all archer study set questions
hyponatremia causes acronym
MOBSFAIL M: meds- diuretics O: ral gastric tube suctioning B: urns S: IADH F: ail of the heart kidney or liver
What is the acronym for hyperkalemia s/s & what does it stand for
MURDER M: muscle weakness & cramping U: urine abnormalities R: respiratory distress D: decreased cardiac contractility (hypotension, bradycardia, weak pulses) E: ekg changes R: depressed reflexes
how fast do we want to replace sodium
about 0.5 meq/hr
what medication treatment is used for syphilis
abx - doxycycline, penicillin g
what is the companion solution for platelet transfusion
NS
both typical and atypical antipsychotics can cause what condition
Neuroleptic malignant syndrome
should you remove a nitroglycerin patch before an mri
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.
what are the 2 corncerning neuro signs that go with hyponatremia
altered mental status & seizures
protein is metabolized to _________ which is converted to ___________ by the _______ & it is then excreted by __________
ammonia, urea nitrogen the liver, the kidneys
what is the acronym for hyponatremia s/s & what is it stand for
SALT LOSS Seizures Active bowels Loss of appetite Tendon reflexes decreased LOC altered & confusion Orthostatic hypotension Stupor & lethargic Stomach cramps
what is the first pass effect
amount of drug absorbed from the GI tract and then metabolized by the liver; thus, reducing the amount of medicine, making it into the circulation. After oral administration, many drugs are absorbed intact from the small intestine and transported first via the portal system to the liver, where they undergo extensive metabolism, therefore usually decreasing the bioavailability of certain oral medications.
what is hepatic clearance
amount of drug eliminated by the liver, how fast/the ability of the liver to clear a drug from the blood (per unit time)
what type of drug is atropine
an anticholinergic
s/s of pancreatitis
Severe pain in the mid-epigastric area radiating to the back, made better by sitting up and forward, n/v, weakness, sweating, anxiety if bad
what is defined as a febrile reaction
an increase in 1C since the transfusion started
what reduces the effects of phenytoin
antacids
what does promethazine do
anti nausea
The standard of care for the treatment of acute DVT is
anticoagulants like heparin and warfarin Blood thinning medications work by allowing blood to flow around a trapped clot while at the same time preventing clot from travelling to the lungs.
kayexelate
Sodium polystyrene sulfonate -Treatment option for hyperkalemia; works in the colon to bind to potassium to aid in excretion. Causes diarrhea! - reduces total potassium in the body (should be in the cells, it's ok to excrete the potassium in the body)
how does hyperkalemia change your ekg
THE NUMBER ONE ASSESSMENT FINDING IS A TALL PEAKED T WAVE prolongation of the PR and QRS intervals -P wave amplitude is diminished in the early stage - T wave amplitude increases. can lead to heart block, v fib or cardic arrest
what is the word for flapping tremor
asterixis
Ephedrine is used for
asthma, nasal decongestion
when a patient has an ng tube connected to low intermittent wall suction, they should wait to turn back on the suction for how long after administering a med
at least 30 mins
is sensorineural hearing loss reversible
This type of hearing loss is often not reversible
Is conductive hearing loss reversible?
This type of hearing loss may be reversible
Why is MAGNESIUM SULFATE given to pregnant women?
To prevent seizures with the complication of pregnancy induced hypertension (PIH).
what does veal chop stand for
V(ariable decels) E(arly decels) A(ccelerations) L(ate decels) C(ord compression) H(ead compression) O(okay) P(lacental insufficiency)
how do we treat euvolemic hypernatremia
WATER BY PO euvolemic: normal amount of water, high amount of salt a little bit of water to dilute the extra sodium. because they're euvolemic, we don't really want to give iv fluids, just by mouth. -monitor neuro status -correct imbalances slowly for risk of cerebral edema
what is primary nursing
Where one nurse plans and directs care for a patient over a 24-hour period. A registered nurse plans and organizes care for a group of clients and cares for this group during their entire hospitalization.
what is autonomic dysreflexia
a condition in which the involuntary nervous system overreacts to external or bodily stimuli
what is diabetes insipidus
a disorder caused by an inadequate amounts of ADH which causes excessive water loss when the kidneys are unable to prevent the excretion of water, resulting in constant thirst and frequent urination. Usually, a person will produce about 2 quarts (qt) of urine per day. People with diabetes insipidus may produce up to 20 qts of urine daily.
what is euvolemic hypernatremia
a little bit decreased water but near normal sodium they have a little decrease in water, but is still considered normal, but the fluid loss causes sodium to be more concentrated decreased water
what is clozapine used for
atypical antipsychotic reserved for those who have not responded to other agents. This medication is used to treat schizophrenia as well as mood disorders that may cause significant aggression or violence.
what meds should not be given with ect
benzos & anticonvulsants because they will increase the seizure threshold & may attenuate the efficacy of ect
what is labetalol
beta blocker used for hypertensive emergencies
what antihypertensives slow down heart rate
beta blockers, calcium channel blockers (dipine) & ivabradine
what does ccbs do to the heart rate
bradycardia
dipine
calcium channel blocker
how does siadh affect sodium
causes euvolemic hyponatremia
what precautions is impetigo
contact
shellfish allergy may carry a concurrent risk for allergic reaction to contrast dye
contrast dye
what fluids & meds drive potassium back into the cells
d5w, regular insulin, sodium bicarb, albuterol
BUN is less specific of an indicator than cr because BUN also is elevated by
dehydration
not enough adh leads to
diabetes insipidus
when the kidneys are unable to prevent the excretion of water, resulting in constant thirst and frequent urination.
diabetes insipidus
Both "typical" and "atypical" antipsychotic medications work by blocking a specific type of ______receptor in the brain.
dopamine d2 receptors
what is diplopia
double vision
ptosis
drooping
hyperkalemias can lead to dangerous arrhythmias like
eart block, v fib or cardic arrest
Low dietary intake of sodium causes what type of sodium imbalance
euvolemic hyponatremia
too much hypotonic ivf causes what type of sodium imbalance
euvolemic hyponatremia
hyperthyroidism is
excessive activity of the thyroid gland produces abnormally high levels of thyroid hormone
the duty to keep promises
fidelity
what is the acronym for hypernatremia & what does it stand for
fried salted F: fever (low grade) R: restless I: increased fluid retention E: edema if hypervolemic (peripheral and pitting) D: ry mouth S: skin flushed A: altered LOC L: lethargic T: thirst E: elevated BP (if hypervolemic) D: decreased UO
what should be going on in the suction control chamber of the chest tube
gentle bubbling no tidaling
what shouldn't you eat with calcium channel blockers
grapefruit juice
what does ranitidine do
h2 antagonist used to treat GER and GERD it blocks histamine receptors in the stomach lining, decreasing acid production & preventing ulcers
A BNP test is utilized to assist in the diagnosis of
heart failure - chf
what does sodium do
help regulate the water in your body - water follows sodium. keeps water in the right places
hyperadrenalism does what to potassium and sodium
high sodium, low potassium, high cortisol
ace inhibitors can cause what electrolyte imbalance
hyperkalemia
tall peaked T waves on an ekg is what
hyperkalemia
how do we treat hypervolemic hypernatremia
hypervolemic hypernatremia: have too much of both fluid and water. we need to get rid of both. 1. find the cause - we're probably giving the client too much of these things, whether it is sodium bicarb, steroids, hypertonic fluids, idk. or they might have hyperaldosteronism or cushing's. we need to find the cause & stop it 2. diuretics to get the fluid off - loop diuretics 3. free water administration - PO water intake. replace hypertonic fluids with water that isn't salty -monitor neuro status -correct imbalances slowly for risk of cerebral edema
Water intoxication causes what type of sodium imbalance
hypervolemic hyponatremia
● Seizures ● Confusion ● Lethargy ● Stupor ● Cerebral edema ● Increased ICP hyper or hyponatremia
hyponatremia
manifestations of shock (vs)
hypotension, tachycardia, increased respiratory rate, fever, sweating, feeling of impending doom
what type of hypernatremia has hypotension and weak pulses - hypervolemic or hypovolemic
hypovolemic
hepatic encephalopathy
impaired ammonia metabolism d/t liver issues causes cerebral edema. s/s: change in LOC, memory loss, asterixis (flapping tremor) impaired handwriting, hyperventilation w/ resp alkalosis. Rx: lactulose, low protein, safety, rest
when does a transfusion reaction usually occur
in the first 15 minutes
glaucoma is caused by
increased intraocular pressure
what does albuterol do to hr
increases, can cause tachycardia
phlebitis
inflammation of a vein
causes of hypervolemic hypernatremia
infusion of hypertonic ivf, increased sodium intake, giving too much sodium bicarb, corticosteroids, cushing's, hyperaldosteronism
how does cushing's disease lead to hypernatremia
it is an endocrine disorder where the body makes too many steroids, like aldosterone & ACTH. the body makes too many steroids & that causes the body to salt regulate, decrease the excretion of sodium & retain both water and sodium
the equitable & fair distribution of resources
justice
intervention for late decels
laying the mother on her left side, increasing IV fluids, administering oxygen, and notifying the healthcare provider quickly
what side effects does phenytoin have
less seizures, gingival hyperplasia-get regular dental checkups
what is considered fetal bradycardia
less than 110 bpm
what metabolizes drugs and toxins
liver
what part of the body converts ammonia to urea nitrogen
liver
what part of the body converts glucose to glycogen for storage
liver
what part of the body produces bile, albumin and cholesterol
liver
what produces clotting factors and regulates blood clotting
liver
who does a nurse report suspected child abuse to
local child protection agency
what is hypovolemic hypernatremia
loss of fluid and sodium, but more so fluid than sodium
how can you have little water and a lot of sodium, leading to hypovolemic hypernatremia
loss of fluid via being npo, vomiting, diarrhea, dehydration, burns & diuretics leads to a relative increase in the amount of sodium in the blood
prescribed treatment for torsades de pointes.
mag sulf
what are the live vaccines
measles, mumps, rubella, vaccinia, varicella, zoster (which contains the same virus as varicella vaccine but in a much higher amount), yellow fever, rotavirus, and influenza (intranasal).
what are diuretics
medications that act on the kidney to increase production of urine & increase elimination of h2o, metabolic wastes & electrolytes from the body
aspirin overdose causes what abg imbalance
metabolic acidosis
cyanide poisoning antidote
methylene blue
the failure to exercise the care toward others that a reasonable or prudent person would do in the circumstances or taking action that such a reasonable person would not
negligence
ampho b is ____toxic
nephro
what do we need to monitor for a high sodium diet
neuro status
can dig be given im
no
do ace inhibitors affect hr
no
does ampho b raise blood glucose
no
is hep b a live vaccine
no
is hsv reportable to the cdc
no
is ipv polio a live vaccine
no
what should be going on in the drainage collection chamber of the chest tube
no bubbling, no tidaling, normal serosanguinous pink drainage
should you remove weight from someones traction
no-only the physician
the duty to cause no harm to others
nonmaleficence
what is euvolemic hyponatremia
normal amount of water and sodium basically, but a little more water to dilute
what diuretics are used to treat hyperkalemia
not potassium sparing - loop/potassium wasting hctz & furosemide HCTZ can cause electrolyte and/or fluid imbalances, including hypokalemia, hyponatremia, hypercalcemia, and/or hypomagnesemia
addison's disease
occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone
alternative options to xray for tube placement
pH of tube aspirate
nociceptive pain
pain from a normal process that results in noxious stimuli being perceived as painful (somatic or visceral, acute, results abruptly)
Immediate treatment of cardiac tamponade would be
pericardiocentesis A needle is inserted to aspirate the pericardial fluid in this ultrasound-guided procedure. The provider may elect to leave a temporary catheter in place in the pericardium to drain more fluid.
warfarin antidote
phytonadione/vitamin k
what electrolyte do we need to monitor with ace inhibitors & why
potassium - can cause hyperkalemia
risk factors to reaction to contrast dye
previous bad reaction asthma dehydration extremes of age shellfish allergy does not count
heparin & lovenox antidote
protamine sulfate
risperidone is used for
psychosis atypical antipsychotic
Following a myocardial infarction (MI), the client is at risk for developing
pulmonary edema
immediately after a bronchoscopy, is reddish brown sputum normal or an emergency
reddish-brown sputum is expected because as the scope passes by the mucosa, it may irritate
Dysautonomia
reduced tear gland secretions, poor vasomotor control, motor incoordination, skin blotching, absence of pain sensation, difficulty in swallowing, hyporeflexia, excessive vomiting, and emotional instability.
percutaneous thrombectomy
removal of a clot surgically
why would someone have a hypophysectomy
removal of the pituitary gland to treat cancerous or benign tumors, cushing's disease or if your body is exposed to too much cortisol
When identifying a suspected piece of faulty electric care equipment, what is the priority
removing the piece of equipement
opioid overdose causes what abg imbalance
resp acidosis
pneumothorax would cause what abg imbalance
resp acidosis
anxiety would cause what abg imbalance
resp alkalosis
what meds cause your urine to turn reddish orange
rifampin or phenazopyridine
haloperidol is used for
schizophrenia, tourettes typical antipsychotic improve thinking, mood, and behavior.
3% saline is to be utilized only for the patient with
severely symptomatic hyponatremia
s/s of hypoglycemia
shakiness, diaphoresis, tachycardia, anxiety/irritability, nervousness, chills, nausea, headache, weakness, confusion, dilated pupils
do we correct hyponatremia fast or slow & why
slow because of risk for cerebral edema Changing the sodium level too quickly causes fluid shifts - cerebral edema & increased icp
corticosteroids cause people to retain what electrolyte
sodium and water - causes hypervolemic hypernatremia
does an mri use contrast dye
sometimes
what is functional nursing
staff members are assigned to complete certain tasks for a group of patients rather than care for a specific patient Ex. Operating room and ER (everyone does an assigned task) In functional nursing, each caregiver on a specific nursing unit is given specific tasks that fall into their scope of practice for various patients, instead of caring for a specific patient. In this situation, the nurse manager may administer medications to the entire group, while a licensed practical nurse performs treatments, and the client care attendants provide physical care.
TSH (thyroid stimulating hormone)
stimulates secretion of thyroid hormone t3 & t4
lead antidote
succimer
signs of a pneumothorax, especially after a thoracentesis
sudden chest pain with dyspnea, decreased lung sounds/affected side, nagging cough, air hunger, tachycardia & tachypnea
side effects of injecting contrast dye
sudden nausea, a feeling of facial flushing, warmth, sudden urge to urinate, a headache but only for a short time
signs of embolism in a picc
tachycardia, hypotension, chest pain, dyspnea, tachypnea, and hypoxia
meds used for organ rejection
tacrolimus, cyclosporine, prednisone
nonmaleficence
the duty to cause no harm to others
justice
the equitable & fair distribution of resources
A CMP is testing that may detect problems with
the liver / other electrolyte abnormalities
where should there be tidaling in the chest tube
the water seal chamber (the middle)
t3 and t4
thyroid hormones
what is hypervolemic hypernatremia
too much water and sodium, but more so sodium so more water follows
what is hypervolemic hyponatremia
too much water, salt is diluted/not enough
what type of reactions happen with transfusion of blood
transfusion reaction fevers hypotension respiratory distress urticaria panic itching
external ventricular drain
tube placed in ventricle of brain to drain blood/CSF after a hemorrhagic stroke
what are the musculoskeletal symptoms that come with hypernatremia
twitching, cramps, weakness
what are non reassuring signs on a fetal heart strip
variable decelerations, late decelerations, fetal bradycardia
what type of reaction can happen with platelets
vary from febrile NHTR and allergic reactions to chills, discomfort, tachycardia, and respiratory difficulties
This hormone is responsible for helping the kidneys balance the amount of fluid and electrolytes in the body
vasopressin (ADH)
the obligation to tell the truth
veracity
what is homonymous hemianopia
visual field loss on the same side in both eyes
how to treat euvolemic hyponatremia
water increased a little bit to dilute the sodium, but still a normal balance. don't want to give tons & tons of fluids restrict free water (po water) sodium tablets & a high salt diet osmotic diuretics if you need to get some fluid off
when we're measuring the 3.5-5 for potassium, what are we measuring
were not measuring most of the potassium, we're measuring what's out in the serum/blood & that's not where most of the potassium lives but we need potassium inside the cells o control nerve impulse conduction
what do we administer plasma with
with a straight line set
The gold standard to verify tube placement like an ng tube is
xray
gold standard for tube placement confirmation
xray
can you wear a shirt under your halo vest
yes
do clients have to be npo for an endoscopic retrograde cholangiopancreatography
yes
is hep a reportable to the cdc
yes
is hiv reportable to the cdc
yes
is mmr a live vaccine
yes
do you need to filter red blood cells during a transfusion
yes- use standard blood filter Blood components must be filtered during transfusion to remove clots and small clumps of platelets and white blood cells that form during collection and storage.
what gi symptoms are caused by hyponatremia
● Loss of appetite ● Hyperactive bowel sounds
what are causes of hypovolemic hyponatremia
● Vomiting ● Diarrhea ● NG suction ● Diuretics ● Burns ● Excessive sweating because water and sodium are both lost
what type of fluid is 3% ns
hypertonic
edentulous
without teeth
acetaminophen antidote
acetylcysteine
the respect for individuals right to choose
autonomy
what is a hyphema & what do we do about it
blood in the anterior chamber of the eye, an oncologic emergency 1) shield the eye 2) elevate hob at least 30 degrees 3) prescribe pain meds not aspirin or nsaids 4) don't raise IOP by doing things like coughing, sneezing, muscle exertion, bending at the waist or vomiting
cv symptoms of hypervolemic hyponatremia
bounding pulses & htn
sodium is important for what parts of the body
brain, nerves and muscle cells
malignancy can do what to calcium
cause hypercalcemia because of breakdown of bones
how does hypoadrenalism affect sodium
causes euvolemic hyponatremia
how does hypoaldosteronism/addison's affect sodium
causes euvolemic hyponatremia
what medicine causes redmans syndrome
ciprofloxacin, vanc, ampho b, rifampin, teicoplanin
variable decelerations are often caused by
cord compression-prolapsed cord VEAL CHOP V=Compression
_____ is the most specific indicator of renal function/failure
cr
dysphagia
difficulty swallowing
digitalis (digoxin) antidote
digoxin immune FAB
ccb ending
dipine
what medication do we give to get rid of fluid for hypervolemic hypernatremia
diuretics - preferably loop
what does the client wear during the mri
gown & ear plugs
what. is contact precautions
gown and gloves
does hyper or hyponatremia cause a coma
hypernatremia
when to hold dig for an adult
if HR <60 or >120 or markedly changed rhythm
craniotomy
incision of the skull
A tonometer device is used to determine what
intraocular pressure & helps diagnose ocular problems such as glaucoma
Hepatic encephalopathy treatment
lactulose and rifaximin
how should you lay after a pneumonectomy- nonoperative or operative
on the OPERATIVE SIDE
what is mannitol
osmotic diuretic indicated for cerebral edema
salt substitutes contain
potassium
what meds increase k excretion
potassium wasting diuretics (lasix, hctz) kayexalate
what is your #1 concern when you hear hyponatremia
seizures
do we correct hypernatremia fast or slow & why
slow because risk of cerebral edema
hypophysectomy
surgical removal of the pituitary gland
neuro symptoms of hyponatremia
● Seizures ● Confusion ● Lethargy ● Stupor ● Cerebral edema ● Increased ICP
foods high in potassium
-bananas -milk -oranges/citrus fruits -salmon -dried beans -brocolli
what do you check before giving blood
-blood type & Rh -blood component tag name & numer -provider's order -client's identity - name & dob -hospital Id band name and MRN
indications for tpn
-enteral nutrition is contraindicated -client isn't tolerating enteral nutrition well -high risk for aspiration -GI tract obstruction
causes of hypercalcemia
-excessive calcium in the diet -thiazide diuretics -hyperparathyroidism -excessive vit D intake/toxicity -cancer of the bones, causing bone breakdown -immobility
complications of tpn
-infection -insertion problems -fluid volume overload -intolerance -hypo/hyperglycemia -embolism
how fast can you transfuse albumin
1 ml/min
how often do you do vitals for blood transfusions
1) preset 2) 15 mins after it starts 3) hourly until it is done 4) 1 when it is complete
What are the 5 rights of delegation?
