making observations B) Giving recognition C) Active listening D) Offering hope
A A) Making observations When using therapeutic communication, a nurse may make observations about the client's behavior or actions. B) Giving recognition An example of giving recognition is the following statement; "I noticed you took all your medications." C) Active listening An example of active listening occurs when the nurse encourages the client to continue to talk, with nodding and statements such as, "I see." D) Offering hope An example of offering hope is the following statement; "I will be here to help you get through this.
A 25-year-old client is undergoing a CA-125 test for detection of increased cancer antigens. The CA-125 test would most likely be associated with detecting which type of cancer? A) Pancreatic cancer B) Leukemia C) Basal cell carcinoma D) Thyroid cancer
A A) Pancreatic cancer CA-125 is a type of cancer antigen that can be detected in the blood through a lab test. The CA-125 test demonstrates the presence of a biomarker, which is associated with certain types of cancer. Some of the types of cancer that this test can detect include ovarian, breast, liver, pancreatic, stomach, colon, and lung cancers. B) Leukemia C) Basal cell carcinoma D) Thyroid cancer
A hospitalized client has been diagnosed with Grave's disease. The nurse knows that the most common treatment for this condition is which of the following? A) Radioactive iodine B) Thyroxine C) Triiodothyronine D) ACTH
A A) Radioactive iodine Grave's disease is an autoimmune disorder in which the thyroid is producing too much thyroid hormone. The most common first-line treatment for Grave's disease is radioactive iodine. The goal of radioactive iodine treatment is hypothyroidism due to destruction of the thyroid gland. B) Thyroxine This is a thyroid hormone, which is contraindicated in Grave's disease. C) Triiodothyronine This is also a thyroid hormone, which is contraindicated in Grave's disease. D) ACTH ACTH is also known as adrenocorticotropic hormone, is a pituitary hormone that regulates cortisol in the body.
A nurse is educating a group of pregnant clients on the risks of taking ibuprofen during pregnancy. A client asks why the fetus has holes in its heart. What is the most appropriate explanation of the purpose for the ductus venosus? A) Shunts blood to the brain quickly by bypassing the liver B) Shunts blood from the brain to the rest of the fetus C) Delivers oxygenated blood to the liver from the umbilical vein D) Shunts blood from the umbilical artery to the inferior vena cava
A A) Shunts blood to the brain quickly by bypassing the liver The ductus venosus shunts blood to bypass the fetal liver which delivers the blood quickly to the brain. B) Shunts blood to the brain quickly by bypassing the liver The ductus venosus shunts blood to bypass the fetal liver which delivers the blood quickly to the brain. C) Delivers oxygenated blood to the liver from the umbilical vein The liver is bypassed in fetal circulation. D) Shunts blood from the umbilical artery to the inferior vena cava Blood comes through the umbilical vein to the inferior vena cava, not the umbilical artery.
The nurse caring for a four-year-old knows that preschoolers sometimes have magical thinking. The nurse accurately adapts nursing care in which of the following ways? Choose the best answer. A) Stating directly that procedures are never a form of punishment B) Using fairy tale stories as a distraction C) Involving the child with the procedure by allowing the child to choose what color bandage to have D) Allowing the parents to remain at the bedside and hold the child's hand
A A) Stating directly that procedures are never a form of punishment The nurse is addressing the fact that a preschooler may think that what is happening is a punishment for a bad thought he or she had earlier in the day. B) Using fairy tale stories as a distraction Even though stories may help distract the child, it doesn't address their concerns and anxieties that stem from magical thinking. C) Involving the child with the procedure by allowing the child to choose what color bandage to have Allowing a child to make decisions about their care is important, but this does not address their belief that their thoughts can make things happen. D) Allowing the parents to remain at the bedside and hold the child's hand It doesn't address the particular cognitive stage of the preschooler.