1. Right task- can it be delegated 2. Right Circumstance- Should it be delegated 3. Right person- can this person do the task 4. Right direction/ communication- is the task being conveyed in a clear manner 5. Right supervision- is the task being followed up on once complete.
how to treat a HEMORRHAGIC stroke
1. get the bleeding under control 2. if caused by aneurysm, either coiling or clipping 3. craniotomy 4. external ventricular drain-tube placed in ventricle of brain to drain blood/CSF after a hemorrhagic stroke
when checking the residual of an ng tube, generally residuals over _____ mL are considered above-normal volumes, although there is no need to withhold feeding for gastric residual volume (GRV) less than 500ml.
150
in the first 3 months of life, how much weight should a baby gain
175-210 g/week
by one year of age, baby should weigh ____x their birth weight
3x
what should your cholesterol be in mmol/L
40-60 mmol/l
what should your range be for HDLs
40-80 mg/dL
what should your range be for LDLs
85-125 mg/dL
who can A blood donate to
A & AB
who can A receive from
A & O
Which of the following clients require droplet precautions in addition to standard precautions as a priority? Select all that apply. A. A patient diagnosed with rubella B. A patient diagnosed with diphtheria C. A patient diagnosed with varicella D. A patient diagnosed with tuberculosis E. A patient diagnosed with MRSA F. An infant diagnosed with adenovirus
A. A patient diagnosed with rubella C. A patient diagnosed with varicella E. A patient diagnosed with MRSA
The nurse is caring for a critically ill client receiving enteral nutrition through a nasogastric tube. Before initiating the next bolus feed, the nurse checks the residual and notes 225 mL of bright green fluid. Which actions by the nurse are appropriate? Select all that apply. A. Auscultate for bowel sounds B. Document the residual C. Discard the residual D. Do not administer the tube feeding 6014
A. Auscultate for bowel sounds B. Document the residual Choices A and B are correct. ( Choice A) Generally, residuals over 150 mL are considered above-normal volumes, although there is no need to withhold feeding for gastric residual volume (GRV) less than 500ml. The nurse should auscultate bowel sounds to detect potential signs of delayed gastric emptying in a patient with a large residual. According to a research study, the gastric emptying delay is classified into three levels based on the amount of residual volume - an amount of more than 150mL up to 250 mL is considered a mild delay. In contrast, amounts greater than 350 mL are classified as a severe delay. Per the American Society of Parenteral and Enteral Nutrition (ASPEN) and many other critical care society guidelines, the nurse should not hold feeding for a GRV of less than 500 mL in the absence of any clinical signs of intolerance. Therefore, the nurse should auscultate for bowel sounds and assess any nausea, emesis, or abdominal distention. Should there be any clinical signs of intolerance, the nurse should hold the feeding. When a large-volume residual is aspirated, it may indicate delayed gastric emptying. A prokinetic agent can be given to enhance gastric emptying. ( Choice B) The nurse should document the color, odor, consistency, and amount of the residual. One can remember this documentation from the mnemonic COCA: color, odor, consistency, and amount. For example, the nurse can document the aspirate as bright green, non-odorous, thin, 250 mL residual in this case. Such documentation will help establish a baseline for the client and identify changes that could indicate a concern. Choice C is incorrect. There is no information regarding feeding intolerance in the question stem. In the absence of feeding intolerance, the nurse should not discard the residual if it is less than 250 ml. Residuals up to 250 mL can be safely returned to the client. The nurse has aspirated stomach contents rich in electrolytes such as potassium and chloride. If the nurse discards the residual, the electrolytes will be lost, potentially exacerbating the imbalance. Choice D is incorrect. Guidelines recommend holding tube feeding only when the residual is greater than 500 mL or in the presence of any clinical signs of feeding intolerance. It is premature not to administer tube feeding without auscultating the bowel sounds and checking for signs of intolerance. If there are no signs of intolerance, the nurse should return this residual to the client, flush the tube with saline to ensure it remains patent, continue the tube feeding, and notify the physician. 37% correct, adult, GI, reduction of risk potential
Which of the following are signs of brainstem involvement in a pediatric patient with a neurologic injury? Select all that apply. A. Dilated pupils B. Narrowing pulse pressure C. Bradycardia D. Tachypnea
A. Dilated pupils B. Narrowing pulse pressure C. Bradycardia
Which question would you ask to assess the family as the basic unit of society when applying the systems theory of family? A. Tell me about the traditions that your family has and practices. B. What form of discipline is used in the home? C. Tell me about your involvement in school activities with your children. D. Are you able to share home responsibilities with your spouse?
A. Tell me about the traditions that your family has and practices.
You are a nurse working on an adult medical-surgical floor when you hear "Code Pink" repeated three times over the hospital-wide speaker system, indicating an infant or child abduction. Since you know the hospital has infant/child abduction drills every two months, and you are working in an area without infants or pediatric clients, you should do which of the following? A. You must respond and perform your role in this "Code Pink." B. Ask the unit secretary to respond to the "Code Pink" for you. C. Ignore the "Code Pink" because you are caring for clients. D. Ignore the "Code Pink," as you are not staffing in obstetrics, the nursery, NICU, or pediatrics.
A. You must respond and perform your role in this "Code Pink."
The client that is under sodium restrictions is asking the nurse about which seasonings he can use that are low in sodium. The nurse should respond by saying: A. "You can use soy sauce as a dip." B. "You can use ketchup to make it taste better." C. "You can add some rosemary to increase your food's flavor." D. "Steak sauce is a nice way to enhance your food."
B. "You can use ketchup to make it taste better."
A nurse is preparing a client for angiography using contrast media. The nurse should educate the client that he may experience the following side effects when the contrast media is injected, except which of the following? A. Sudden nausea B. A headache lasting several days C. A feeling of facial flushing D. Sudden urge to urinate 2545
B. A headache lasting several days
The nurse is talking to a group of female teenagers regarding the dangers associated with human papilloma virus. Which cancer mentioned by the group would indicate an understanding of the topic? A. Neuroblastoma B. Cervical cancer C. Osteoblastoma D. Osteosarcoma
B. Cervical cancer
A 32-year-old man comes into the emergency department after being hit by a baseball bat in his chest. The nurse would suspect a pneumothorax because of which sign? A. Decreased respiratory rate B. Diminished breath sounds C. Presence of a barrel chest D. A sucking sound at the injury site 3428
B. Diminished breath sounds Choice B is correct. A client who experiences a pneumothorax may initially experience shortness of breath and chest pain. When the pneumothorax increases in size the client will display an increased respiratory rate, cyanosis, diminished breath sounds, and subcutaneous emphysema. Choice A is incorrect. The client who has a pneumothorax would display tachypnea (an increase in respiratory rate), not a decrease in respiratory rate. Choice C is incorrect. A barrel chest would indicate emphysema, a form of COPD. Patients with pneumothorax do not exhibit a barrel chest. Choice D is incorrect. The client's injuries are from a blunt object; therefore, the resulting pneumothorax would be a closed one. A sucking sound at the site of injury would denote an open chest injury. 60% correct
The nurse is preparing a client for a paracentesis. Which nursing actions should not be included in the nursing care plan? A. Obtain the client's vital signs and weight before and after the procedure. B. Have the client void before the procedure. C. Apply a large pressure dressing after the procedure. D. Maintain the client on bed rest.
B. Have the client void before the procedure
You are working in the emergency department. Your adult patient has an endotracheal tube (ETT) in place and a team member is providing assisted ventilation. Which of the following medications can be instilled in the ETT? Select all that apply. A. Morphine B. Lidocaine C. Epinephrine D. Atropine 4439
B. Lidocaine C. Epinephrine D. Atropine
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. 8099
B. filtered intravenous tubing.
between 6 months & 1 year, how much weight should a baby gain
400 g/month
how fast do you give 1 unit of red blood cells
2-4 hours
normal dig levels
0.5-2
The nurse is taking a sample of the fluid pulled from a nasogastric tube to ensure proper placement. The nurse will confirm appropriate placement of the NG tube if the stomach contents have a pH of: A. 3.4 B. 7 C. 5.9 D. 8 3909
A. 3.4 pH of stomach should be below 5.5
what should meals look like for dumping syndrome
A low carbohydrate, moderate fat, and moderate protein content will promote tissue healing and help to meet the body's increased energy demands.
What is SJS?
A rare, serious disorder of the skin and mucous membranes causing a red, painful, blistering rash that rapidly spreads typically a reaction to the medication
When assessing self-perception, the nurse should ask the client which of the following? A. "How would you describe yourself?" B. "What gives you hope when times are troubled?" C. "Is your normal way of dealing with stress helpful to you?" D. "Are you having difficulty handling any family problems?"
A. "How would you describe yourself?"
who can AB donate to
AB
who can AB receive blood from
AB, A, B & O
musculoskeletal symptoms of hyponatremia
Abdominal cramps ● Weakness ● Shallow respirations ● Decreased deep tendon reflexes ● Muscle spasms ● Orthostatic hypotension
most common complication of a thoracentesis
a pneumothorax Manifestations of a pneumothorax that are concerning include a nagging persistent cough, increased heart and respiratory rate, dyspnea, and potentially a feeling of air hunger.
visceral pain
a poorly localized, dull, or diffuse pain that arises from the abdominal organs, or viscera
should you suction after a pneumonectomy
no
hypoadrenalism is
Addison's disease
what is ephedrine
Adrenergic agonist; oral form of epinephrine
spironolactone
potassium sparing diuretic
the duty to do good to others
Beneficence
are benzos anticonvulsants
Benzodiazepines are commonly prescribed as anxiolytics, sedatives, and anticonvulsants.
what does blockage in the bowel sound like
Bowel sounds are high-pitched, occasional gurgles, or clicks that last from one to several seconds. They occur every 5 to 15 seconds in the average adult.
cv symptoms of hypovolemic hyponatremia
Weak pulse, Tachycardia, Hypotension, Dizziness
What is case management?
Case management is a form of primary nursing that involves a registered nurse who manages the care of an assigned group of clients. This nurse coordinates care with the entire health care team.
Ampho B causes what side effects
Causes hypokalemia; must pre-medicate prior to giving and client's will more likely develop a fever
worst comes to worst, correcting hypernatremia too fast can cause what
a seizure
hyperadrenalism is
Cushing's disease
The nurse is evaluating the laboratory results of a client with severe pressure ulcers. Which of the following should prompt the nurse to intervene? A. Serum albumin level of 2.5 g/dL B. Serum potassium level of 4 mmol/L C. Serum sodium level of 140 mEqL D. WBC count of 9000 cells/uL
D. WBC count of 9000 cells/uL
The nurse is caring for a client with bulimia nervosa. The nurse anticipates a prescription for which medication? A. metformin B. bupropion C. fluoxetine D. clozapine
D. clozapine
iron antidote
Deferoxamine
mag sulf antidote
calcium gluconate
hypoxia s/s
Early- restless & anxious; Late- combative, unconscious, seizures, cyanosis, dyspnea, tachypnea, tachycardia, accessory muscle use
what does FRIED SALTED stand for
F: fever (low grade) R: restless I: increased fluid retention E: edema (pitting and peripheral) D: dry mouth S: skin flushed A: altered LOC L: lethargic T: thirsty E: elevated BP if hypervolemic D: decreased UP hypernatremia s/s
what is the FLAG acronym & what does it stand for
F: free water PO L: loop diuretics A: agent causing we need to remove G: give isotonic or hypo iv fluids correction for hypernatremia euvolemic: give po water hypovolemic: give isotonic iv fluids hypervolemic: figure out the cause, remove fluid with diuretics, give free water
benzo antidote
Flumazenil
hctz causes what fluid and electrolyte imbalances
HCTZ can cause electrolyte and/or fluid imbalances, including hypokalemia, hyponatremia, hypercalcemia, and/or hypomagnesemia
what are late decelerations
HR DECREASES AFTER PEAK OF CONTRACTION AND RECOVERS AFTER CONTRACTION ENDS. (BEING LATE IS BAD). dips in the fetal heart rate that occur after a contraction
what is the acronym used for appendicitis s/s
PAINS P: pain rlq A: anorexia I: increased temperature & wbc N: nausea S: signs (mcburney's, psoas)
what are the cardiovascular symptoms that come with hypernatremia
fever
s/s of phlebitis
Local, acute tenderness; redness with a streak, warmth, and slight edema of the vein above the insertion site
when we hear of a sodium, we need to think of what types of symptoms
NEURO the brain nerves & muscles are important for sodium and water balance - essential to these organs
what is the MD SPIED acronym & what does it mean
M-malignancy D-diuretics (thiazide) S-steroids P-hyperparathyroid I-immobilization E-endocrine (addisons) D-vitamin D causes of hypercalcemia
what does MOBS FAIL stand for
M: meds- diuretics O: ral gastric tube suctioning B: urns S: IADH F: ail of the heart kidney or liver hyponatremia causes
what does the MURDER acronym stand for
M: muscle weakness & cramping U: urine abnormalities R: respiratory distress D: decreased cardiac contractility (hypotension, bradycardia, weak pulses) E: ekg changes R: depressed reflexes hyperkalemia s/s
what is the companion solution for packed rbcs kaplan pg 33
NS
isotonic fluids
NS, RInger's Solution, Lactated Ringer's
narcotics antidote
Naloxone
alcohol antidote
Metadoxine
somatic pain
Pain that originates from skeletal muscles, ligaments, or joints.
Patients experiencing dumping syndrome should be instructed to drink or not drink during meals?
Patients experiencing dumping syndrome should be instructed to avoid drinking during meals to prevent fullness and distention.
prednisone
Prednisone is a corticosteroid used for inflammatory conditions. This drug causes an increase in aldosterone, which increases sodium and water retention used for organ transplants
what does the SALT LOSS acronym stand for
Seizures Active bowels Loss of appetite Tendon reflexes decreased LOC altered & confusion Orthostatic hypotension Stupor & lethargic Stomach cramps hyponatremia s/s
what is the side effect of lamotrigine
Steven-Johnson Syndrome - skin blistering
THE #1 ASSESSMENT FINDING FOR HYPERKALEMIA ON AN EKG IS
TALL PEAKED T WAVE
the nurse is caring for a client whose most recent serum sodium was 152. which of the following s/s do they suspect are caused by the client's sodium level? SATA a. lethargy b. dry mucous membranes c. tachypnea d. cyanosis e. dry mouth
a. lethargy b. dry mucous membranes e. dry mouth
nursing managers 5 functions are
The five major management functions are planning, organizing, staffing, directing, and controlling.
what is considered dig toxicity
The therapeutic range for digoxin is 0.5 to 2.0 ng/mL [0.64 to 2.6 nmol/L]). Levels greater than 2.2 ng/mL (2.8 nmol/L) indicate toxicity.
who can O blood donate to
anyone
Sulfamethoxazole (SMX) is used to treat
UTIs
where is the pituitary gland
base of the brain
what are common loop diuretics
furosemide, bumetanide, torsemide
Typically, diabetes insipidus occurs due to problems with
vasopressin (ADH)
how does hyperkalemia change your vs
-bp: low -rr: respiratory distress, very low -pulses: weak -hr: low
what are causes of hypovolemic hypernatremia
-dehydration -npo -diarrhea -vomiting -burns -diuretics
by 2 years of age, baby should weigh ____x their birth weight
4x
by what age should a baby double their birth weight
5 months
Most guidelines recommend that the pH of an NGT aspirate should be ≤ ______ to confirm proper placement.
5.5
what does autonomic dysreflexia do to youur blood pressure
A dangerous spike in blood pressure
Which of the following interventions does the nurse expect when caring for a toddler who has a diagnosis of phenylketonuria? Select all that apply. A. Initiation of a keto diet B. IV iron dextran treatments C. Elimination of dairy, meat, and eggs from the diet D. Strict avoidance of aspartame
A. Initiation of a keto diet D. Strict avoidance of aspartame
The nurse is caring for a client who is diagnosed with acute appendicitis. After several hours of pain, the client suddenly states a relief in his pain. What is the initial action of the nurse? A. Notify the physician B. Document the finding C. Insert an IV cannula D. Administer a laxative 3468
A. Notify the physician The nurse should notify the physician immediately to assess the client and prepare for surgery since this could signify a rupture of the appendix; any delay could cause peritonitis.
The nurse is caring for a neonate with a decreased cardiac output. If noted in this patient, which of the following is not a sign of decreased cardiac output? A. Oliguria B. Difficulty breastfeeding C. Bradycardia D. Hypotension
A. Oliguria
The nurse is caring for a client whose latest lab results show a serum calcium level of 13.2 mg/dL. Which medication does the nurse expect to administer based on this lab result? Select all that apply. A. Phosphorus B. Calcitonin C. Vitamin D D. IV calcium gluconate E. IV Bisphosphonates
A. Phosphorus, B. Calcitonin E. IV Bisphosphonates
A 28-year old woman presents to the trauma bay after being shot in the upper back. She can move the left side of her body but is unable to move the right. However, she cannot feel any pain on the left. The nurse knows these symptoms are suggestive of which type of spinal cord injury? A. Incomplete spinal cord injury, central cord syndrome B. Incomplete spinal cord injury, Brown-Sequard syndrome C. Complete spinal cord injury, paraplegia D. Complete spinal cord injury, anterior cord syndrome
B. Incomplete spinal cord injury, Brown-Sequard syndrome
The nurse is performing a head-to-toe assessment of the patient. During the abdominal evaluation, the correct sequence for this assessment is: A. Auscultation, Inspection, Palpation, Percussion B. Inspection, Palpation, Auscultation, Percussion C. Percussion, Auscultation, Palpation, Inspection D. Inspection, Auscultation, Percussion, Palpation
D. Inspection, Auscultation, Percussion, Palpation
causes of hypercalcemia & acronym
MD SPIED M-malignancy D-diuretics (thiazide) S-steroids P-hyperparathyroid I-immobilization E-endocrine (addisons) D-vitamin D
Post-meal rest periods for someone with dumping should be how long to allow enough time for the digestion process to begin
at least 30 mins
foods that are in a high sodium
bacon butter canned food cheese hot dogs lunch meat processed food table salt
s/s of hypercalcemia
-muscle weakness & flacidity -weakened DTRs -bradycardia -cyanosis -dvt -fatigue -decreased LOC -hypoactive bowels -ab pain -n/v -constipation -kidney stones
This nurse is caring for a client who is receiving prescribed cilostazol. Which of the following findings would indicate a therapeutic response? A. Absence of pain while ambulating B. Decreased total cholesterol C. Increased visual acuity D. Improved focus and attention 7483
A. Absence of pain while ambulating Choice A is correct. Cilostazol is a phosphodiesterase inhibitor approved to treat peripheral arterial disease. Its action mechanism decreases platelet aggregation and promotes vasodilation, allowing a client to ambulate distances without pain. Choices B, C, and D are incorrect. Cilostazol is not utilized to mitigate total cholesterol levels. Further, this medication does not improve visual acuity or attention.
Your client comes to the clinic during the second trimester of her pregnancy. She is in the clinic for a "quad screen" and exam. In teaching her about the quad screen, you tell her that this procedure evaluates the chance of carrying a baby with: Select all that apply. A. Down syndrome B. Tay-Sachs disease C. Spina bifida D. Cystic fibrosis
A. Down syndrome D. Cystic fibrosis
The nurse is caring for a client following a bedside thoracentesis. Which action should the nurse take immediately following the procedure? A. Instruct the client to take slow, shallow breaths B. Assess the patient's respiratory status. C. Label the lab specimen for culture. D. Provide nasal cannula oxygen. 4348
B. Assess the patient's respiratory status.
The nurse is planning care for a client with homonymous hemianopia. The nurse should plan for which intervention in the care plan? A. Place an eye patch over the affected eye B. Instruct the client to turn their head from side to side C. Speak slowly, clearly, and in a deeper voice D. Provide the client with ear plugs to promote rest 7763
B. Instruct the client to turn their head from side to side Choice B is correct. Homonymous hemianopia (HH) is vision loss on the same side of the visual field in both eyes. It is appropriate for the nurse to teach the client to scan the room. Scanning the room will expand the visual field because the same half of each eye is affected. Choices A, C, and D are incorrect. An eye patch is an appropriate intervention for a client with double vision (diplopia). HH is not a problem with hearing and changing the approach to speaking to a client and providing ear plugs is irrelevant to this disorder. 42% Subject Adult Health Lesson Neurologic Client Need Area Physiological Adaptation
Which of the following signs and symptoms indicate right-sided heart failure in a pediatric patient? Select all that apply. A. Grunting B. Nasal flaring C. Ascites D. Hepatosplenomegaly
B. Nasal flaring
ampho b
D5 antifungal that is potent can make you feel quite ill - nausea, rigors, fever, chilsl give acetaminophen, ns, benadryl decrease K, Mag can have an infusion reaction
polydipsia causes what type of sodium imbalance
euvolemic hyponatremia
bounding pulses & htn is this hyper or hypovolemic hyponatremia
hypervolemic
what is the 2 big things we worry about with hyperkalemia
muscle weakness & ekg changes/arrhythmias
symptoms of diabetes insipidus
polyuria, polydipsia, dehydration, constipation, dry skin, muscle weakness, bed wetting, irritability
what medications shouldn't you take with grapefruit juice
statins calcium channel blockers anticoagulants antiplatelets immunosuppressants
After hypophysectomy, the client should be monitored closely for
increased intracranial pressure, headaches, urine output, and vital signs
Hypoalbuminemia can lead to
loss of muscle mass, poor wound healing, and other complications.
The nurse is caring for a client with a hyphema. The nurse should plan to take which action? A. Shield the affected eye. B. Place the client supine. C. Apply a cold compress to the eye. D. Request a prescription for aspirin. 7423
Choice A is correct. The initial nursing priorities for a hyphema are shielding the affected eye and raising the head-of-the bed to 30 degrees. Choices B, C, and D are incorrect. Placing a client supine would aggravate the injury. The purpose of raising the head-of-the-bed to 30 degrees is because it promotes the settling of blood in the anterior chamber away from the visual axis. Cold compression of the eye would not be helpful. This compression may raise intraocular pressure which would be contraindicated. Aspirin and NSAIDs should be avoided because of their platelet inhibition which will promote more bleeding. 62% correct Subject Adult Health Lesson Visual/Auditory Client Need Area Physiological Adaptation
what should be going on in the water seal chamber of the chest tube
intermittent bubbling & tidaling
what type of fluid is lactated ringers
isotonic
what type of fluid is d5w
isotonic or hypotonic
what fluid do we give to correct hypovolemic hypernatremia
isotonics - normal saline NS is relatively hypotonic to the body in hypernatremia -monitor neuro status -correct imbalances slowly for risk of cerebral edema
veracity
the obligation to tell the truth
what is autonomy
the respect for individuals right to choose
how to position someone for oral care that is unconscious
side lying, not high fowlers
tamsulosin treats what
treats bph
Is syphilis a reportable disease?
yes
s/s of hypocalcemia
- muscle twitches/tetany - hyperactive DTRs - positive Chvostek's sign (tapping on the facial nerve triggering facial twitching) - positive Trousseau's sign (hand/finger spasms with sustained blood pressure cuff inflation) - seizures
signs of increased icp in infants
-irritability -increasing head circumference -bulging fontanels -bradycardia -widening suture lines -distended scalp veins -"sunset" eyes -high pitched cry
what is team nursing
An RN leads nursing staff who work together to provide care for a specific number of clients. The team typically consists of RNs, LPNs, and client care attendants. The team leader assesses client needs, plans client care, and revises the care plan based on changes in the client's condition. The leader assigns tasks to team members as needed.
The nurse is caring for a client two weeks postpartum with reports of flu-like symptoms, headache, and tenderness to the left breast. On examination, the nurse assesses enlarged axillary lymph nodes. The client is demonstrating manifestations of A. Endometritis B. Mastitis C. Pelvic inflammatory disease D. Cystitis
B. Mastitis
The nurse is caring for a client scheduled for surgery. The nurse should notify the primary healthcare physician (PHCP) of which laboratory abnormality? Sodium 134 Potassium 3.0 BUN 5 Cr 1.0 A. Sodium level B. Potassium level C. BUN D. Creatinine 3879
B. Potassium level
The nurse is caring for a client with the following clinical data, as shown in the exhibit. Which medication would the nurse be concerned about before administration based on the vital signs? See the exhibit. P: 123 RR: 18 BP: 149/85 T: 98.5 O2: 95% A. Metoprolol 50 mg PO Daily B. Lisinopril 40 mg PO Daily C. Albuterol 2.5 mg via nebulizer Daily D. Diltiazem XR 120 mg PO Daily 6578
Choice C is correct. The vital signs (VS) show an increased pulse (123 bpm) and elevated blood pressure. Albuterol is a beta-receptor agonist and would foreseeably worsen the tachycardia that the client is already experiencing. The nurse should clarify the albuterol prescription with the primary health care provider (PHCP) because albuterol may increase heart rate.
anxiolytics
Drugs that alleviate the symptoms of anxiety.
who can O blood receive from
O
renal disease would cause what abg imbalance
Renal disease causes metabolic acidosis because of the kidneys inability to recycle bicarbonate in the body.
what should you keep taped to your halo vest at all times
a wrench to loosen in an emergency
ascites
abnormal accumulation of fluid in the abdomen in the peritoneal cavity sign of rshf
_______________ (medication) should be avoided for clients with hepatic encephalopathy
benzos
what is diltiazem
calcium channel blocker
what does nitroglycerin do to blood pressure
can cause postural hypotension
pulmonary edema s/s
crackles in the lung midline of the lung fields dyspnea & tachypnea cough tachycardia cyanosis/hypoxia jugular venous distention pink frothy sputum*
atropine is
gasoline
beneficence
the duty to do good to others
fidelity
the duty to keep promises
A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to a nursing assistant who is assisting with the client's care? A. Implement contact precautions when handling the client. B. Educate the client and family members on ways to prevent transmission of VRE. C. Monitor the results of the laboratory culture and sensitivity test. D. Collaborate with other departments when the client is transported for an ordered test. 4098
A. Implement contact precautions when handling the client. Choice A is correct. All hospital personnel who care for the client are responsible for the proper implementation of contact precautions. Choices B, C, and D are incorrect. These are all actions that should be carried out by a nurse. 85% correct
When evaluating the heart rate of a 2-year-old patient that is awake, the nurse documents which of the following heart rates as tachycardia? Select all that apply. A. 60 beats per minute B. 130 beats per minute C. 150 beats per minute D. 180 beats per minute
C. 150 beats per minute D. 180 beats per minute
Primary nutrients that are essential for optimal body function include: A. Iron, zinc, and calcium B. Folate, vitamin B12, and iron C. Carbohydrates, proteins, and fats D. Vitamins A, D, E, and K
C. Carbohydrates, proteins, and fats
The nurse is assessing a child with glomerulonephritis. Which assessment finding requires follow-up by the nurse? A. Periorbital edema B. Decreased urine output C. Headache D. Hematuria 8122
C. Headache Choice C is correct. A complication of glomerulonephritis is encephalopathy caused by severe hypertension associated with the disease process. A client's report of a headache should clue the nurse into checking the client's blood pressure. The client should be monitored for this potential complication, which can be avoided by closely monitoring the client's blood pressure. Choices A, B, and D are incorrect. These manifestations are associated (and expected) with glomerulonephritis and do not require follow-up.
You have been asked to lead a health promotion course for the community about cancer. Which of the following symptoms should you include in your education about early signs and symptoms of cancer? Select all that apply. A. Incontinence B. Weight gain C. Trouble swallowing D. Insomnia
C. Trouble swallowing D. Insomnia
Which of the following vaccines contains a live virus? A. IPV B. DTaP C. Varicella D. Hepatitis B
C. Varicella Choice C is correct. Varicella is a live virus. Currently, the available live attenuated viral vaccines are measles, mumps, rubella, vaccinia, varicella, zoster (which contains the same virus as varicella vaccine but in a much higher amount), yellow fever, rotavirus, and influenza (intranasal).
The nurse is caring for a client scheduled for electroconvulsive therapy (ECT). Which medication should the nurse question? A. Sertraline B. Omeprazole C. Alprazolam D. Ziprasidone 6902
Choice C is correct. ECT is a safe therapy that induces seizures theorized to release monoamines, which may assist in treating psychiatric illnesses such as major depressive disorder. If a client is taking the benzodiazepine alprazolam, this will increase the seizure threshold and may attenuate the efficacy of ECT. Benzodiazepines and anticonvulsants should therefore be avoided in patient's receiving ECT. Choices A, B, and D are incorrect. Antidepressant medications (such as sertraline) and antipsychotics (such as ziprasidone) may be given concurrently with ECT. These medications may enhance the efficacy of the treatment. Proton pump inhibitors (such as omeprazole) are typically given the day of treatment to prevent gastric reflux and aspiration. 41% correct
The nurse is caring for a client newly diagnosed with type I diabetes mellitus. It would be essential to educate the client to A. check their hemoglobin A1C level every three months. B. rotate injection sites for insulin administration. C. examine their feet with a mirror daily. D. recognize the symptoms of hypoglycemia. 6611
Choice D is correct. Recognizing the signs and symptoms of hypoglycemia is essential since hypoglycemia can be lethal. Signs and symptoms of hypoglycemia include palpitations, tachycardia, cool and clammy skin, lethargy, and coma. Choices A, B, and C are incorrect. Checking a hemoglobin A1C level every three months, rotating injection sites, and examining the feet in a mirror are key teaching points for a client newly diagnosed with diabetes. However, hypoglycemia may be lethal, and the client must recognize these symptoms. 72% correct
According to the National Council of State Boards of Nursing, the five rights of delegation include: Select all that apply. A. Right task B. Right circumstance C. Right person D. Right direction and communication 4724
Choices A, B, C, and D are all correct. All of these are among the five rights of delegation, according to the NCSBN. The fifth right is the right supervision and evaluation. The proper task means that the responsibility falls within the scope of practice and job description of the person delegated the responsibility. The right circumstance implies that the patient/client is stable enough to have someone other than an RN be responsible for the job. The right person implies that the person doing the job has the skill and knowledge to complete it safely. The right direction and communication mean that the RN must be very specific in what the job involves and how it should be done. This right also means that the LPN/LVN must also communicate back to the RN about the completion of the task or any problems with the completion. Finally, every job must be monitored by the RN to evaluate the outcomes of the procedure. Documentation should be completed per facility policy, but the RN should always ensure that the documentation is correct and complete. 48% correct
what is the difference between conductive and sensorineural hearing loss
Conductive hearing loss is caused by obstruction. Causes of this type of hearing loss include excessive cerumen, foreign body, water, edema, infection, or tumor. This type of hearing loss may be reversible. Impairments of the nerve fibers cause sensorineural hearing loss. Causes of this type of hearing loss include prolonged exposure to noise, ototoxic substances (aminoglycosides), diabetes mellitus, menieres disease and presbycusis (age-related hearing loss). This type of hearing loss is often not reversible.
The nurse is assessing a patient who has a suspected retinal detachment. Which of the following patient statements would be consistent with this diagnosis? A. "My vision has a cloudy appearance." B. "I have intense pain above my eyebrow." C. "I am having trouble with my peripheral vision." D. "I can see bright flashes of light."
D. "I can see bright flashes of light."
In preparing for the admission of a toddler who has been diagnosed with febrile seizures, which of the following is the most important nursing action? A. Order a stat admission CBC. B. Place a urine collection bag and specimen cup at the bedside. C. Place a cooling mattress on his bed. D. Pad the side rails of his bed. 4590
D. Pad the side rails of his bed.
what is the s/s SIADH acronym
S-spasms I-isn't any pitting edema A-anorexia D-disorientation/psychoses H-hyponatremia
rifaximin
antibiotic used with hepatic enceph r/t to increased ammonia levels.
lamotrigine is used for
anticonvulsant for epilepsy
thyroid hormone
modulates activity of growth hormone, ensuring proper proportions & stimulates basic metabolic rate
is hpv a reportable disease
no
striae gravidarium is another term for
stretch marks
can nurses administer bronchodilators
yes
what are the 3 things we need to administer blood products
1) the blood product 2) tubing with the appropriate filter 3) 19 gauge needle for venous access
The nurse is caring for a client prescribed IV heparin. The client is prescribed 12 units/kg/hr. The client weighs 92 kg. The heparin is labeled with 25,000 units in 250 mL of D5W. How many mL/hr should this client receive? Round your answer to the nearest whole number. Fill in the blank.
11
what is considered a hypertensive crisis
180/120 or higher
by 3 year of age, baby should weigh ____x their birth weight
5x
normal calcium
9-10.5
Analyze the following ABG: pH 7.44, CO2 52, HCO3 42 A. Compensated metabolic alkalosis B. Uncompensated metabolic acidosis C. Compensated respiratory acidosis D. Uncompensated respiratory alkalosis 4386
A. Compensated metabolic alkalosis pH between 7.35-7.45 & CO2 & HCO3 are both high, so it is compensated 7.44 is closer to 7.45, so it is alkalosis
The nurse is teaching a patient who is scheduled for a colonoscopy. Which of the following information should the nurse include? A. "The day before the procedure you may have a regular diet." B. "You will not have anything to eat or drink by mouth for 4 to 6 hours prior to the test." C. "You may notice chalky white stools immediately after the procedure." D. "Your abdomen will be painful and distended after the test." 3866
B. "You will not have anything to eat or drink by mouth for 4 to 6 hours prior to the test." Choice B is correct. A colonoscopy is a test used to study the lining of the large intestine. Four to six hours before the procedure. the nurse is correct to instruct the client to not intake anything by mouth (NPO). Choice A is incorrect. The day before the process, the nurse should tell the client to have a clear liquid diet. Choice C is incorrect. Chalky white stools after the procedure are expected with a barium enema - not a colonoscopy. Choice D is incorrect. Abdominal pain and distention are unlikely as this would be worrisome for a perforation. 65% correct adult health, gi, reduction of risk potential
The nurse is developing a staff in-service on negligence. It would indicate correct understanding if the participant states that which element must be met in a negligent lawsuit? Select all that apply. A. Duty owed B. Breach of duty owed C. Causation D. Harm or damages E. Beneficence
Choices A, B, C, and D are correct. For a negligent lawsuit to proceed, the plaintiff (injured client) must prove the following elements: 1. A duty of care was owed to the injured party. 2. There was a breach of that duty. 3. The breach of the duty caused the injury (causation). 4. The plaintiff suffered actual harm or damages. Choice E is incorrect. Beneficence is an ethical principle and has no legal implications in negligence. Beneficence is defined as an individual acting in positive regard for others with a kind spirit.
What is a punch biopsy?