A 28-year-old client with no history of heart disease asks the nurse about whether to have cholesterol checks and how often this should be monitored. Which answer from the nurse is correct? A) We will check it now. Cholesterol should be checked every 4 to 6 years since you are low risk B) You do not need to have your cholesterol checked until you are 40 since you are low risk C) Once you turn 30, you should have your cholesterol checked with each physical exam D) You will need to have it checked now. Cholesterol should be checked every 6 months
A A) We will check it now. Cholesterol should be checked every 4 to 6 years since you are low risk Because high cholesterol levels contribute to atherosclerosis, a client should be checked periodically to ensure that cholesterol levels remain within normal limits. A client without a history of heart disease or cholesterol problems should have their cholesterol checked starting at age 20 and then routinely every 4 to 6 years. B) You do not need to have your cholesterol checked until you are 40 since you are low risk C) Once you turn 30, you should have your cholesterol checked with each physical exam D) You will need to have it checked now. Cholesterol should be checked every 6 months
A nurse arrives on the unit to receive bedside report on a client. When the nurse enters the room the client is assessed to be in pulseless ventricular tachycardia/ventricular fibrillation (VT/VF). The nurse knows to give which two medications to help the client? Select all that apply A) Amiodarone B) Epinephrine C) Adenosine D) Shock the client
A&B A) Amiodarone Amiodarone is an antiarrhythmic drug. It is used during pulseless VT/VF events. B) Epinephrine This is an adrenergic agonist is used during pulseless VT/VF events. C) Adenosine This antiarrhythmic is used during tachycardiac events (with a pulse). D) Atropine This anticholinergic is used during unstable bradycardic events. E) Shock the client Shocking the client might occur in this state but it is not a medication.
The nurse is caring for a client who has a history of DVTs who delivered a baby earlier in the shift. During the assessment, the nurse notices the client's right posterior tibial and dorsalis pedis pulses are diminished. Which of the following interventions would NOT be appropriate at this time? Select all that apply. A) Massaging the area B) Ambulation C) Heat packs D) Notifying the provider E) Obtaining a full set of vitals
A&B A) Massaging the area Massaging a potential clot is never indicated. This increases the risk that the clot dislodges. B) Ambulation Ambulation increases the risk that this clot move to another area of the body, C) Heat packs Giving the client a heat pack is NOT contraindicated in this situation. The heat pack is for symptom relief, and will not actually treat the clot, but it is appropriate if it provides relief to the client. D) Notifying the provider This is an appropriate action. E) Obtaining a full set of vitals This is fully appropriate for the situation.
A nurse had to write an incident report after accidentally administering insulin to a client, even though no harm was done. Which persons should receive a copy of the incident report after it is complete? Select all that apply. A) The facility risk management nurse B) The unit's quality assurance council C) The nurse involved in the incident D) The client's family E) The maintenance and engineering department
A&B The facility risk management nurse B) The unit's quality assurance council C) The nurse involved in the incident D) The client's family E) The maintenance and engineering department
A nurse is getting ready to start an IV on a client who needs fluids and medications. Which of the following must the nurse consider when choosing a vein to use for an IV on a client? Select all that apply. A) Avoid using a vein in an extremity that has a dialysis fistula B) Keep the client's extremity raised above the level of the heart before starting the IV C) Start the IV distally to provide additional site options if the attempt is unsuccessful D) If having difficulty finding a vein to use, place an ice pack on the extremity E) Shave excessive hair over a potential IV site if the hair is too thick
A&C A) Avoid using a vein in an extremity that has a dialysis fistula (When attempting to start an IV, it is important for the nurse to consider the site carefully. If the patient has a dialysis fistula, edema, a restricted extremity due to a mastectomy or infected skin, the area should be avoided. It is also useful to consider if the patient is left or right-handed when selecting the site.) C) Start the IV distally to provide additional site options if the attempt is unsuccessful (The best practice is to start the IV distally, because this leaves the rest of the extremity available for an IV if the attempt is unsuccessful.)
A nurse is caring for a client who is seeking care for symptoms of serotonin syndrome. The client has a prescription for citalopram. Which of the following substances, when combined with this medication, would most likely lead to serotonin syndrome? Select all that apply. A) Bupropion B) Esomeprazole C) Naproxen D) Oxycodone
A&D A) Bupropion Serotonin syndrome occurs when an antidepressant is taken in combination with certain other drugs including; antidepressants, opioids, and/or migraine medications. Serotonin syndrome occurs when drugs interact to cause excessive accumulation of serotonin in the body. This syndrome leads to symptoms of agitation, confusion, muscle rigidity, and headache. B) Esomeprazole It does not effect serotonin levels. C) Naproxen It is an NSAID, which does not effect serotonin levels. D) Oxycodone Serotonin syndrome occurs when an antidepressant is taken in combination with certain other drugs including; antidepressants, opioids and/or migraine medications. Serotonin syndrome occurs when drugs interact to cause excessive accumulation of serotonin in the body. This syndrome leads to symptoms of agitation, confusion, muscle rigidity, and headache.
A client asks the nurse why he has a diagnosis of presbyopia. Which statement accurately explains the condition? Select all that apply A) It happens when the lens becomes less flexible B) It happens when the iris doesn't completely open C) It happens when the lens is blocked by a cataract D) It happens when optic blood vessels become engorged E) It can be corrected with special glasses
A&E A) It happens when the lens becomes less flexible Presbyopia happens when the lens becomes less flexible, disallowing the muscle surrounding the lens to contract to see things close up, affecting vision. It is a normal part of aging and can be corrected with special glasses. B) It happens when the iris doesn't completely open This is not causes of presbyopia. C) It happens when the lens is blocked by a cataract This is not causes of presbyopia. D) It happens when optic blood vessels become engorged This is not causes of presbyopia. E) It can be corrected with special glasses Presbyopia happens when the lens becomes less flexible, disallowing the muscle surrounding the lens to contract to see things close up, affecting vision. It is a normal part of aging and can be corrected with special glasses.
The nurse is caring for a client who is recovering from a stroke. The nurse notes the client has developed neglect syndrome. Which of the following signs does the nurse observe to come to this conclusion? Select all that apply. A) The client exclusively uses the unaffected side of the body B) The client verbalizes a decreased sensation to heat and cold C) The client turns their head to scan the room rather than moving their eyes D) The client refuses to utilize adaptive equipment for transfers E) The client's affected upper limb remains motionless during a meal
A&E A) The client exclusively uses the unaffected side of the body A client with neglect syndrome demonstrates a lack of awareness of the affected side of the body. B) The client verbalizes a decreased sensation to heat and cold This is an assessment finding when the client is having a stroke. C) The client turns their head to scan the room rather than moving their eyes This is an appropriate finding in a client who has blindness in half their visual field following a stroke. D) The client refuses to utilize adaptive equipment for transfers The client who has experienced a stroke and is in the chronic phase may refuse to take part in some interventions. E) The client's affected upper limb remains motionless during a meal This demonstrates neglect of the affected side.
A nurse is caring for a laboring client who experienced PROM over 24 hours ago. Which findings would indicate the mother is experiencing complications of this? Select all that apply. A) Fetal heart rate 170 bpm B) Maternal heart rate 102 bpm C) Maternal temperature of 101°F D) Early decelerations E) Contractions every 2-5 minutes
A,B&C A) Fetal heart rate 170 bpm Having PROM over 24 hours ago puts the client at risk for infection. An elevated fetal heart rate would be a sign of infection. B) Maternal heart rate 102 bpm Having PROM over 24 hours ago puts the client at risk for infection. An elevated maternal heart rate could be a sign of this. C) Maternal temperature of 101°F PROM 24 hours ago means the client could develop infection. A maternal fever would be indicative of this. D) Early decelerations This is simply caused by head compression during contractions and is not a sign of complications of PROM - Late decelerations would show fetal distress from possible infection. E) Contractions every 2-5 minutes This is not a complication of PROM and is expected as labor progresses.
A client is suffering from excess cortisol excretion as a result of an adenoma on the pituitary gland. Which of the following changes is an expected finding in a client with this condition? Select all that apply. A) Increase in the number of stretch marks B) Skin that bruises easily C) Fatty tissue deposits in the face and upper back D) Swelling in the neck and throat E) Lesions on the peripheral extremities
A,B&C A) Increase in the number of stretch marks Skin changes that may be seen with excess cortisol include purple stretch marks, easy bruising, weight gain, fatty tissue deposits in the midsection, upper back and face, excess body hair in women, and decreased fertility in men. B) Skin that bruises easily Excess cortisol leads to easily bruised skin. C) Fatty tissue deposits in the face and upper back Excess cortisol production can causes, including obesity and fatty tissue deposits on the face and upper back. D) Swelling in the neck and throat Swelling in the neck and throat would indicate an emergency situation and require immediate medical attention. E) Lesions on the peripheral extremities Excess cortisol secretion does not cause lesions.