Punch biopsy removes a full-thickness skin plug (up to 10 mm in diameter) and is useful in identifying diseases marked by pathologic changes in the deeper dermis. Sutures may not be needed for small punch biopsy sites. Small punch biopsy wounds (i.e., < 3mm) often do not require suture closure. Larger punch biopsy wounds are often closed with sutures. PRIORITY: LOOK OUT FOR BLEEDING
what foods can be suspected of a latex allergy
apple, avocado, banana, carrot, celery, chestnut, kiwi, melons, papaya, raw potato and tomato.
early decels are caused by
fetal head compression pressure of the head of the fetus on the pelvis or soft tissue
what is the one vaccine you get at birth
hep b
twitching, cramps, weakness hyper or hyponatremia
hyper
An RPR is a common screening test for
syphilis infections
The purpose of the chest tube is
to create negative pressure and remove the air that has accumulated in the pleural space.
magnesium sulfate
to prevent seizures due to worsening preeclampsia, to slow or stop preterm labor, and to prevent injuries to a preterm baby's brain
what is hyperkalemia
too much potassium, greater than 5.0 too much moving from intracellular where it belongs into the extracellular/the serum
is rotavirus a live vaccine
yes
is varicella a live vaccine
yes
should you cough after a pneumonectomy
yes, it is encouraged
are mris safe during pregnancy
yes, there's no radiation, but may become unsafe if the mri has contrast dye
what fluid do we give for mild hypovolemic hyponatremia
0.9% ns
important treatment for an ischemic stroke
1. permissive hypertension-ensure there is perfusion to the brain 2. antithrombolytics-tPA. break up clots to restore blood flow. give tPA within 60 mins of a suspected stroke 3. percutaneous thrombectomy-removal of a clot surgically
CHF causes what type of sodium imbalance
hypovolemic hypotremia
how to intervene with fetal bradycardia
repositioning the mother on her left side, increasing IV fluids, discontinue oxytocin if on it, administering oxygen, and notifying the healthcare provider quickly
what are preventative measures for syphilis
wearing condoms
Tolvaptan
treats symptoms of siadh & depletes water but not sodium
the primary purpose of a continuous passive motion device is to what
maintain joint flexion and mobility and reduce contractures.
he nurse is evaluating their client's lab results and notes that the potassium is 5.5 mEq/L. They review the telemetry monitor, looking for which of the following signs? Select all that apply. a. Inverted T waves b. Widened QRS interval c. Tall, peaked T waves d. Prominent U-waves e. Prolonged PR interval
Answer: B, C, and E A is incorrect. The normal range for potassium is 3.5 - 5 mEq/L. This client is experiencing hyperkalemia. In hyperkalemia, there are Tall, peaked T waves. Inverted T waves is a sign of hypokalemia. B is correct. A widened QRS interval is a very important EKG finding in hyperkalemia. Other EKG changes clients may experience when they are hyperkalemic include wide, flat P waves, a prolonged PR interval, a depressed ST segment, and tall, peaked T waves. C is correct. Tall, peaked T waves is a hallmark sign of hyperkalemia on an EKG. Remember this one - it is a very common topic for NCLEX questions!! Hyperkalemia leads to serious arrhythmias, and can progress to heart block, ventricular fibrillation, or even asystole if left untreated. D is incorrect. The normal range for potassium is 3.5 - 5 mEq/L. This client is experiencing hyperkalemia. Prominent U-waves are a sign of hypokalemia, or a potassium less than 3.5, not hyperkalemia. E is correct. A prolonged PR interval is one of the EKG changes that occurs with hyperkalemia.
symptoms of autonomic dysreflexia
Anxiety and apprehension Nasal congestion High blood pressure with systolic readings often over 200 mmHg A pounding headache Flushing of the skin Profuse sweating, particularly on the forehead Lightheadedness Dizziness Confusion Dilated pup
how to treat hypervolemic hyponatremia
restrict free water (po water) sodium tablets & a high salt diet if needed osmotic diuretics
sunset eyes
sclera above iris-sign of increased icp in infants priority assess neuro
Symptoms of dumping syndrome generally resolve how long after gastrectomy surgery.
several months to a year
when to hold dig for an infant
if hr is less than 90
how to correct variable decelerations
sharp and profound drops in the fetal heart rate unrelated to the time of contraction lying the mother on her left side, increasing IV fluids, administering oxygen, and notifying the healthcare provider quickly
Immediately following abdominal surgery, _____________ is a concern to nurse
shock
why are corticosteroids given to pregnant women
for fetal lung development
-restless -agitation -drowsy -lethargic -stupor -coma -Changes in LOC hyper or hyponatremia
hyper
does hyper or hyponatremia cause restlessness and agitation
hyper
thiazide diuretics can cause what electrolyte imbalance
hypercalcemia
causes of euvolemic hypernatremia
hyperventilation, excessive sweating, fever, diabetes insipidus they have a little decrease in water, but is still considered normal, but the fluid loss causes sodium to be more concentrated
what type of hypernatremia has edema, htn and bounding pulses - hypervolemic or hypovolemic
hypervolemic
Liver failure causes what type of sodium imbalance
hypervolemic hyponatremia
Nephrotic syndrome causes what type of sodium imbalance
hypervolemic hyponatremia
does hyper or hyponatremia cause increased ICP
hyponatremia
a sudden, noticeable drop in heart rate is a symptom found in a client actively experiencing what response
vasovagal response
kidney failure causes what type of sodium imbalance
hypervolemic hyponatremia
Abdominal cramps ● Weakness ● Shallow respirations ● Decreased deep tendon reflexes ● Muscle spasms ● Orthostatic hypotension hyper or hyponatremia
hypo
● Loss of appetite ● Hyperactive bowel sounds hyper or hyponatremia
hypo
siadh causes what electrolyte imbalance
hyponatremia
side effect of tamsulosin
hypotension/fall risk
NG suctioning causes what type of sodium imbalance
hypovolemic hyponatremia
What is the most appropriate instruction to give a client with osteoporosis regarding exercise? A. Avoid exercise activities that increase the risk of fractures. B. Exercise to strengthen muscles and thereby protect bones. C. Exercise to reduce weight. D. Exercise doing weight-bearing activities.
B. Exercise to strengthen muscles and thereby protect bones.
Most guidelines recommend that the pH of an NGT aspirate should be ≤5.5 (acidic) to confirm proper placement. An alkaline pH ( >7.0) often indicates a ______ aspirate rather than gastric, & is not in the right place
lung A false-negative pH reading greater than 5.5 may be seen with the use of antacids and proton pump inhibitors. If the pH is greater than 5.5, an X-ray must be performed as a second-line test.
symptoms of NMS
muscle rigidity, high fever, autonomic instability, dysautonomia and mental status changes (delirium)
is tdap a live vaccine
no
When can you give tPA?
once deterrmined that it is an ischemic stroke, & within 60 mins of onset
neuropathic pain
pain from damage to neurons of either the peripheral or central nervous system
cilostazol is used to treat
peripheral arterial disease. Its action mechanism decreases platelet aggregation and promotes vasodilation, allowing a client to ambulate distances without pain.
laxatives waste what type of electrolyte know this!!!
potassium
myexedema coma is
progresses from hypothyroidism and shows decreases in mental status
A client arrives to the emergency department (ED) with complaints of vomiting for three days. The client's spouse reports the client has been getting progressively weaker with increasing dyspnea. The nurse notes that the client's respiratory rate is ten (10) breaths/min. An electrocardiogram (ECG) indicates tachycardia with a heart rate of 120 beats/min. Arterial blood gases (ABG) are subsequently ordered and drawn. When reviewing the ABG results, the nurse should anticipate which of the following? A. A decreased pH and an elevated CO2 B. An elevated pH and a decreased CO2 C. A decreased pH and a decreased HCO3- D. An increased pH with an increased HCO3- 2582
Vomiting 3 days- metabolic alkalosis Choice D is correct. This client has presented with one of the most common causes of metabolic alkalosis: Persistent nausea and vomiting leading to metabolic alkalosis due to the loss of gastric acid, therefore causing an increase in the pH and HCO3-. Hypoventilation and tachycardia are some symptoms the client may experience. Tachycardia occurs from volume depletion, while decreased respiratory effort may be associated with skeletal muscle weakness related to the metabolic alkalosis. Choice A is incorrect. This type of result would be indicative of a client experiencing respiratory acidosis. Choice B is incorrect. This type of result would be indicative of a client experiencing respiratory alkalosis. Choice C is incorrect. This type of result would be indicative of a client experiencing metabolic acidosis.
what type of fluid is 0.9% ns
isotonic
who can B blood donate to
B & AB
who can B receive from
B & O
interventions of HELLP syndrome
-bedrest -blood pressure medication because of hemolysis -blood transfusion because of hemolysis -mag sulf to prevent seizures caused by pregnancy induced htn -corticosteroids for fetal lung development -continuous monitoring of mother and baby
what care should we provide for hepatic encephalopathy
-fall precautions -neuro checks frequently -reorientation -administering prescribed meds
what fluids causes hypervolemic hypernatremia (lots of sodium and fluid)
-hypertonic fluids -sodium bicarb
normal phenytoin levels
10-20
The primary healthcare provider (PHCP) prescribes 400,000 units of penicillin G benzathine. The label on the medication reads penicillin G benzathine 300,000 units / 10 mL. The nurse prepares how many milliliters to administer the appropriate dose? Fill in the blank. Round your answer to the nearest whole number. 7642
13 ml 400000/x = 300000/10, x=13.33
normal sodium
135-145
how long does the operative lung take to recover after a pneumonectomy
2-4 days
what is considered lithium toxicity
2.0 and over
when checking the residual of an ng tube, residuals up to ____ mL can be safely returned to the client
250 ml
what fluid do we give for severe hypovolemic hyponatremia
3% ns
what is raynauds
Episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress
patients with dumping syndrome should drink how long after a meal instead of during?
30-45 mins after
would a client adversely affected with dysphagia likely receive tpn or enteral nutrition
A client who is adversely affected with dysphagia would not likely receive total parenteral nutrition. A client who is adversely affected by dysphagia would most likely receive enteral nutrition rather than parenteral nutrition to meet their nutritional needs. Enteral nutrition can be given via tube feedings in the setting of dysphagia.
hypothyroidism is & can lead to
A disorder caused by a thyroid gland that is slower and less productive than normal hair loss, feeling cold, goiter, fatigue, slow hr, weight gain, constipation, brittle nails high TSH & low T3/T4, or high TSH & normal T3/T4 myxedema coma
The nurse is visiting an older adult client with impaired vision. It would be necessary for the nurse to follow up if the client states which of the following? Select all that apply. A. "I secured my throw rugs to the floor with tape." B. "I switched to using an electric shaver instead of a razor." C. "I usually sit in a recliner while I listen to the television." D. "I use different shaped containers with lids to organize my medications." E. "I use the upstairs bathroom instead of the one downstairs." 6427
A. "I secured my throw rugs to the floor with tape." E. "I use the upstairs bathroom instead of the one downstairs." Choices A and E are correct. An older patient with impaired vision that lives alone has significant risk factors for falls. The nurse should follow up if the client states that they secured the scattered rugs with tape. The client should not have any scattered rugs. Finally, a client climbing the stairs to use the bathroom increases the risk of falls. The nurse should advise the patient to use the closest bathroom. Choices B, C, and D are incorrect. It is appropriate for a client to use an electric shaver versus manual shaving because of the lessened risk of injury. Reclining while watching television poses no threat to the client, and the client should be encouraged to use different shaped containers to organize their medications.
The nurse supervises a novice nurse interviewing a client with a borderline personality disorder. Which client statement would demonstrate the client using transference? A. "You are just like my mother bothering me with these questions." B. "Instead of breaking objects, I have joined a kickboxing class." C. "I cannot be an alcoholic because I still go to work every day." D. "I told my boyfriend if he leaves me, I will kill myself."
A. "You are just like my mother bothering me with these questions." Choice A is correct. This is an example of transference. In transference, the client's unconscious feelings toward a healthcare worker come to the surface that originally stems from someone else. For instance, if a client starts to have hostility towards the healthcare worker because they remind them of a family member with whom they had (or have) a negative relationship. The client bringing up their mother and pinning it on the healthcare worker exemplifies transference. Choices B, C, and D are incorrect. Instead of breaking objects, the client joining a kickboxing class demonstrates sublimination, a positive defense mechanism. The client denying their alcoholism is an example of denial, which is a common defense mechanism used in borderline personality disorder. The client stating she will kill herself if her boyfriend leaves her is an example of manipulation. This is commonly used in borderline personality disorder.
The registered nurse is on a shift in the emergency department of a pediatric hospital. There are four patients in the ED; which patient would the nurse see first? A. A 1-month-old infant that is crying with retractions during inspiration. B. A 5-year-old with pneumonia with 95% pulse oxygen saturation. C. A 10-year-old with diarrhea and vomiting with a potassium level of 3.6 mEq/L. D. A 15-year-old diabetic with a blood glucose level of 190 mg/dL. 2777
A. A 1-month-old infant that is crying with retractions during inspiration. Choice A is correct. The child with inspiratory retractions indicates respiratory distress in the child and should be assessed first. Choice B is incorrect. The child with pneumonia is stable. The nurse does not need to assess this patient urgently. Choice C is incorrect. The child still has an average potassium level even though he is having diarrhea and vomiting. The nurse does not need to assess this child first. Choice D is incorrect. A glucose level of 190 mg/dL is not threatening. The nurse does not need to assess this child first.
A patient recovering from myocardial infarction is presenting with heart rate 110 beats per minute, blood pressure 86/58 mmHg, crackles, shortness of breath, dusky skin, and jugular vein distention. Which action should the nurse recognize as the highest priority? A. Administer medications to increase stroke volume. B. Provide analgesics. C. Obtain a STAT electrocardiogram and troponins. D. Administer fluid replacement to increase blood pressure. 3990
A. Administer medications to increase stroke volume. Choice A is correct. Based on the assessment information, the nurse can determine the patient is experiencing cardiogenic shock secondary to myocardial infarction. Since cardiogenic trauma occurs as a result of the heart not pumping effectively, the highest priority is to increase cardiac output to ensure adequate tissue perfusion. Cardiac Output = Stroke volume x Heart rate. Medications that improve stroke volume will improve cardiac output in cardiogenic shock. The following agents may be used in the pharmacological management of cardiogenic shock. Inotropes: Positive inotropes strengthen the heart contractility (increase stroke volume). Dobutamine has more beta-adrenergic action than alpha activity. It causes peripheral vasodilation while increasing contractility. But in higher doses, it may increase heart rate and exacerbate myocardial ischemia. Vasopressors: In severe shock, vasopressors (Dopamine, Norepinephrine) maintain blood pressure but decrease blood flow to organs. They increase afterload and reduce cardiac output. However, they may be needed initially to provide hemodynamic support. Dopamine increases myocardial contractility and maintains blood pressure. If dopamine fails to support blood pressure, norepinephrine is added. Vasodilators: Vasodilators (Nitroglycerin) decrease venous return (preload) to the heart and decrease peripheral resistance (afterload). Although vasodilators may drop blood pressure, they sustain cardiac output and help achieve hemodynamic stability when combined with vasopressor support in cardiogenic shock. Supplemental oxygen may also be necessary to increase tissue oxygenation. Choice B is incorrect. There is no assessment information in the question that points to chest pain. If a patient in cardiogenic shock is showing signs or complaining of pain, this action would be appropriate, but not the highest priority. Choice C is incorrect. The patient recently experienced MI, so they should already be on a telemetry monitor. ECG will likely be abnormal and troponins may still be elevated. This action may be appropriate but will not change the immediate treatment of shock, so it would not be the highest priority. Choice D is incorrect. Fluid replacement is not the correct immediate action because the patient is showing signs of pulmonary edema (crackles, shortness of breath, jugular vein distention). Cardiac output needs to be improved before considering the additional fluid volume. This action might be appropriate if the patient was in hypovolemic shock, not cardiogenic. Subject Adult Health Lesson Cardiovascular Client Need Area Physiological Adaptation
You are completing a health history of a 4-year-old male at the primary care office. When checking with his mother about milestones in fine motor development. You would expect that the 4-year-old is able to do which of the following? Select all that apply. A. Complete a puzzle with 5 or more pieces B. Copy a triangle onto a piece of paper C. Dress himself D. Use a fork to eat dinner 5348
A. Complete a puzzle with 5 or more pieces B. Copy a triangle onto a piece of paper C. Dress himself D. Use a fork to eat dinner Choices A, B, C, and D are all correct. These are all fine motor skills that are expected in preschool-age children, who are 3 to 5 years old. Other fine motor developmental milestones include: pasting things onto paper, completing puzzles with 5 or more pieces, cutting out simple shapes with scissors, and brushing their teeth.
The nurse is caring for an assigned client. Which prescription requires clarification with the primary healthcare provider (PHCP) based on the laboratory data? Calcium: 9.7 Potassium: 3.3 Sodium: 145 BUN: 18 Cr 2.0 Select all that apply. A. Furosemide 40 mg PO Daily B. Metformin 1-gram PO Daily C. Ibuprofen 800 mg PO Daily PRN Pain D. Citalopram 20 mg PO Daily E. Lisinopril 20 mg PO Daily 6590
A. Furosemide 40 mg PO Daily B. Metformin 1-gram PO Daily C. Ibuprofen 800 mg PO Daily PRN Pain E. Lisinopril 20 mg PO Daily Choices A, B, C, and E are correct. Furosemide, Metformin, Ibuprofen, and Lisinopril are all medications that may lead to nephrotoxicity, & it is a red flag because Cr is high even though BUN is normal. The laboratory data showed hypokalemia and an increase in creatinine which should prompt the nurse to clarify the prescriptions with the PHCP.
The registered nurse (RN) observes licensed practical/vocational nurses (LPN/VN) care for assigned clients. Which of the following actions by the LPN would require the RN to intervene? Select all that apply. A. Irrigates an indwelling catheter with warm tap water. B. Administers glargine insulin for a client with nothing by mouth (NPO) status. C. Obtains a 12-lead electrocardiogram for a client with hyperkalemia. D. Clamps a chest tube while the client ambulates. E. Repositions a client who requires log rolling by using a gait belt. 6512
A. Irrigates an indwelling catheter with warm tap water. D. Clamps a chest tube while the client ambulates. E. Repositions a client who requires log rolling by using a gait belt. Choices A, D, and E are correct. An indwelling catheter is irrigated with sterile water or sterile normal saline. Irrigating an indwelling catheter with tap water would introduce pathogens into the bladder. A chest tube should never be clamped as it will cause a rapid increase in intrathoracic pressure, which may cause a tension pneumothorax. A client requiring log rolling should be repositioned with more than one staff member and with a transfer sheet. A gait belt is used when a patient is ambulating. Choices B and C are incorrect. Glargine insulin is long-acting insulin with no peak. This insulin does not need to be withheld when a client is NPO. This insulin provides a client with basal glucose control preventing hyperglycemia. An LPN obtaining a 12-lead electrocardiogram for a client with hyperkalemia is an appropriate action. 32% correct
A nurse caring for a client on digoxin therapy receives the client's serum digoxin level taken earlier in the day, noting the result indicating 2.5 ng/mL (3.2 nmol/L). Which of the following should be the nurse's initial response? A. Notify the primary health care provider (PHCP) regarding this laboratory result. B. Review the client's medical record for the most recent pulse rate. C. Record this laboratory value as within the therapeutic range. D. Administer the next dose of digoxin as prescribed. 2583
A. Notify the primary health care provider (PHCP) regarding this laboratory result. Choice A is correct. The therapeutic range for digoxin is 0.5 to 2.0 ng/mL [0.64 to 2.6 nmol/L]). Levels greater than 2.2 ng/mL (2.8 nmol/L) indicate toxicity. The client's most recent digoxin level of 2.5 ng/mL indicates toxicity. The nurse's initial response should be to notify the client's healthcare provider (HCP) of this laboratory value. Following the notification, the nurse should document the notification. Choice B is incorrect. Due to the amount of time that has elapsed since the prior assessment of the pulse rate, the nurse should perform a new assessment of the client's vital signs following the receipt of the digoxin laboratory result. Ideally, following the nurse paging the health care provider (HCP), the nurse could obtain the client's vital signs and relay those to the HCP once the HCP returns the call. Choice C is incorrect. This value is not within the therapeutic range; therefore, it cannot be recorded as such on the client's flow sheet. Choice D is incorrect. Due to the client's serum digoxin level indicating toxicity, all further doses of the medication should be held until further notice, which will include the client's serum digoxin level returning to a therapeutic level.
The nurse is developing a plan of care for a client who has epilepsy and is undergoing an electroencephalogram. Which of the following should the nurse include in the client's plan of care? Select all that apply. A. Provide padding to the side rails B. Verify suction is at bedside and working properly. C. Keep bite block at bedside in case of seizure. D. Ensure nasal cannula is available and working at the bedside. E. Establish peripheral vascular access 4518
A. Provide padding to the side rails B. Verify suction is at bedside and working properly. E. Establish peripheral vascular access Choices A, B, and E are correct. Ensuring the side rails are raised and padded will provide a safe environment for the client in case of a seizure. It is imperative to have suction ready at the bedside should the client vomit during a seizure. Timely clearing of the airway will prevent aspiration, maintain a patent airway, and keep your client safe. Suctioning the client should only occur once the seizure has terminated, as it is contraindicated to putting objects in the client's mouth. Ensuring that peripheral vascular access is essential because if the client has a seizure, parenteral benzodiazepines (diazepam/lorazepam) are necessary. Choices C and D are incorrect. It is not appropriate to put a bite block or any other object into a client's mouth that is seizing. This could result in injury to yourself or the client. Nursing priorities during a seizure are ensuring the client is safe and has a patent airway. While it is essential to have oxygen available in the room, a nasal cannula is inappropriate for this client. There should be a face mask or Ambu bag readily available that is an appropriate size and connected to 10 L of 100% oxygen.