The nurse is caring for a client who has a kidney stone. Which of the following foods should the nurse teach the client to avoid? Select all that apply. A) Milk B) Potato chips C) Chocolate D) Rice E) Grapes
A,B&C A) Milk Stones are mainly made out of phosphorus, calcium and vitamin D, purines, and proteins. The nurse should teach the client to avoid dairy products, sodium, oxalated products such as spinach, soda, teas, and chocolate as well as foods with vitamin D. B) Potato chips Potato chips contain oxalate and therefore contribute to kidney stones. C) Chocolate Chocolate contains oxalate which contributes to kidney stones. D) Rice This does not cause calculi. E) Grapes These do not cause calculi.
The nurse is performing a focused lung assessment on a client. The client is experiencing respiratory distress and the nurse notes wheezing upon auscultation. Which of the following treatments would be helpful for this client? Select all that apply. A) Oral steroid administration B) Inhaled bronchodilator administration C) Supplemental oxygen D) Suctioning E) Supine positioning
A,B&C A) Oral steroid administration Wheezing indicates inflamed airways. Oral steroids will reduce inflammation, so they are an appropriate treatment for this client. B) Inhaled bronchodilator administration Bronchodilators are used to open airways and reduce inflammation. This is a desired outcome for a client who is wheezing and experiencing respiratory distress. C) Supplemental oxygen A client in respiratory distress will benefit from supplemental oxygen. Wheezing means the client is having difficulty moving air in and out of the lungs, so additional oxygen is helpful to increase gas exchange at the alveolar level. D) Suctioning E) Supine positioning Supine positioning will not help a client who is wheezing and in respiratory distress. Instead, sitting the client upright or in the tripod position will decrease the work of breathing.
A nurse is providing a complete bed bath for a client who is in the hospital. Which of the following steps would be included as part of a complete bed bath? Select all that apply. A) Position the bed flat, if possible B) Protect the client's privacy by closing the door C) Cover the client with a bath blanket D) Remove only one piece of clothing or jewelry at a time E) Start at the client's lower legs and move toward the head
A,B&C A) Position the bed flat, if possible The nurse should try to position the bed flat. B) Protect the client's privacy by closing the door The nurse should protect the client's privacy by closing the door and keeping the client covered, providing a clean gown at the end of the bath. C) Cover the client with a bath blanket A complete bed bath is an option for bathing for many clients who cannot get out of bed to get to a shower. The nurse should try to position the bed flat if the client can tolerate this. The nurse should protect the client's privacy by closing the door and keeping the client covered, providing a clean gown at the end of the bath. D) Remove only one piece of clothing or jewelry at a time The client should have all clothing removed. E) Start at the client's lower legs and move toward the head The nurse cleanses the client from the head down, cleaning the client's genital area last.
A nurse mistakenly administered heparin after reading the order incorrectly, and the client started bleeding uncontrollably. The nurse is documenting the occurrence. Which elements should be included as part of documentation in this situation? Select all that apply. A) The nurse involved in the occurrence B) The exact details of the occurrence C) The time the client's family was notified of the incident D) The place where the incident report is filed in the chart E) The name of the provider who was notified
A,B&E A) The nurse involved in the occurrence When documenting an adverse event, the nurse can best be protected by accurately and thoroughly describing the situation. This includes the date and time of the event, who was involved in the situation, what happened to the client, and how the situation was handled. B) The exact details of the occurrence C) The time the client's family was notified of the incident The incident report should include that the client's family was notified if the client has a decision maker other than him or herself. D) The place where the incident report is filed in the chart The incident report is never filed in the client's chart. E) The name of the provider who was notified
A nurse must position the client prone after a diagnosis of acute respiratory distress syndrome (ARDS). Which of the following is a benefit of using this position? Select all that apply. A) Decreased atelectasis B) Reduced need for endotracheal intubation C) Mobilization of secretions D) Decreased pleural pressure E) Increased response to corticosteroid therapy
A,C&D A) Decreased atelectasis The prone position reduces pressure on the lungs. When there is less pressure exerted on the lungs, atelectasis decreases. B) Reduced need for endotracheal intubation The prone position has not been shown to decrease the likelihood of intubation. C) Mobilization of secretions Studies have shown that many clients in the prone position have increased lung secretions, which improves oxygenation. D) Decreased pleural pressure When the client is placed in prone position, the heart and diaphragm are not pressing against the lungs, which means that pleural pressure is reduced. E) Increased response to corticosteroid therapy Positioning does not change the body's response to steroid therapy.
A nurse is working at a family care clinic in the community. The nurse sees many different types of family structures among the clients who come into the clinic. Which of the following answers constitute a blended family? Select all that apply. A) Stepsiblings in the family who do not share a biologic parent B) Couples who are together after a previous divorce or death of a spouse C) Couples who are together after a previous divorce or death of a spouse D) Couples who are together after a previous divorce or death of a spouse E) A couple gives birth to a child who becomes a half-sibling to the other children
A,C&E A) Stepsiblings in the family who do not share a biologic parent A blended family is one in which there are children from a previous parent who is no longer in the picture, due to various reasons including divorce and remarriage, or death and remarriage. B) Couples who are together after a previous divorce or death of a spouse A couple in which one or both was previously married does not constitute a blended family because there are no children. C) A spouse who formally adopts the stepchildren This constitutes a blended family. D) A traditionally extended family This simply includes other family members such as grandparents, aunts and uncles. This does not constitute a blended family. E) A couple gives birth to a child who becomes a half-sibling to the other children This constitutes a blended family.
A nurse who works in the post anesthesia care unit has just received a client from surgery. Which tasks are most important for this nurse to perform during the client's immediate post-op phase in the recovery room? Select all that apply. A) Pain management B) Ambulation C) Residual narcosis D) Control of hemorrhage E) Voiding
A,C,&D A) Pain management The goal of the nurse caring for a client post-anesthesia care unit (PACU) is to stabilize the client, monitor for complications, control pain, and monitor airway, breathing and circulation. B) Ambulation Ambulating is not a priority in the immediate post-operative phase. C) Residual narcosis Residual narcosis is continued unconsciousness. The nurse also observes the client for signs that they are awakening, and will make frequent attempts to awaken the client. D) Control of hemorrhage Post-operatively, the client is at risk for hemorrhage, so the nurse will monitor the surgical site for signs of bleeding. E) Voiding In the immediate post-operative phase, the nurse focuses on stabilizing the client and returning the client to consciousness.
A nurse is preparing to administer two types of insulin to mix together for administration. The first vial has intermediate acting insulin and is cloudy. The second vial has short acting insulin and is clear. Which of the following principles of administration is related to drawing up the medication from the second vial? Select all that apply. A) The nurse should first inject air into the vial B) The nurse should draw up the exact same amount of medication from the second vial as from the first vial C) The nurse should inject the medication from the first vial into the second vial D) The nurse should draw up medication from the second vial before the first vial E) The nurse should inject air into the first vial and then the second vial
A,D&E A) The nurse should first inject air into the vial There is a specific method of mixing clear and cloudy insulin correctly. The nurse should inject air into the first vial (intermediate or long acting insulin, cloudy) and then the second vial (short acting insulin, clear). B) he nurse should draw up the exact same amount of medication from the second vial as from the first vial Based on the diabetic person's response to insulin and their blood glucose level, there will be a specific amount of each type of insulin to be administered. C) The nurse should inject the medication from the first vial into the second vial The two types of insulin should not be mixed except in the syringe, right before administration. D) The nurse should draw up medication from the second vial before the first vial E) The nurse should inject air into the first vial and then the second vial
A nurse is caring for a client who has a nasogastric tube in place and is receiving enteral feedings. The nurse must administer formula to the client that has been prepared by the hospital dietary staff and consists of milk-based, blenderized foods. This type of formula is known as: A) Polymeric formula B) Specialized formula C) Modular formula D) Elemental formula
B A) Polymeric formula There are four main types of enteral nutrition formulas, which are elemental, semi-elemental, polymeric, and specialized. The type of formula prescribed is based on the client's nutritional needs and whether there is pre-existing malnutrition. Polymeric formulas are typically created from regular foods that have been mixed in a blender. They contain complete nutrition. B) Specialized formula This type of formula is specialized according to a specific health condition, like renal disease. C) Modular formula This type of formula is used as an addition to other foods. It is not nutritionally complete, and the combination of ingredients varies. D) Elemental formula This type of formula is nutritionally complete, and the protein and fat are broken down to their simplest form so they are easy to digest.