The nurse and the Licensed Practical Nurse (LPN) are assigned to a busy medical unit. Which of the following tasks would be appropriate for an LPN to do? Select all that apply. A. Reinforcing newborn care education to a 24-year-old first-time mother. B. Adjustment of a 68-year-old stable patient's cervical traction as ordered by the provider. C. Obtaining a fecal occult blood sample from a 16-year-old patient with ulcerative colitis. D. An assessment of a 36-year-old man newly admitted for chest pain. 4560
A. Reinforcing newborn care education to a 24-year-old first-time mother. B. Adjustment of a 68-year-old stable patient's cervical traction as ordered by the provider. C. Obtaining a fecal occult blood sample from a 16-year-old patient with ulcerative colitis. Choices A, B, and C are correct. Initial teaching does not fall within the scope of practice of an LPN. A registered nurse always performs initial instruction. However, LPNs can "reinforce" education (Choice A) to a client. Generally, the tasks that require "critical thinking" should not be delegated to an LPN. Tasks such as obtaining stool samples for occult blood (Choice B) and following health care provider's orders to adjust cervical traction (Choice C) are all within the scope of practice for an LPN and do not require a critical thinking process. LPNs can also apply and remove the cervical collar on stable spinal patients. If cervical traction is being applied for neck fractures, RNs or LPNs should not remove or add the traction weight since such patients have spinal instability. For an unstable client in traction, an RN should assess the neurovascular status, and document as ordered. Assessment or caring for unstable clients is not within the scope of LPN practice. However, cervical traction may also be applied for other reasons such as osteoarthritis, etc. In a client with stable clinical status and predictable outcomes, adjusting cervical traction as ordered by the provider falls within the scope of LPN practice. Choice B does not mention any unstable findings that fall outside the scope of an LPN. For any question regarding delegation to LPNs, please make sure you determine the complexity and predictability of the client. A Registered Nurse (RN) is responsible for determining the level of complexity and predictability of a client's presentation. The RN documents this in an established plan of care. The LPNs' accountability for the outcomes of care and independence of practice depends mostly on the predictability and complexity of the client presentation. Please note that the scope of practice is based on decisions around a task, not the job itself. Predictability involves the assessment of how effectively a health condition is managed, the changes likely to occur, and whether the type and timing of change can be predicted. Complex or unstable situations are those where the patient's status is fluctuating with unexpected responses resulting in an elaborate plan of care. In cases where there is a high degree of complexity and a low degree of predictability, RNs are solely accountable for outcomes of care ("unstable" situations). The LPN practice in these cases is DIRECTED by the RN in that decisions of care are made by the RN only. Interventions change often, and patients' responses to intrusions may be unexpected or high risk. In acute cases where there are equal degrees of complexity and predictability, RNs and LPNs share accountability for the outcomes of care. LPN practice is COLLABORATIVE with the RN in that decisions of responsibility are made by the RN and LPN together. In stable situations where there is a low degree of complexity and a high degree of predictability, the plan of care can be readily established. It can be managed with interventions that have predictable outcomes. Here, LPNs are solely accountable for the results of care. LPN practice is INDEPENDENT of the RN. The LPN is responsible for determining that the skills are appropriate for the patient. Planning is not within the scope of an LPN. LPNs cannot formulate a care plan but may collaborate with an RN's care plan. In short, one may remember a popular mnemonic "DO NOT DELEGATE WHAT YOU EAT (LPNs cannot Evaluate, Assess, Teach)." Choice D is incorrect. LPNs can perform focused assessments. However, initial and comprehensive assessments should always be performed by a registered nurse or an attending physician. The client with chest pain may involve a high degree of complexity and a low degree of predictability. Such assessment and planning require the critical thinking process. 24% correct
The nurse is performing a physical assessment. The nurse should assess the client's visual acuity by obtaining which of the following? A. Snellen chart B. Tonometer device C. Penlight D. Slit lamp 4777
A. Snellen chart Choice A is correct. Having a client stand 20 feet away from a Snellen chart is an appropriate assessment tool to determine a client's visual acuity. Snellen chart can be used to diagnose myopia ( near-sightedness) and hyperopia ( far-sightedness). While using a Snellen chart, the normal vision at a distance is set at 20/20. The numerator represents the distance that the patient is away from the chart ( in feet). The denominator represents the distance at which a person with normal vision can clearly read the smallest font that the patient perfectly sees at 20 feet. Choices B, C, and D are incorrect. A tonometer device is used to determine intraocular pressure. The normal intraocular pressure is generally between 10- and 20 mm Hg. A tonometer helps diagnose ocular problems such as glaucoma. A penlight can be used for various ocular assessments, including if the pupils are reactive to light. A slit lamp is a tool used by an advanced provider that may determine any abnormality in the cornea, lens, or anterior vitreous humor. Subject Adult Health Lesson Visual/Auditory Client Need Area Health Promotion and Maintenance 58% correct
You are providing education to a mother who has been laboring for 18 hours with hypotonic contractions. Which of the following educational points are appropriate to include? Select all that apply. A. The pain she is experiencing is expected and she has options for pain medication should she choose it. B. Bedrest is the safest for the fetus. C. Oxytocin may be prescribed. D. Right-side lying is the best position for her to rest.
A. The pain she is experiencing is expected and she has options for pain medication should she choose it. C. Oxytocin may be prescribed. Choices A and C are correct. This mother is experiencing dystocia, or prolonged, difficult labor. Her hypotonic contractions have been ineffective in causing dilation and effacement, and she is not progressing. Dystocia is known to be extremely painful but there are many options for pain medication. Some mothers may feel ashamed asking for pain medication, so education regarding her options is critical (Choice A). Oxytocin, or Pitocin, is a medication that could be prescribed for hypotonic contractions. This medication will help to coordinate and intensify the mother's contractions, hopefully helping her progress past the prolonged labor (Choice C). Choice B is incorrect. The best rest is not appropriate for this mother, considering her labor is hypotonic. Dystocia can present in different forms, but for this mother, her hypotonic contractions have been ineffective in causing dilation and effacement, and she is not progressing. She should be encouraged to walk, which could help get her contractions into a coordinated pattern. Choice D is incorrect. The left-side lying is the best position for her to rest, not the right-side. The left-side lying is the encouraged position of rest for all expectant mothers, as it promotes optimal oxygenation to the placenta and fetus.
A patient with a chest tube drainage system has just been admitted to the unit. The nurse notes that the fluid in the water seal column is not fluctuating. The nurse knows that the best explanation of fluctuation cessation is that: A. There may be fibrin clots in the tubing B. The lung is collapsing C. There has been an increase in intrapleural pressure D. The tubing may have become dislodged from the chest 4020
A. There may be fibrin clots in the tubing Choice A is correct. Fibrin clots from the lungs sometimes become lodged in the chest tube system resulting in the cessation of fluctuations in the water seal column. This may also occur when the lung becomes fully expanded. Choice B is incorrect. A collapsing lung is usually the indication for a chest tube. Choice C is incorrect. An increase in pleural pressure is healthy and fluctuates, causing movement in the water seal chamber. Choice D is incorrect. All functions and displays will cease to function correctly if the tubing is dislodged from the chest. This is not the most likely option. 29% correct
A client with a history of long-standing hypertension and hyperlipidemia is complaining of shortness of breath and weakness in the legs. Which of the following may be occurring? A. The patient may be having a heart attack. B. The patient is exhibiting signs of pulmonary embolism. C. The patient may be experiencing the onset of peripheral vascular disease. D. The patient is developing chronic obstructive pulmonary disease. 4647
A. The patient may be having a heart attack. Choice A is correct. Myocardial infarction (MI) may present with symptoms of shortness of breath and muscle weakness. Silent MI is something that may not occur with pain. Other symptoms of myocardial infarction include: Chest discomfort. Most heart attacks involve pain in the center of the chest that lasts more than a few minutes - or it may go away and then return. It can feel like uncomfortable pressure, squeezing, fullness, or pain. Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, back, neck, jaw, or stomach. Shortness of breath can occur with or without chest discomfort. Other signs include breaking out in a cold sweat, nausea, or lightheadedness. Since hyperlipidemia has no symptoms, it can cause damage before an individual realizes there is a problem. It can cause atherosclerosis and limit blood flow, increasing the risk of heart attack or stroke. Factors that can increase your risk of bad cholesterol include a poor diet, including foods that are high in saturated fat (found in animal products), and trans fats (found in some commercially baked products) can contribute to an elevated cholesterol level. Additionally, obesity, lack of exercise, age, and history of diabetes can increase the chances of experiencing hyperlipidemia. Hypertension is often referred to as "the silent killer" because some people do not experience any significant symptoms until their blood pressure is extraordinarily elevated or if symptoms (such as headache, palpitations, and dizziness) become bothersome. It is a significant public health problem and an essential area of research due to its high prevalence as well as a significant risk factor for cardiovascular diseases and other complications. The combination of hypertension and hyperlipidemia can result in several harmful health consequences. Choice B is incorrect. While a pulmonary embolism (PE) can present with shortness of breath, it is essential to correlate the answers with risk factors present in the question (hypertension and hyperlipidemia). Hypertension and hyperlipidemia are not necessarily risk factors for PE. Choice C is incorrect. While peripheral vascular disease can present with weakness and leg pain, it does not cause shortness of breath. Choice D is incorrect. While COPD can present with shortness of breath, it is not associated with hypertension and hyperlipidemia as risk factors.
what is isometric exercise
An exercise in which muscles are contracted and held for a few seconds, but the body doesn't move. Isometric exercises involve applying pressure against a stable object, like pressing the hands together or pushing an extremity against a wall.
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 4723
B. Administering PO medications to patients on the unit C. Removal of a urinary catheter D. Completing a dressing change Choices B, C, and D are correct. 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 RN must understand the limits prescribed by the state's nurse practice act since some states allow more freedom than others. Choice A is incorrect. The LPN/LVN role does NOT include assessment, initial patient education, or any activity that requires critical nursing decision-making. 74% correct
The nurse is caring for a patient following the placement of a gastrostomy tube. The Unlicensed Assistive Personnel (UAP) reports that the patient has thin, pale, and yellow-green drainage with a sour odor and a small amount of blood. Which is the best action for the nurse to take? A. Obtain specimen for culture. B. Assess the drainage. C. Instruct the UAP to obtain a full set of the patient's vitals. D. Assess patient's temperature for fever. 4278
B. Assess the drainage. Choice B is correct. The nurse should assess the patient's drainage to confirm it is within reasonable expectations for the patient's condition. Up to 1500 mL/day of thin, pale, yellow-green drainage with sour odor and a small amount of blood would be expected for this patient. Choice A is incorrect. There would be no reason to culture this drainage since it is within expectations for the patient's condition. Choice C is incorrect. This would not be an indication to collect a unique set of vitals since this drainage is expected with the placement of a gastrostomy tube. If there is any doubt, the nurse should visualize and assess the patient, not delegate this task to the UAP. Choice D is incorrect. There would be no reason to expect the patient would be febrile since this drainage is usually seen with the gastrostomy tube. 70% correct
While working in an outpatient pediatric clinic, the RN knows that as a mandated reporter it is important to monitor for suspected child abuse in all clients. The most common physical sign of child abuse is _________. A. Malnourishment B. Bruising C. Poor hygiene D. Burns 6167
B. Bruising Choice B is correct. The most common physical sign of child abuse is bruising. The physical maltreatment of a child can manifest in many ways, but bruising is indeed the most commonly recognized physical sign that starts off the investigation. It is important to note that all nurses are mandatory reporters of abuse. If they have any suspicion that a child is being abused, they are required by law to report it. Choice A is incorrect. Malnourishment is not a sign of physical abuse, rather it is a sign of neglect. Neglect is to fail to care for properly, so if the child is malnourished and the parent is not providing them sufficient or proper nutrition, the child is being neglected. Choice C is incorrect. Poor hygiene is not a sign of physical abuse, rather it is a sign of neglect. Neglect is to fail to care for properly, so if the child is very dirty, disheveled, and clearly uncared for in the home environment, they are being neglected. Choice D is incorrect. Burns are a sign of physical abuse, but they are not the most common type. The most common physical sign of child abuse is bruising.
Which of the following are management functions that nurse managers fulfill? Select all that apply. A. Empowering B. Directing C. Planning D. Organizing 2454
B. Directing C. Planning D. Organizing Choices B, C, and D are correct. The five major management functions are planning, organizing, staffing, directing, and controlling. Each of these functions are discussed in detail in the additional information section below. Choice A is incorrect. Although effective leadership often utilizes empowerment, it is important to note that leadership and management differ from one another. Empowering others is not considered a management function. 53% correct
The patient is admitted to the ICU following a motor vehicle accident in which he sustained multiple fractures. He is scheduled to go to surgery for repair of his fractured femur. The physician has ordered famotidine 20 mg IV as one of the pre-operative medications. The nurse knows that this medication will: A. Decrease pain B. Help prevent ulcers C. Promote post-op healing D. Treat nausea
B. Help prevent ulcers
Your client presents with conjunctivitis, numbness in the extremities, and atrioventricular heart block following a tick bite that occurred two months ago. You suspect Lyme disease. Which stage of Lyme disease does this presentation represent? A. First stage B. Second stage C. Third stage D. Fourth stage 4324
B. Second stage The first stage of Lyme disease usually presents with a red rash the size of a pimple or as a large ring. The patient generally complains of flu-like symptoms. The second stage has manifestations of cardiac, ocular and neuro involvement. Such as av block, neuropathy, conjunctivits. The third stage of lyme disease is joint involvement and arthritis there's no 4th stage
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
B. Strict intake and output measurements
The ICU nurse is taking care of a client who sustained a head injury due to a motorcycle accident. In the morning, the client is responsive to pain and assumes a decorticate position. After 4 hours, which assessment would indicate to the nurse that the client needs immediate intervention? A. The client displays purposeful movement when the nurse performs a sternal rub. B. The client extends his arms and legs when the nurse rubs his sternum. C. The client flails his arms and legs when a noxious stimulus is applied. D. The client moves his fingers upon request.
B. The client extends his arms and legs when the nurse rubs his sternum.
Which of the following is a priority that must be considered and critically thought about by the nurse before referring a client to a healthcare setting or service external to their current healthcare setting? A. The external healthcare setting's or service's cultural values and beliefs. B. The external healthcare setting's or service's admission criteria. C. The current healthcare facility's actual and potential census. D. The current healthcare facility's actual and potential case mix. 2382
B. The external healthcare setting's or service's admission criteria. Choice B is correct. The external healthcare setting's or service's admission criteria is the priority that must be considered and critically thought about by the nurse before referring a client to a healthcare setting or service external to their current healthcare setting. Choice A is incorrect. Although the external healthcare setting's or service's cultural values and beliefs should be considered, it is not the priority that must be found and critically thought about by the nurse before referring a client to a healthcare setting or service external to their current healthcare setting. Choice C and D are incorrect. The current healthcare facility's actual and potential census is not a consideration that the nurse should think about before referring a client to a healthcare setting or service external to their current healthcare setting; it is the client's needs that must be considered. 55% correct
You are a home health nurse caring for an elderly client in her home. She has children and grandchildren. However, they live far from the couple and they typically visit only once or twice a year. The client is beginning to show some signs of Alzheimer's. The husband is 88-years-old and had a stroke that left him with right-sided weakness. What support should you give the husband in terms of caring for his wife? A. You should advise the couple to move closer to their children so that they can care for their father. B. You should teach the husband about the progression of Alzheimer's and the need to promote as much independence as possible. C. You should teach the husband about this progressive disease and the need to do all that he can for his wife to help prevent anxiety and depression. D. You should advise the couple to decrease their social activities in order to preserve the wife's dignity and self-esteem. 4222
B. You should teach the husband about the progression of Alzheimer's and the need to promote as much independence as possible. Choice B is correct. You should teach the husband about Alzheimer's and the need to promote as much independence as possible. Adults diagnosed with dementia are faced with a disease that is irreversible and progressive. The loss of judgment, reasoning, memory, and communication skills leads to an inability to discern risk and danger. Dementia can limit a person's ability to live independently, which can be very distressing for the individual and family members. Caregivers need to embrace a patient-centered approach that allows people with dementia to maintain as much autonomy and control as possible, while still preserving their safety. Choice A is incorrect. Moving closer to the children may not be appropriate advice, mainly if the children are unable or unwilling to care for their mother. Choice C is incorrect. Client's with Alzheimer's disease and other disabilities, including physical disabilities, should be coached and encouraged to be as independent as possible. Choice D is incorrect. The couple should be advised to continue their social activities.
A nurse listens to a 2-year old's lungs and hears inspiratory stridor. After suspecting an upper airway obstruction, what is the nurse's first action? A. Tell the patient to cough to relieve the obstruction B. Apply a bag valve mask C. Perform the Heimlich maneuver D. Perform a blind finger sweep E. Place the patient in prone position 4486
C. Perform the Heimlich maneuver they are choking & conscious as far as we know so we do the heimlich not a because the kid is 2 & cannot be told to cough, is not old enough to cough it out anyways. READ ALL THE DETAILS OF THE QUESTION
A client scheduled for hip replacement surgery expresses anxiety to the nurse regarding the upcoming surgery. Which response by the nurse is most therapeutic? A. "Everyone is nervous before any surgery. What you feel is completely normal." B. "Here's what's going to happen to you during the procedure. I will explain it to you in detail." C. "Can you tell me what you have been told about the surgery?" D. "Let me tell you about the care you will receive and the pain you should anticipate after the surgery." 2590
C. "Can you tell me what you have been told about the surgery?"
The nurse is supervising an LPN in the psychiatric ward. Which statement by the LPN would warrant attention by the nurse? A. "I bathed the client already this morning" B. "I will be attending a team meeting in the next hour." C. "I already gave the client his intravenous Olanzapine." D. "I will be joining the clients with their games today in the day room." 2769
C. "I already gave the client his intravenous Olanzapine." Choice C is correct. The LPN cannot give intravenous medications. LPNs can administer oral medications under RN supervision or under the guidance of the RN. Here, the LPN needs to be reminded that he/she cannot deliver any medication (except saline and heparin flushes) by direct IV push technique. Choice A is incorrect. The LPN can assist the clients in their activities of daily living. Choice B is incorrect. The LPN needs to be included in the team meeting; he/she is a vital part of the team. Choice D is incorrect. The LPN can join activities with the clients to ensure their safety. 90% correct
The nurse is caring for a client who is taking prescribed venlafaxine. Which statements made by the client would be highly concerning to the nurse? A. "I have trouble sleeping at night." B. "I experience diarrhea at least once a day." C. "I just cannot go on like this anymore." D. "I am using artificial tears for my dry eyes."
C. "I just cannot go on like this anymore."
A nurse receives a client who has just returned from a circular skin punch biopsy to confirm a skin cancer diagnosis. The nurse should prioritize observing the site for: A. Dehiscence B. Infection C. Bleeding D. Swelling 2674
C. Bleeding Choice C is correct. A punch biopsy is usually performed using a circular blade ranging in size from 1 mm to 10 mm. The priority post-procedure concern is to monitor the site for bleeding. Choice A is incorrect. Dehiscence is a partial or total separation of previously approximated wound edges due to a failure of proper wound healing. This scenario typically occurs 5 to 8 days following surgery when healing is still in the early stages. Additionally, dehiscence is more likely to occur in extensive wounds of the abdomen or thorax than minor wounds similar to those incurred while undergoing a punch biopsy. Choice B is incorrect. Although infection is always a concern when a break in the skin occurs, this is not the primary concern at this time for two reasons. First, this wound was performed in a sterile, controlled environment. Second, if an infection is present, it would be too early for any signs or symptoms of an infection to be present. Choice D is incorrect. Swelling is a normal reaction to any event that breaks the skin. 80% correct
The nurse needs to assess the use of complementary and alternative medicine (CAM) because: A. Patients should be warned that most CAM therapies are potentially dangerous B. Additional treatment may not be needed if the patient is using CAM C. CAM therapy could interact with prescription and over-the-counter medications D. Most CAM therapies are essentially ineffective 4188
C. CAM therapy could interact with prescription and over-the-counter medications
The nurse has received the following prescriptions for newly admitted patients. The nurse should first administer which of the following? A. Subcutaneous (SubQ) epoetin for anemia B. By-mouth (PO) oxycodone pain C. Intravenous (IV) fluids for sepsis D. Intramuscular (IM) hydroxyzine for anxiety
C. Intravenous (IV) fluids for sepsis
The nurse is caring for a hospitalized infant due to dehydration and failure to thrive. The nurse notes that her mother is a drug user. With this knowledge, the nurse would expect the child to develop: A. Autonomy B. Trust C. Mistrust D. Shame and doubt 2805
C. Mistrust
A 16-year-old was rushed to the emergency department after falling off his motorcycle earlier in the day. He sustained a closed head injury but is still conscious. The physician in the ED orders a set of medications for the client. Which medication should the nurse question? A. Ranitidine 50 mg IV B. Docusate sodium 50 mg PO C. Morphine sulfate 10 mg IM D. Promethazine 25 mg IM 3655
C. Morphine sulfate 10 mg IM Morphine sulfate is a narcotic analgesic. Narcotic analgesics should not be given to patients with a head injury as it masks signs of increased intracranial pressure.
The RN is caring for a 72-year-old patient on the medical-surgical floor. Which of the following factors would not be an indication for this patient to receive parenteral nutrition? A. Dysphagia B. Gastrointestinal obstruction C. Severe anorexia nervosa D. Severe burns
C. Severe anorexia nervosa
The nurse is triaging a child with suspected impetigo. Which action should the nurse take? Select all that apply. A. Initiate droplet precautions B. Set up a decontamination room C. Use a disposable blood pressure cuff D. Initiate contact precautions E. Apply sterile gloves while examining the client 4371
C. Use a disposable blood pressure cuff D. Initiate contact precautions Choices C and D are correct. Impetigo is a contagious infection of the skin commonly seen in young children. This condition is highly infectious, and the nurse should utilize standard and contact precautions. Part of this involves using disposable client care equipment (blood pressure cuff, thermometer, etc.). Contact precautions require the nurse to wear a gown and gloves when engaging in client care. Choices A, B, and E are incorrect. Droplet precautions are not appropriate for impetigo. It is spread through contact with the skin, not respiratory droplets. Although very contagious, a decontamination room is not indicated for impetigo. Sterile gloves are not necessary to don during client care. Using this would be a waste of organizational resources.
what is the acronym for hyperkalemia treatment
CRIED C-calcium iv R-remove k I-increase k excretion (diuretics, kayexelate) E-enhance k uptake into the cells (d5w, regular insulin, sodium bicarb) D-dialysis
The most serious adverse effects of hypophysectomy surgery is
CSF leakage, increased intracranial pressure, infection, and diabetes insipidus
A nurse is taking care of a client undergoing cerebral angiography. Which statement by the client would most warrant additional attention from the nurse? A. "I feel like I'm going to vomit." B. "I hope my results are okay." C. "It's getting a bit hot in here." D. "My throat is getting a bit itchy, and my eyes are getting watery." 2490
D. "My throat is getting a bit itchy, and my eyes are getting watery." Choice D is correct. Iodinated contrast materials are used during cerebral angiography, potentially causing severe allergic reactions. Here, the client's itchy throat and watery eyes are classic indications of an allergic reaction that may progress to an anaphylactic reaction. Symptoms of a severe anaphylactic reaction include airway compromise due to laryngeal edema or angioedema (stridor), bronchoconstriction (wheezing, cough, and dyspnea), and/or circulatory collapse (shock). This is an extreme emergency, as the client's airway is at risk of compromise. The nurse should promptly assess the client for additional signs of anaphylaxis, notify the health care provider (HCP), and initiate interventions to stop further symptom progression while alleviating the current manifestations. Choice A is incorrect. Nausea is likely a reaction to the administration of contrast material, presumably capable of being alleviated by the administration of a PRN (as needed) intravenous antiemetic medication. While this statement should be of concern to the nurse, this is not the priority concern. The nurse should prioritize airway-related symptoms in this client.
The nurse is precepting a graduate nurse as they perform resuscitation on an adult with cardiac arrest. Which action by the graduate requires immediate follow-up by the nurse? A. Assesses the client's pulse by palpating the carotid artery. B. Allows for chest recoil after every chest compression. C. Compresses at a depth of 2 inches on the center breastbone. D. Asks for an automatic external defibrillator after one cycle of CPR.
D. Asks for an automatic external defibrillator after one cycle of CPR.
Which of the following clients is the most likely to receive total parenteral nutrition? A. A client who is adversely affected with dysphagia. B. A client who is adversely affected with aphasia. C. A client with a dangerous positive nitrogen balance. D. A client with a dangerous negative nitrogen balance 3725
D. A client with a dangerous negative nitrogen balance Choice D is correct. A client with a dangerous negative nitrogen balance is most likely to receive total parenteral nutrition (TPN). For example, a client who has endured a severe burn injury may have a negative nitrogen balance, which requires the administration of total parenteral nutrition. Amino acids are building blocks of proteins and nitrogen is an essential component of amino acids. Therefore, protein metabolism can be determined by measuring nitrogen balance. Nitrogen balance is given by subtracting nitrogen output from nitrogen input. A negative balance means the amount lost is greater than the amount ingested. A negative nitrogen balance is used to assess malnutrition. Clients with severe negative nitrogen balance will benefit from total parenteral nutrition. Other conditions where total parenteral nutrition is indicated include advanced cancer, advanced acquired immunodeficiency disorder, and severe gastrointestinal disease, which requires complete bowel rest. Choice A is incorrect. A client who is adversely affected with dysphagia would not likely receive total parenteral nutrition. A client who is adversely affected by dysphagia would most likely receive enteral nutrition rather than parenteral nutrition to meet their nutritional needs. Enteral nutrition can be given via tube feedings in the setting of dysphagia. Choice B is incorrect. A client who is adversely affected with aphasia would not likely receive parenteral nutrition. A client who is negatively affected by aphasia has a communication disorder, rather than a nutritional disease or nutritional need. Choice C is incorrect. A client with a dangerous positive nitrogen balance would not be likely to receive parenteral nutrition to meet their nutritional needs. Additional protein is not necessary.
Which of the following members of the intradisciplinary team should be consulted for an infant suspected of having Celiac disease? A. Pharmacist B. Pulmonologist C. Occupational therapist D. Dietician 5941
D. Dietician Choice D is correct. Consulting with a dietician is of the utmost importance for the patient who is suspected of having Celiac disease. The dietician is the expert in this area and will provide support, education, and a dietary plan for this patient. Learning to avoid gluten can be difficult for the family, so the dietician is the best resource to help them navigate this. Choice A is incorrect. A pharmacist may be involved in the intradisciplinary team, but there is another specialist of particular importance in the answer choices (a dietician) for the patient with Celiac disease. Choice B is incorrect. It is not necessary to consult with a pulmonologist for a patient with Celiac disease. They should not be experiencing respiratory issues, as Celiac disease is a gastrointestinal disorder. Choice C is incorrect. It is not necessary to consult with an occupational therapist for a patient with Celiac disease. Celiac disease is a gastrointestinal disorder that should not affect the normal functioning and ADLs of this patient.
When orienting an older patient to the safety measures in his hospital room. What is the priority component of this admission routine? A. Explain how to use the telephone B. Introduce the patient to his roommate C. Review the hospital policy on visiting hours D. Explain how to operate the call light 5003
D. Explain how to operate the call light
Which lab value alteration is likely a result of corticosteroid treatment in a type 1 diabetic patient diagnosed with pneumonitis? A. Potassium 5.1 mEq/L (5.1 mmol/L) B. Sodium 138 mEq/L (138 mmol/L) C. Albumin 3.5 g/dL (5.07 µmol/L) D. Glucose 200 mg/dL (11.1 mmol/L) 4618
D. Glucose 200 mg/dL (11.1 mmol/L) Choice D is correct. Type 1 diabetes is characterized by hyperglycemia secondary to the body's inability to create insulin. Corticosteroids cause a rise in blood sugar even in a non-diabetic patient by increasing insulin resistance and triggering the liver to release additional glucose. Prednisone and other steroids can cause a spike in blood sugar levels by making the liver resistant to insulin. Steroids can make the liver less sensitive to insulin because they cause it to keep releasing sugar, even if the pancreas is also releasing insulin. This continued release of sugar triggers the pancreas to stop producing the hormone.
Which of the following is an example of the appropriate care of a client with neutropenia? A. Usual hand washing B. Offer a semi-private room C. Provide fresh fruits and vegetables D. Have the patient wear a mask when outside of their room
D. Have the patient wear a mask when outside of their room
You are caring for a client who is using the defense mechanism of denial after hearing a diagnosis of HIV/AIDS. This client is stating that this diagnosis must be a mistake. You should: A. Know that all reasonable clients should know that mistakes like this are rarely made in healthcare. B. Tell the client that this is not a mistake and that the client must accept this diagnosis as accurate. C. Recognize the fact that this denial of the diagnosis is not rationale or adaptive for the client. D. Recognize that the use of this defense mechanism is useful and constructive for the client at this time.
D. Recognize that the use of this defense mechanism is useful and constructive for the client at this time. Choice D is correct. You should recognize that the use of this defense mechanism of denial is useful and constructive for the client at this time because this denial protects the client from an extreme stressor until the client can cope with it. Choice A is incorrect. It is inaccurate to think that all reasonable clients should know that mistakes like this are rarely made in healthcare for two reasons: mistakes are sometimes made and many sensible clients adapt with an ego defense mechanism such as denial. Choice B is incorrect. The nurse should not tell the client that this is not a mistake and that the client must accept this diagnosis as accurate. Nurses and other healthcare professionals must not strip defense mechanisms away from clients because these ego defense mechanisms are protective for the client. Choice C is incorrect. The nurse should know that denial, although not rational or conscious, is adaptive for the client.
The nurse reviews the client's continuous telemetry monitor and observes the following. As the nurse reviews the client's current medications, which prescribed medication is most likely cause a tracing of sinus bradycardia? A. Losartan B. Nitroglycerin transdermal patch C. Clonidine D. Verapamil 7897
D. Verapamil Choice D is correct. This tracing reflects sinus bradycardia. Verapamil is a calcium channel blocker, and a property unique to verapamil is that it decreases both blood pressure and heart rate. Verapamil may be indicated for the prevention of migraine headaches, hypertension, or vascular spasms. Choices A, B, and C are incorrect. Losartan is an ARB and may be used for hypertension or congestive heart failure. This medication does not lower heart rate. Nitroglycerin via a transdermal patch would increase the heart rate because of the reflex tachycardia it causes as it decreases blood pressure. Clonidine is an effective agent in treating hypertension and does not lower heart rate. Subject Adult Health Lesson Cardiovascular Client Need Area Physiological Adaptation Client Need Topic Alterations in Body Systems Question Type 44% correct
You are a nurse working in a medical unit with a trained aide. You have admitted a new patient and have received the following orders. Place the answer choices in the correct sequential order based on the prioritization for performing these tasks. Amoxicillin 250 mg by mouth first dose now and then every 6 hours. Insulin 2 units Humulin subcutaneous now. CBC, electrolytes, urinalysis, and 2 sets of blood cultures. Vital signs every 4 hours.
Insulin 2 units Humulin subcutaneous now. CBC, electrolytes, urinalysis, and 2 sets of blood cultures. Amoxicillin 250 mg by mouth first dose now and then every 6 hours. Vital signs every 4 hours. While prioritizing the orders from the physician, the nurse should look for the orders that specify urgency - such as "STAT" or "as soon as possible" or "now." A "now" prescription for insulin should be done as soon as possible after the patient arrives on the floor. The nurse should understand that insulin lowers the patient's blood sugar and can help to prevent sequelae associated with high blood sugar. Since the patient is being initiated on antibiotics, it appears there is a suspicion of infection. In patients with suspected infection, glycemic control is helpful in achieving good outcomes. Collecting the labs is the second task that should be completed since blood cultures have been ordered. Blood cultures must always be collected BEFORE the administration of an antibiotic so that the antibiotic does not interfere with the results. Obtaining cultures after antibiotics may give false-negative results. As soon as the blood cultures are drawn, the nurse should administer the amoxicillin since it is ordered for "now" and then every 6 hours. In almost any infection including sepsis, guidelines allow a 1 to 2 hour window from the time of patient arrival before which antibiotics can be administered. Blood cultures must be obtained before antibiotics. Finally, vital signs are the lowest priority for the nurse since this is a task that can be delegated to the aide following an initial assessment. It can be executed after the above orders are completed.
how do we correct hypovolemic hypernatremia
ISOTONIC FLUIDS 1. give isotonic fluid - NS. NS is relatively hypotonic to the body in hypernatremia 2 restrict sodium in the diet
While working in a pediatric cardiac intensive care unit, you are caring for a child diagnosed with tetralogy of Fallot. Upon entering the room in the morning for your first assessment you find the child crying, cyanotic, and tachycardic. You recognize this as a hypercyanotic tet spell. Place the following actions in order of priority: -Administer 100% oxygen -Place the infant in the knees to chest position -Administer an IV fluid bolus -Administer morphine sulfate -Document the event 4393
-Place the infant in the knees to chest position -Place the infant in the knees to chest position -Administer morphine sulfate -Administer an IV fluid bolus -Document the event Correct answer: The priority in a hypercyanotic tet spell is to place the child in a knee to chest position. Tet spells occur when the infant with tetralogy of Fallot becomes acutely cyanotic due to infundibular spasm usually associated with feeding or crying. When this spasm occurs, there is decreased flow from the right ventricle due to the obstruction, resulting in severe hypoxia. Putting the child in a knee-chest position increases the intrathoracic pressure and increases blood flow to the lungs, therefore increasing oxygenation to body tissues. The next priority action is to administer 100% oxygen to assist in meeting the child's oxygenation requirements and relieving the hypoxia quickly. The following priority action is to administer morphine sulfate. This is the drug of choice for tet spells because it helps to calm the child down while simultaneously reducing the infundibular spasm that causes right ventricular outflow obstruction and, therefore, the hypercyanotic tet spell. The next priority nursing action is to administer an IV fluid bolus. This increases preload and consequently, cardiac output, helping to increase perfusion and oxygenation to the tissues. Lastly, the nurse should document the event, actions taken, and the patient's response.
Trusseau's sign
-pump blood pressure cuff up more than needed -patient involuntarily contracts forearm and flexes wrist inward sign of hypocalcemia
what causes hyperkalemia
-renal failure -impaired excretion -DKA or acidosis of some sort -potassium sparing diuretics -ace inhibitors -tissue damage/cellular distruction -burns/cellular distruction -hypoaldosteronism
what are the neurological symptoms that come with hypernatremia
-restless -agitation -drowsy -lethargic -stupor -coma -changes in LOC
The primary healthcare provider (PHCP) prescribes 0.5 grams of cefaclor by mouth, twice a day. The medication label reads cefaclor 500 mg capsule. The nurse prepares to administer how many capsules per dose? capsule(s) 7637
0.5g=500 mg per dose 1 capsule per dose
Per the American Society of Parenteral and Enteral Nutrition (ASPEN) and many other critical care society guidelines, the nurse should not hold feeding for a GRV of less than _____ mL in the absence of any clinical signs of intolerance.
500 Therefore, the nurse should auscultate for bowel sounds and assess any nausea, emesis, or abdominal distention if less than 500
what is the process for transfusing blood
1) get an order from the provider 2) do a type and screen 3) ask about previous reactions & allergies 4) cross match to make sure they can receive the blood 5) check with 2 nurses: -blood type & Rh -blood component tag name & numer -provider's order -client's identity - name & dob -hospital Id band name and MRN 6) spike the bag 7) check with baseline vitals 8) start running the normal saline 9) run blood slow for the first 15 mins & stay for 15-30 mins after transfusion starts 10) check vitals after 15 11) if no effects, speed up to infuse over 2 hours per unit 12) obtain vitals every hour until completed then every hr for 3 hrs
how do we treat hyperkalemia
1) monitor ekg changes-get them on a heart monitor 2) Drive potassium into cells with d5w, regular insulin, albuterol &/or bicarb 3) reduce total body potassium (outside the cells) with kayexelate & potassium wasting diuretics (furosemide, hctz) 4) dialysis when severe hyperkalemia isn't responding to fluids & diuretics 5) dc potassium supplements (iv potassium and po supplements 6) restrict potassium in the diet
how many nurses do you need to check blood
2
when checking the residual of an ng tube, generally residuals over 150mL are considered above-normal volumes, although there is no need to withhold feeding for gastric residual volume (GRV) less than ____ml.
500
The nurse is caring for a group of clients. Which client should the nurse see first? Drag and drop each client in order of priority starting with the first client to be seen. Press and hold an option to rearrange A 65-year-old newly admitted client with an acute coronary syndrome (ACS) who is receiving a heparin infusion. A 51-year-old client who has a discharge prescription following a heart failure exacerbation. A 46-year-old client two days post-operative from a vaginal hysterectomy reporting burning at the indwelling catheter site. A 31-year-old client three days post-operative who requires a sterile dressing change. 3874
A 65-year-old newly admitted client with an acute coronary syndrome (ACS) who is receiving a heparin infusion. A 46-year-old client two days post-operative from a vaginal hysterectomy reporting burning at the indwelling catheter site. A 31-year-old client three days post-operative who requires a sterile dressing change. A 51-year-old client who has a discharge prescription following a heart failure exacerbation. The nurse initially should see the client with ACS because of the instability that coincides with this condition. The client who is two days post-operative complaining of burning at the urinary catheter site should be assessed next. After that, the client requiring a sterile dressing change who is three days post-operative should be evaluated. Finally, the client requesting discharge teaching should be seen last because this would be considered low priority. 55% correct
Which of the following observations are non-reassuring when assessing a fetal heart rate strip? Select all that apply. A. Fetal bradycardia B. Variable decelerations C. Late decelerations D. Early decelerations 5885
A is correct. Fetal bradycardia, or a decrease in fetal heart rate below 110 bpm, is a non-reassuring sign on a fetal heart rate strip. When the nurse notes this sign, she will need to intervene by repositioning the mother on her left side, increasing IV fluids, administering oxygen, and notifying the healthcare provider quickly. Also, fetal bradycardia is often a result of uterine hyperstimulation. If the client is on the oxytocin drip, the nurse should discontinue the infusion. B is correct. Variable decelerations, or sharp and profound drops in the fetal heart rate unrelated to the time of contractions, are a non-reassuring sign on a fetal heart rate strip. Anytime that the nurse notes this sign, she will need to intervene by lying the mother on her left side, increasing IV fluids, administering oxygen, and notifying the healthcare provider quickly. Variable decelerations are often caused by cord compression, such as a prolapsed cord, and would be an emergency requiring quick nursing intervention. C is correct. Late decelerations, or dips in the fetal heart rate that occur after a contraction, are a non-reassuring sign on a fetal heart rate strip. Anytime that the nurse notes this sign, she will need to intervene by laying the mother on her left side, increasing IV fluids, administering oxygen, and notifying the healthcare provider quickly. Late decelerations are due to uteroplacental insufficiency and require intervention by the nurse. Choice D is incorrect. Early decelerations are not a non-reassuring sign on a fetal heart rate monitoring strip. Early decelerations are when the fetal heart rate decreases at the same time as a contraction. Early decelerations are due to the pressure of the head of the fetus on the pelvis or soft tissue and are characterized by a return to baseline at the end of the contraction. The nurse requires no intervention after an early deceleration.