The nurse is caring for a 35-year-old client who reports a history of syphilis infection discovered at age 25. The nurse knows that which of the following is true regarding syphilis at this stage? A) The client can begin treatment with IV penicillin and become cured B) The client can begin treatment with IV penicillin and become cured C) The client can no longer spread the infection to their child in utero D) The client will have chancre-like sores in the genital area
B A) The client can begin treatment with IV penicillin and become cured At this stage, PCN treatment will only decrease progression. It does not cure late stage syphilis. B) The client is no longer contagious through sexual contact A client with a latent syphilis infection is no longer contagious through sexual contact, but can pass the infection to a fetus. Latent syphilis can last up to 25 years from initial infection. C) The client can no longer spread the infection to their child in utero In the latent stage, a mother can still pass syphilis on to the fetus. D) The client will have chancre-like sores in the genital area This is evident in the primary infection stage, which lasts from 10-90 days after exposure.
The nurse is caring for a 70-year-old client who has just started PO ciprofloxacin for a urinary tract infection. Which of the following statements by the client demonstrates understanding of this drug? Select all that apply. A) "After I take this antibiotic, I will be free from bladder infections" B) "I'll take this medication with a full glass of water" C) "I'm going to stay out of the sun while taking this drug" D) "If I have pain or swelling near my heel or calf, I will call my doctor right away" E)"I had an allergic reaction to a sulfa drug, so I cannot take this antibiotic"
B,C&D A) "After I take this antibiotic, I will be free from bladder infections" This drug will treat the client's current UTI, but not prevent future infections. B) "I'll take this medication with a full glass of water" This drug should be used with caution in older adults, especially older adults with any renal or hepatic disorders. Cipro should be taken with a full glass of water, and the nurse should observe for any CNS effects such as dizziness, depressed feelings, and light sensitivity. C) "I'm going to stay out of the sun while taking this drug" Precautions should be taken to avoid direct sunlight while taking this medication. D) "If I have pain or swelling near my heel or calf, I will call my doctor right away" Ciprofloxacin carries a risk of tendon rupture. E) "I had an allergic reaction to a sulfa drug, so I cannot take this antibiotic" This drug is a fluoroquinolone, not a sulfonamide antibiotic.
A 56-year-old client is preparing to have an intravenous pyelogram. Select all of the following measures the nurse would take to prepare the client for this test. A) Ask the client about any allergies to peanuts B) Determine how much the client understands about the procedure C) Ensure that the client has signed the consent D) Assess BUN and creatinine levels E)Assess blood cultures and WBC count
B,C&D A) Ask the client about any allergies to peanuts The nurse should ensure the client is not allergic to contrast dye B) Determine how much the client understands about the procedure An intravenous pyelogram is an x-ray of the kidneys, bladder, ureters and urethra. A contrast dye is injected into the bloodstream to visualize the structures on x-ray. C) Ensure that the client has signed the consent D) Assess BUN and creatinine levels The nurse should assess kidney function through BUN and creatinine levels E) Assess blood cultures and WBC count The nurse will assess lab values that are related to kidney function, but blood cultures and WBC count are not related so would not need to be assessed for the IV pyelogram test.
A nurse is educating a client on signs and symptoms of compartment syndrome. Which of the following signs would be included? Select all that apply. A) Fever B) Numbness and tingling C) Severe pain D) Paralysis of affected extremity E) Pale skin
B,C,D&E A) Fever This is not a sign of compartment syndrome. However, if left long enough, the client will develop tissue necrosis which would eventually become infected if not medically treated. B) Numbness and tingling The client with compartment syndrome will have numbness and tingling because the nerves are compressed. C) Severe pain The client will have severe pain with this condition because swelling builds up and causes pressure which compresses the tissues, resulting in an increased pain level. D) Paralysis of affected extremity A sign of compartment syndrome is an inability to move the affected area. E) Pale skin The skin becomes pale from a lack of blood flow when a client has compartment syndrome.
While talking to a patient about how she lost her job, the nurse utilizes clarifying techniques as therapeutic communication. Which of the following are examples of clarifying during the conversation? Select all that apply. A) Do you have to use the restroom? B) Would you like to sit or stand while you talk? C) Would you like to sit or stand while you talk? D) Are you saying you do not regret this? E) Do you have a plan for the future?
C&D A) Do you have to use the restroom? B) Would you like to sit or stand while you talk? C) What would you say is most important about this?Clarifying questions center on the current topic of conversation in which the nurse asks the client to explain a little further to clarify what was just said. Clarifying questions do not focus on topics outside of the conversation, or subjects that have not been brought up in the conversation. D) Are you saying you do not regret this? E) Do you have a plan for the future? This question is introducing a new topic that the client has not discussed, so this is not a clarifying question.