Which of the following statements by a patient who was recently placed in a cast on the right lower extremity should be the most alarming to the nurse? A. "I've been having pain in my right calf." B. "My right leg feels really itchy." C. "I didn't keep my leg elevated as the doctor asked me to." D. "When I put weight on my crutches, it makes the arthritis in my wrists ache." 4640
A. "I've been having pain in my right calf." Choice A is correct. Pain in the casted extremity could indicate neurovascular compromise. Patients who have been cast should be educated on safety measures and signs of complications before discharge from care. It is not uncommon for the skin inside a cast to itch. However, any signs of neurovascular compromise should be immediately reported. Any time a patient reports pain in a casted extremity, this is an alarming sign that requires immediate assessment/intervention. Patients should be instructed to report pain, tingling, and edema in the extremity that is greater than before the cast was applied, or if the cast feels too loose. Choice B is incorrect. Itching is not an immediate reason for alarm. Heat and sweat will cause the skin under the cast to itch. Patients should be instructed to keep the cast and surrounding skin fresh, clean, and dry. Choice C is incorrect. This answer does indicate a need for further education but is not a sign of immediate distress. Patients should be encouraged to keep the injured limb elevated, especially during the first 48 hours following injury and casting. Elevation helps to decrease swelling and pain at the site of injury. Choice D is incorrect. Although the patient is experiencing pain, this answer option is no reason for alarm. Instead, the patient may need to be educated on how to use crutches properly. Some discomfort is reasonable because the hands and arms were not meant to hold the weight of the entire body. However, with proper instruction on how to use crutches, the patient's discomfort may be reduced.
A mother tells the nurse that she knows for a fact that her baby is in the stage called, "Trust vs. Mistrust" and wants to know more about it. An accurate explanation from the nurse would be: A. "Trust vs. Mistrust" is the first stage of development in Erikson's theory that describes the eight developmental tasks everyone must face. B. It is a theory based on how an individual derives pleasure from different parts of the body. C. It is a theory that outlines the development of logical thinking. D. It is parallel to Selye's adaptation theory. 2745
A. "Trust vs. Mistrust" is the first stage of development in Erikson's theory that describes the eight developmental tasks everyone must face. Choice A is correct. "Trust vs. Mistrust" is the first of eight stages, or crises, of psychosocial development centered on an individual relationship with the social environment. Erikson developed it. Choices B, C, and D are incorrect. Theories of psychosexual development were developed by Freud, characterized by focusing on and deriving pleasure from different body parts. Piaget formed theories that concentrate on cognitive development. A person's response to stress is described by methods of Hans Selye but is not related to Erikson's theories.
A client is experiencing spiritual distress after receiving a diagnosis of advanced brain cancer. Which of the following would be appropriate interventions? Select all that apply. A. Ask the patient how he/she is feeling. B. Provide food compatible with the person's religious needs. C. Help the patient identify feelings of guilt. D. Offer to massage the client's shoulders. E. Offer encouragement based on assumptions about the patient's beliefs. F. Assess the patient's needs for reconciliation.
A. Ask the patient how he/she is feeling. B. Provide food compatible with the person's religious needs. E. Offer encouragement based on assumptions about the patient's beliefs.
You are providing education to the parents of a toddler suffering from gastroesophageal reflux disease (GERD). You know they understand your teaching when they make which of the following statements. Select all that apply. A. "We should feed him 6 small meals a day instead of a few big ones." B. "Making sure he is sitting upright while eating may help the reflux." C. "He should try to sleep on his left side so that his stomach can empty more easily." D. "There are no medications that can help with this disease so we will have to make lifestyle changes." 5360
A. "We should feed him 6 small meals a day instead of a few big ones." B. "Making sure he is sitting upright while eating may help the reflux." Choices A and B are correct. A is correct. Small, frequent meals are an excellent recommendation to help alleviate GERD symptoms. This will ensure the stomach does not overfill and helps to decrease the amount of reflux the patient is experiencing. B is correct. The upright position is very important for GERD patients while they are eating. This is good education. Upright positioning will help to prevent or decrease the passage of gastric contents into the esophagus. Choice C is incorrect. Left-side lying is not the recommended position overnight for patients suffering from GERD. These parents do not understand your teaching. You should teach them to encourage an upright position to help with GERD overnight. This can be accomplished in the hospital by elevating the head of the bed, or at home by using pillows to prop the head up. Choice D is incorrect. This is not true. While the healthcare provider will likely recommend lifestyle changes before prescribing any medications, there are a variety of pharmacological interventions that can be tried if severe symptoms persist. These include medications such as omeprazole and ranitidine.
The nurse is assessing assigned clients. Which client has a risk for urinary retention? Select all that apply. A. A 78-year-old man diagnosed with an enlarged prostate. B. An 83-year-old woman on bed rest. C. A 75-year-old woman with vaginal prolapse. D. An 89-year-old man with dementia. E. A 73-year-old woman on antihistamines to treat allergies. F. A 90-year-old man with difficulty walking to the restroom. 8% of peers got it right
A. A 78-year-old man diagnosed with an enlarged prostate. C. A 75-year-old woman with vaginal prolapse. E. A 73-year-old woman on antihistamines to treat allergies Choices B, D, and F are incorrect. All these answer options (immobility, dementia, walking difficulty) may place the clients at risk for urinary incontinence, not urinary retention. Retention can occur because of mechanical obstruction of the bladder outlet (enlarged prostate in a man or vaginal prolapse in a woman). Antihistaminic medications (such as diphenhydramine) tend to have anticholinergic side effects. Urinary retention can occur from the use of drugs with anticholinergic side effects. The bladder muscle's (detrusor smooth muscle) primary function is to "contract" and fully empty the bladder. Detrusor smooth muscle has muscarinic (cholinergic) receptors that facilitate this contraction. Anticholinergic agents impair this function and predispose to urinary retention. Excessive urinary retention eventually results in "overflow" incontinence.
The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the RN? Select all that apply. A. A patient newly diagnosed with type II diabetes mellitus. B. requiring sterile dressing changes to an infected wound. C. who requires enteral feedings and tracheostomy care. D. with an acute kidney injury (AKI) with a potassium 5.6 mEq/l. E. who is two days post-operative following a mastectomy F. receiving intravenous nitroglycerin for acute coronary syndrome. 6439
A. A patient newly diagnosed with type II diabetes mellitus. D. with an acute kidney injury (AKI) with a potassium 5.6 mEq/l. F. receiving intravenous nitroglycerin for acute coronary syndrome. Choices A, D, and F are correct. When making client assignments, the RN should be assigned to the unstable client who has the least predictable outcome and may require frequent assessment or teaching. A client newly diagnosed with type II diabetes mellitus will require a large amount of teaching. A client with an AKI and hyperkalemic is at risk for cardiac instability. Finally, a client experiencing acute coronary syndrome receiving IV nitroglycerin will need frequent assessment because of the unpredictable nature of the condition. Choices B, C, and E are incorrect. The LPN should assume care for stable clients with predictable outcomes. The client requiring sterile dressing changes is within the LPN's scope, as well as providing enteral feedings and tracheostomy care. A client two days post-operative is stable. i put a c d f 44% correct
The nurse is caring for a client who has Addison's disease. Which of the following interventions would be a priority? A. Administer prescribed hydrocortisone B. Offer salty snacks and water C. Assess skin integrity D. Encourage frequent rest periods 6892
A. Administer prescribed hydrocortisone Choice A is correct. A lack of cortisol and aldosterone characterizes Addison's disease. The priority for the nurse is to administer the prescribed hydrocortisone to prevent the client from developing a life-threatening Addisonian crisis. Choices B, C, and D are incorrect. The nurse should incorporate a plan of care that involves offering salty snacks and water since sodium levels may be low in a client with Addison's disease. Changes to the integument are common with Addison's and include increased pigmentation. Fatigue is a common manifestation that should enable the nurse to encourage frequent rest periods. Addison's disease is when the client has insufficient cortisol and aldosterone. The mainstay treatment is lifelong corticosteroid replacement with hydrocortisone. If the client experiences stressful events or illnesses, the dosage may need to increase. During an adrenal crisis, the priority treatment is administering hydrocortisone intravenously. The client is volume depleted, hypoglycemic, and hyponatremic and will need rapid fluid resuscitation. Dangerously high potassium levels are also evident in an adrenal crisis and require cardiac monitoring and medications such as sodium polystyrene. Subject Adult Health Lesson Endocrine Client Need Area Physiological Adaptation 68% correct- know this!
The NICU nurse is caring for an infant with heart failure and watching for interventions that necessitate administering oxygen. Of the following procedures, which will the nurse most likely need oxygen to be available? A. Administering vaccinations B. During the infant's naps C. While the infant nurses D. After the parents have held the baby 4006
A. Administering vaccinations Choice A is correct. The nurse would be most accurate if they applied oxygen to the infant receiving vaccinations. Since injections are often painful, most babies cry while receiving them. Crying uses much of an infant's energy, increasing its demand for oxygen. Choices B, C, and D are incorrect. Since napping, nursing, and being held are generally calming moments for an infant, there will likely not be an increased need for oxygen. 43% correct
Which of the following are a type of social support? Select all that apply. A. An emotional social support B. An informational social support C. A physical help social support D. A sensory social support E. An instrumental social support F. An appraisal social support 2718
A. An emotional social support B. An informational social support E. An instrumental social support F. An appraisal social support Choices A, B, E, and F are correct: Choice A is correct. An emotional, social support is one type of social support. Passionate social support people and networks provide clients with the emotional and psychological support that is often needed to decrease client stress and enhance client coping. Choice B is correct. An informational social support is one type of social support. Informational social support people and networks provide clients with the knowledge and skills needed to adapt to and cope with a stressor. Choice E is correct. An instrumental social support is one type of social support. Helpful social support people and networks provide clients with tangible help, for example: transportation and household help. Choice F is correct. An appraisal of social support is one type of social support. Appraisal social support people and networks provide clients with the opportunity to gain insight and to self evaluate their strengths and limitations. Choices C and D are incorrect: Choice C is incorrect. Physical help social support is non-existent. The four types of social support are informational, emotional, instrumental, and appraisal support systems. Choice D is incorrect. Sensory social support is non-existent. The four types of social support are informational, emotional, instrumental, and appraisal support systems.
The nurse is caring for a patient with left-sided heart failure. Which of the following signs and symptoms is related more to right-sided heart failure? A. Ascites B. Tachypnea C. Cough D. Crackles and wheezes 4004
A. Ascites Choice A is correct. Ascites is a symptom of right-sided heart failure, not left-sided. Right-sided heart failure involves congestion in the systemic circulation. Patients with right-sided heart failure may also experience jugular vein distention, oliguria, weight gain, and peripheral edema. Choice B is incorrect. Tachypnea, or more frequent than normal respirations, is seen in left-sided heart failure as breathing becomes more difficult. In left-sided heart failure, fluid backs up into the lungs and makes breathing more difficult. Choice C is incorrect. A cough, along with other heart failure symptoms, is a sign of left-sided heart failure. As fluid backs up in a patient's lungs, the patient may present with a cough. Choice D is incorrect. Crackles and wheezes upon respiratory auscultation are a sign of left-sided heart failure. As fluid backs up into the lungs because the heart is unable to pump properly, the lungs sound wet, wheezy, and may present with crackles. 72% correct NCSBN client need Topic: Physiologic integrity, alterations in body systems Subject Adult Health Lesson Cardiovascular Client Need Area Physiological Adaptation
A patient with a crush injury to her left arm calls the nurse's station and requests pain medication an hour after initial administration. The patient is still complaining of intense pain. What is the next nursing action? A. Ask the patient to describe the pain in quality and intensity. B. Offer the patient a distraction, such as a book or television. C. Tell the patient she can have more medication in three hours. D. Tell the patient that crush injury victims should expect intense pain. 4179
A. Ask the patient to describe the pain in quality and intensity. Choice A is correct. A crush wound is a wound caused by force, which leads to compression or disruption of tissues. It is often associated with fractures. Usually, there is minimal to no break in the skin. While other external symptoms, such as bruising or edema, may be visible, nurses should also rely on subjective symptoms reported by the patient. Unrelieved pain is an indication of a complication. Patients who experience a crush injury are at risk for developing compartment syndrome. Therefore, asking the patient to be specific about the quality and intensity of pain will help the nurse re-evaluate her status. Choice B is incorrect. While distractions are an excellent resource for people experiencing pain, with a severe injury, such as a crush injury, illness that is unrelieved by medication may suggest a complication and should be evaluated. Choice C is incorrect. While the order for pain medication may be every 4 hours as needed, simply telling the patient that the medicine can be given in 3 hours is inappropriate. The unrelieving pain must be evaluated to verify if complications have occurred. Choice D is incorrect. Although pain may be expected, dismissing the patient's complaint of discomfort by telling him that "it is to be expected" is never a proper nursing response.
The nurse is caring for a client with Borderline Personality Disorder. Which of the following actions should the nurse take? Select all that apply. A. Assess the client for suicidal ideation B. Encourage independent decision-making C. Establish therapeutic boundaries D. Refer the client for group therapy E. Encourage social relationships 6481
A. Assess the client for suicidal ideation C. Establish therapeutic boundaries D. Refer the client for group therapy Choices A, C, and D are correct. Individuals with Borderline Personality Disorder (BPD) often engage in self-harm/parasuicide behaviors in which the intent is not death. These gestures may be superficial cutting, etc. All clients should be assessed for suicide regardless of their diagnosis. Therapeutic boundaries should be established as a characteristic of this personality disorder is polarizing individuals and splitting. Referring the client for group therapy is one of the cornerstone treatments for BPD. Choices B and E are incorrect. Independent decision-making is not impaired for an individual with BPD. This would be an intervention for Dependent Personality Disorder. Finally, the client with BPD can establish social relationships - although they may be unstable, this would be an intervention for Avoidant Personality Disorder.
The nurse observes the following tracing on the telemetry monitor, and it looks like vfib. The nurse should take which initial action? See the image below. A. Assess the client's level of consciousness B. Prepare the client for immediate defibrillation C. Administer a dose of intravenous epinephrine D. Evaluate the client's cardiac lead placement
A. Assess the client's level of consciousness Choice A is correct. This tracing depicts ventricular fibrillation. This rhythm is highly concerning because it can be fatal. Because the nurse has just seen this tracing on the telemetry monitor, the first action the nurse should take is to assess the client. Artifact may be confused for ventricular fibrillation, therefore the nurse should always assess the client first and not the monitor. Choices B, C, and D are incorrect. All of these actions may be appropriate for a client experiencing ventricular fibrillation. However, none of these assess the client's level of consciousness, which is the initial step in the basic life support algorithm. The client with ventricular fibrillation requires immediate defibrillation as the priority treatment if the client is unconscious and has no pulse.
The oncoming nurse learns that her new patient is suffering from Syndrome of Inappropriate Antidiuretic Hormone (SIADH) secretion. Which of the following nursing actions is the most important? A. Assess the patient's mental status B. Provide oral hygiene C. Keep accurate intake and output measurements D. Reduce stress and discomfort
A. Assess the patient's mental status Choice A is correct. When caring for a patient with SIADH, the nurse should carefully monitor for changes in mental status and level of consciousness. SIADH causes excess free water retention and hyponatremia, which may lead to confusion and behavioral changes. These alterations in the mental state may also lead to seizures. Patients with SIADH may also experience cardiac dysrhythmias. Choice C is incorrect. SIADH creates alterations in a patient's fluid and electrolyte balance, and thus nurses must keep accurate accounts of all intakes and outputs. However, monitoring the patient's mental status is more important. 48% correct
The nurse is caring for a client with the following clinical data. Which medication would the nurse clarify with the primary healthcare provider (PHCP) before administration based on the vital signs? pulse: 54 bpm RR: 16 O2: 96 BP: 120/65 T: 99.2 A. Atenolol 50 mg PO Daily B. Simvastatin 40 mg PO Daily C. Albuterol 2.5 mg via nebulizer Daily D. Spironolactone 25 mg PO Daily 6576
A. Atenolol 50 mg PO Daily Choice A is correct. Atenolol is a selective beta-blocker that is utilized for hypertension. This medication not only decreases blood pressure but pulse as well. The vital signs (VS) are all within normal limits except the pulse, which is 54 bpm. This should cause the nurse to clarify the prescription with the PHCP. Choices B, C, and D are incorrect. Simvastatin is a medication intended to decrease cholesterol and does not lower pulse. Albuterol is a bronchodilator indicated for acute and chronic respiratory diseases. Like simvastatin, it does not lower pulse. Spironolactone is an antagonist to aldosterone and is utilized in heart failure. This medication lowers blood pressure - but not pulse.
he nurse is caring for a client with the following clinical data. Based on the vital signs, which medications would the nurse clarify with the primary healthcare provider (PHCP) prior to administration? p: 61 rr: 16 bp: 90/60 t: 99.1 o2: 95% Select all that apply. A. Atenolol 50 mg PO Daily B. Spironolactone 50 mg PO Daily C. Albuterol 2.5 mg via nebulizer Daily D. Fentanyl 50 mcg IV Push q 6 hours PRN Pain E. Modafinil 100 mg PO Daily 6592
A. Atenolol 50 mg PO Daily B. Spironolactone 50 mg PO Daily D. Fentanyl 50 mcg IV Push q 6 hours PRN Pain Choices A, B, and D are correct. The vital signs show hypotension (90/60 mm Hg). The nurse should clarify the prescriptions of atenolol, spironolactone, and fentanyl. All these medications decrease blood pressure, and considering how low the client's blood pressure is, it would be highly detrimental. Choices C and E are incorrect. Albuterol is a beta-adrenergic agonist; thus, this medication would cause an increase in blood pressure and heart rate. Modafinil is a stimulant medication used in the management of narcolepsy. Therefore, this medication tends to raise blood pressure, not lower it.
Which of the following nursing improvements follow the recommendations of the Institute of Medicine's Committee on Quality Healthcare in America? Select all that apply. A. Basing patient care on continuous healing relationships B. Customizing care to reflect the competencies of the staff C. Using evidence-based decision making D. Having a charge nurse as the source of control E. Using safety as a system priority F. Recognizing the need for secrecy to protect patient privacy
A. Basing patient care on continuous healing relationships C. Using evidence-based decision making E. Using safety as a system priority Choices A, C, and E are correct. Standards are the levels of performance accepted and expected by the nursing staff or other healthcare team members. They are established by authority, custom, or consent. The Committee on Quality Health Care in America of the Institute of Medicine, in its report Crossing the Quality Chasm, highlights six aims to be met by health care systems about quality care: Safe: Avoiding injury Useful: Avoiding overuse and underuse Patient-centered: Responding to patient preferences, needs, and values Timely: Reducing waits and delays Efficient: Avoiding waste Equitable: Providing care that does not vary in quality to all recipients Choices B, D, and F are incorrect.
The nurse is caring for a client who has polycystic kidney disease (PKD). Which of the following would indicate the client is achieving treatment goals? A. Blood Pressure 128/63 mmHg B. Creatinine 2.3 mg/dL C. Proteinuria D. Sodium 132 mEq/L 6526
A. Blood Pressure 128/63 mmHg Choice A is correct. Treatment goals for a patient with Polycystic Kidney Disease (PKD) include maintaining normotension, the glomerular filtration rate (GFR), and the prevention of sodium wasting, which is evidence of a decline in renal function. Hypertension is a cardinal finding in PKD, and if a client is achieving the treatment goals, they will maintain regulated blood pressure. Choices B, C, and D are incorrect. An elevated creatinine indicates that kidney function is declining. Proteinuria and sodium in the urine are also evidence of decreased renal function. Both findings would not indicate that the client is improving; rather, they would indicate that the client's renal function is declining.
The nurse is educating the client with urinary tract calculi regarding diet. Which of the following foods may the client have? Select all that apply. A. Broccoli B. Lettuce C. Cheese D. Apples 4570
A. Broccoli B. Lettuce D. Apples Choices A, B, and D are correct. The client may have broccoli, lettuce, and apples. Lettuce and apples are low in calcium and oxalate. Broccoli is high in calcium. However, it is low in oxalate and high in potassium. Being high in potassium, broccoli reduces calcium excretion in urine and reduces the formation of kidney stones. Therefore, this is the reason that it need not be held back in renal calculi. Kidney stones in the urinary tract are formed in several ways. Calcium can combine with chemicals, such as oxalate or phosphorous, in the urine. This can happen if these substances become so concentrated that they solidify. Kidney stones can also be caused by a buildup of uric acid related to the metabolism of protein. Most urinary tract calculi, especially calcium oxalate stones, can be prevented by following dietary recommendations. Generally, clients should avoid high calcium and high oxalate-containing foods. Clients should also be instructed to avoid stone-forming, high oxalate foods such as beets, chocolate, spinach, rhubarb, and tea. Most nuts are rich in oxalate and colas are rich in phosphate, both of which can contribute to kidney stones. Fluids, especially water, help to dilute the chemicals that form stones. Patients should be encouraged to drink at least eight glasses of water every day. Choice C is incorrect. Cheese has a high calcium content, which can increase the risk of developing urinary tract calculi and should, therefore, be avoided. 45% correct Subject Adult Health Lesson Gastrointestinal/Nutrition Client Need Area Basic Care and Comfort
The nurse assesses an infant who sustained a traumatic brain injury (TBI). Which assessment finding requires follow-up? Select all that apply. A. Bulging fontanel B. Tachycardia C. Bradycardia D. Ptosis E. Distended scalp veins 4372
A. Bulging fontanel C. Bradycardia E. Distended scalp veins Choices A, C, and E are correct. A tense, bulging fontanel is a classic sign of increased ICP in an infant. Associated symptoms that are concerning include bradycardia and distended scalp veins. Choices B and D are incorrect. Tachycardia is a clinical manifestation of shock but not for increased ICP. The client would exhibit triad symptoms such as bradycardia, bradypnea, and widening pulse pressure. Ptosis is drooping of the eyelid and is not associated with increased ICP. Pupillary changes would be assessed as a late sign of increased ICP, which would be nonreactive on an assessment.
While ambulating a patient who has an infusion running through their peripherally inserted central catheter (PICC) in the right arm, they suddenly complain of dyspnea and chest pain. You immediately sit them down in the closest chair and assess them. Their BP is 72/38 mmHg and their heart rate is 186. What is the priority nursing action? Select all that apply. A. Clamp the catheter B. Notify the health care provider C. Lay the patient flat D. Administer oxygen
A. Clamp the catheter B. Notify the health care provider D. Administer oxygen Choices A, B, and D are correct. The nurse suspects that the patient has an air embolism related to their PICC line. This is a potential complication of central venous catheters and the nurse is expected to monitor for it. Signs and symptoms include tachycardia, hypotension, chest pain, dyspnea, tachypnea, and hypoxia. Since the nurse suspects an air embolism, she should clamp the catheter immediately to prevent any further air entry. This is a medical emergency, and the health care provider should be notified promptly. Hypoxia is a symptom of an air embolism; therefore the patient should immediately begin receiving oxygen to prevent tissue ischemia and further complications. Choice C is incorrect. Laying the client supine could cause air embolism to exit the right atrium of the heart and travel to the brain or lungs, causing complications such as a stroke or pulmonary embolism (PE). The patient should be positioned on their left side with their head lower than their feet. This will trap the embolism in the right atrium of the heart and prevent further complications.
The nurse is assessing a child with reports of right eye irritation, drainage, and itchiness. This client is at highest risk for A. Conjunctivitis B. Amblyopia C. Nystagmus D. Ocular herpes 3781
A. Conjunctivitis Choice A is correct. This client is demonstrating classic manifestations of conjunctivitis. Conjunctivitis is characterized by Itching, burning, or scratchy eyelids. Additionally, the client has drainage to the affected eye(s), a common conjunctivitis finding. Choices B, C, and D are incorrect. Amblyopia is, also known as 'lazy eye,' is not an infectious process and is characterized by differences between the two eyes in their ability to focus. Nystagmus is also a condition that is not infectious and is characterized by repetitive and uncontrolled movements of the eye. Ocular herpes is a viral infection that does not produce drainage. 46% correct
The nurse is conducting a community health class on skin changes for older adults. It would be appropriate for the nurse to state which of the following are normal age-related changes? Select all that apply. A. Decreased dermal blood flow B. Development of actinic lentigo C. Degeneration of elastic fibers D. Loss of subcutaneous fat E. Increased epidermal thickness 4829
A. Decreased dermal blood flow B. Development of actinic lentigo C. Degeneration of elastic fibers D. Loss of subcutaneous fat Choices A, B, C, and D are correct. Age-related skin changes include decreased dermal blood flow, which causes dry skin. The development of actinic lentigo (known as liver spots but have nothing to do with the liver) are darkened parts of the skin commonly found on the wrists, back of the hands, and forearms. Other age-related changes include the degeneration of elastic fibers, which causes decreased tone and elasticity. Finally, loss of subcutaneous fat is an expected finding which may cause hypothermia and pressure ulcers. Choice E is incorrect. Increased epidermal thickness is not an age-related change; instead, the decreased epidermal thickness occurs, causing the skin to be fragile and transparent.
The nurse is developing a plan of care for a client hospitalized with anorexia nervosa. Which nursing diagnosis is a priority? A. Deficient fluid volume B. Disturbed thought process C. Deficient knowledge D. Disturbed body image 6906
A. Deficient fluid volume Choice A is correct. For a client hospitalized with anorexia nervosa, fluid volume deficit is a priority concern. Client with anorexia nervosa may restrict their intake of food and fluids, thereby causing unhealthy weight loss. The nurse must be focused on the client's airway, breathing, and circulation. A deficient fluid volume would be a problem under circulation. Choices B, C, and D are incorrect. Disturbed thought processes, deficient knowledge, and disturbed body image are all essential to integrate into the care plan; however, these are psychological needs. Addressing them does not prioritize physical needs such as deficient fluid volume. According to Maslow's hierarchy of needs, physical alterations are always prioritized over psychological ones.
The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss? Select all that apply. A. Diabetes mellitus B. Menieres disease C. Excessive cerumen D. Exposure to loud noise E. Excessive fluid 8297
A. Diabetes mellitus B. Menieres disease D. Exposure to loud noise hoices A, B, and D are correct. These are all risk factors for sensorineural hearing loss. Diabetes may cause an insult to vasculature supplying the cochlea. Thus, causing hearing loss. Meniere's disease is a condition that features vertigo, hearing loss, and tinnitus. Exposure to loud noise is a significant risk factor because of the insult it causes to the nerve fibers. Choices C and E are incorrect. Obstruction in the ear is a cause of conductive hearing loss, which may be reversed. Conductive hearing loss is caused by obstruction. Causes of this type of hearing loss include cerumen, foreign body, water, edema, infection, or tumor. This type of hearing loss may be reversible. Impairments of the nerve fibers cause sensorineural hearing loss. Causes of this type of hearing loss include prolonged exposure to noise, ototoxic substances (aminoglycosides), diabetes mellitus, and presbycusis (age-related hearing loss). This type of hearing loss is often not reversible.
Which statements describe the action of the medications? Select all that apply. A. Diazepam is given to alleviate anxiety. B. Ranitidine is given to facilitate patient sedation. C. Atropine is given to decrease oral secretions. D. Morphine is given to depress respiratory function. E. Cimetidine is given to prevent laryngospasm. F. Fentanyl citrate-droperidol is given to facilitate a sense of calm. 4840
A. Diazepam is given to alleviate anxiety. C. Atropine is given to decrease oral secretions. F. Fentanyl citrate-droperidol is given to facilitate a sense of calm. Choices A, C, and F are correct. A: Sedatives, such as diazepam (Valium), midazolam (Versed), and lorazepam (Ativan), are given to alleviate anxiety and decrease the recall of events related to surgery. C: Anticholinergics, such as atropine and glycopyrrolate (Robinul), are given to decrease pulmonary and oral secretions in order to prevent laryngospasm. F: Neuroleptanalgesic agents, such as fentanyl citrate-droperidol (Innovar), are given to cause a general state of calm and sleepiness. Choices B, D, and E are incorrect. B and E: Histamine-2 receptor blockers, such as cimetidine (Tagamet) and ranitidine (Zantac) are given to decrease gastric acidity and volume. D: Narcotic analgesics, such as morphine, are given to decrease the amount of anesthetic agent needed.
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 4066
A. Diminished breath sounds Choice A is correct. Since this is a closed chest injury, the most common sign of pneumothorax (PTX) will be diminished breath sounds. Choice B is incorrect. A barrel chest occurs over time and indicates chronic obstructive pulmonary disease (COPD). Choice C is incorrect. With most cases of pneumothorax, the patient will become tachypneic rather than have a lower than usual respiratory rate. Choice D is incorrect. A sucking noise is noted in an open chest injury. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential
The nurse is caring for a client with newly prescribed amphotericin b for a systemic fungal infection. The nurse should anticipate a prescription for which medication before the infusion? Select all that apply. A. Diphenhydramine B. Acetaminophen C. 0.9% saline bolus D. Regular insulin E. Sodium bicarbonate 8276
A. Diphenhydramine B. Acetaminophen C. 0.9% saline bolus Choices A, B, and C are correct. Amphotericin B is a potent antifungal medication. The infusion can make the client feel quite ill, and preventative treatments such as acetaminophen, 0.9% saline bolus, and diphenhydramine are often used. Symptoms the client experiences during the infusion include nausea, rigors, fever, and chills. Thus, premedication is necessary. Amphotericin B is nephrotoxic, and the client should increase their fluid intake. Choices D and E are incorrect. Amphotericin does not raise blood glucose, and regular insulin is not indicated. Sodium bicarbonate is not necessary during the course of the therapy. 23% correct Subject Adult Health Lesson Infectious Disease Client Need Area Pharmacological and Parenteral Therapies
The nurse is assessing a client who is suspected of having myasthenia gravis. Which of the following would be an expected finding? Select all that apply. A. Diplopia B. Butterfly rash C. Facial muscle weakness D. Shuffling gait E. Ptosis 8080
A. Diplopia C. Facial muscle weakness E. Ptosis Choices A, C, and E are correct. Key clinical features of myasthenia gravis (MG) include diplopia, ptosis, facial muscle weakness, and may progress to respiratory failure. Some of the earlier manifestations associated with MG are ocular. Choices B and D are incorrect. Shuffling gait is a classic manifestation associated with Parkinson's disease. A butterfly rash is a common dermatological finding associated with lupus.
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate follow-up? A. Disorientation B. High urine specific gravity C. Oliguria D. Increased thirst
A. Disorientation Hyponatremia is a classic clinical feature associated with the syndrome of inappropriate antidiuretic hormone (SIADH). The hyponatremia may become severe and cause the client to have an altered mental status (AMS). This AMS is concerning because this signals that the serum sodium is quite low and warrants immediate intervention. Expected findings associated with SIADH include increased urine-specific gravity (concentrated urine), oliguria (reduced urinary output), and inappropriately increased thirst. These are expected findings, so they would not require immediate follow-up.
You are instructing a 65-year-old adult patient about his risk for measles, mumps, or rubella and whether he needs to receive the vaccination. He has a history of allergy to neomycin. Your instruction should include: A. Due to his age, the patient likely has natural immunity. B. The vaccine does not include a live virus. C. The individual with an unclear immunization history should not receive the vaccine. D. He should not receive the vaccination due to his neomycin allergy. 4430
A. Due to his age, the patient likely has natural immunity. D. He should not receive the vaccination due to his neomycin allergy. Choices A and D are correct. Individuals born before 1957 typically have a natural immunity to the diseases; most older people were exposed to or contracted the diseases. A known allergy to neomycin is a contraindication to the vaccination. Although a contraindication in the past, an egg allergy is no longer considered a contraindication to this vaccine and the treatment seems to be safe for these individuals. Choice B is incorrect. The vaccine contains a live, attenuated virus. Choice C is incorrect. Adults born after 1957 with an unclear immunization history should receive two immunizations one month apart. Even if the individual has received the MMR in the past, there is no danger in receiving the vaccine again. NCSBN Client Need Topic: Health Promotion and Maintenance, Sub-Topic: Health Promotion/Disease Prevention, Safety/Infection Control 21% correct, adult, infectious disease, health promotion & maintenance
The nurse is taking vital signs for a client who has a chest tube in place. While counting the client's respirations, the nurse notes that the water in the water-seal-chamber is fluctuating. Which action by the nurse is most appropriate based on this finding? A. Finish counting the client's respirations B. Empty the water-seal chamber C. Assist the client with incentive spirometry D. Notify the charge nurse
A. Finish counting the client's respirations Choice A is correct. It is appropriate for the nurse to finish counting the client's respirations and continue to monitor them as normal. Fluctuations of water in the water-seal chamber with inspiration and expiration are a sign that the drainage system is patent. Normally, the water level will increase when the client breathes in, and then decrease when they breathe out. This is due to changes in intrathoracic pressures. Choice B is incorrect. The nurse should not empty the water-seal chamber. This would cause a break in the closed drainage system and could result in injury to the client. Choice C is incorrect. It is not necessary for the nurse to help the client with incentive spirometry (IS) based on this finding. The nurse has noted an expected finding of the chest-tube system and can continue to assess the client as normal. Choice D is incorrect. It is not necessary for the nurse to notify the charge nurse based on this finding. The nurse has noted an expected finding of the chest-tube system and can continue to monitor the client as normal. 82% right - know this
Your client has continuous intravenous fluid replacement at 75 mL per hour. At 2 pm, the client complains about the intravenous line and states, "The IV is hurting me." You assess the site and note that it is red with a streak. You palpate the area and you can barely feel a venous cord. What would you suspect and what is the first thing that you would do? A. Grade 3 phlebitis: You would immediately stop the intravenous fluid infusion. B. Grade 4 phlebitis: You would immediately place a cool compress on the site. C. Infiltration: You would immediately stop the intravenous fluid infusion. D. Catheter embolus: You would immediately tourniquet the area distal to the site. 3578
A. Grade 3 phlebitis: You would immediately stop the intravenous fluid infusion. Choice A is correct. You would suspect a grade 3 phlebitis and you would immediately stop the intravenous fluid. Grade 3 phlebitis is characterized by pain, a visible streak, site redness, and a palpable venous cord less than 1 inch. Grade 4 phlebitis is characterized by pain, a visible streak, site redness, a palpable venous cord more than 1 inch, and possible drainage. Lastly, as with all intravenous therapy, any suspicion of a complication is immediately addressed with the discontinuation of the intravenous line. Choice B is incorrect. The signs and symptoms in this question indicate the presence of phlebitis. However, it is not a grade 4 phlebitis. Additionally, after discontinuing the intravenous line, you would apply heat and not a cold compress onto the IV site. Choice C is incorrect. Although you would immediately stop the intravenous fluid infusion when an intravenous therapy complication occurs, this complication is not infiltration according to the signs and symptoms that are in the question. Choice D is incorrect. The signs and symptoms that are in the question do not indicate the presence of a catheter embolus; these signs and symptoms indicate the presence of another intravenous therapy complication. Additionally, when a catheter embolus occurs, a tourniquet would be placed proximal to the site to prevent migration and further damage. 51% correct
The nurse is caring for a client with cardiac tamponade. Which vital signs are expected? A. HR: 109 bpm; RR: 26; BP: 88/71 mmHg B. HR: 90 bpm; RR: 32; BP: 90/52 mmHg C. HR: 115 bpm; RR: 22; BP: 140/78 mmHg D. HR: 54 bpm; RR: 14; BP: 161/52 mmHg 7451
A. HR: 109 bpm; RR: 26; BP: 88/71 mmHg Choice A is correct. Classic manifestations of cardiac tamponade include tachycardia, tachypnea, jugular venous distention, and hypotension with a narrowed pulse pressure. Choices B, C, and D are incorrect. Cardiac tamponade would typically cause features of tachycardia, hypotension, tachypnea, and a narrowed pulse pressure. 52% correct Subject Adult Health Lesson Cardiovascular Client Need Area Physiological Adaptation
A patient is rushed to the emergency department following a near-drowning episode at a local beach. Which conditions would the nurse anticipate to be present in the patient? A. Hypoxia, hypercarbia, and acidosis B. Coma, hyperthermia, and alkalosis C. Hypothermia, hypocapnia, and alkalosis D. Hyperthermia, hyperoxia, and acidosis
A. Hypoxia, hypercarbia, and acidosis Choice A is correct. Following a near-drowning incident, the patient will most likely exhibit symptoms of hypoxia (decreased oxygen levels in the blood), hypercarbia (increased carbon dioxide levels in the blood), and acidosis (respiratory type) due to a prolonged period of having a lack of oxygen. Choice B is incorrect. Although the patient may be in a coma after near-drowning, hyperthermia and alkalosis are unlikely. There would be a high chance of acquiring hypothermia if the patient stayed in the water for too long before being rescued. Alkalosis will not result from a lack of oxygen in the body; instead, acidosis will occur. Choice C is incorrect. Although hypothermia is a possibility in near-drowning situations, lack of oxygen for long periods will produce hypercapnia/hypercarbia and acidosis. Choice D is incorrect. Hypoxia will result from long periods without oxygen, not hyperoxia. Hyperthermia is unlikely to occur in near-drowning incidents.
The nurse just finished a shift in the emergency department during winter when she notices a homeless man outside with frostbite on his hands. The nurse brings the man into triage and starts to treat the frostbitten area by rewarming it. Which action by the nurse is most appropriate? A. Immerse the affected area in heated water at 40-46°C. B. Immerse the affected area in heated water at 80-90°C. C. Remove the blood-filled blisters. D. Apply snug, sterile dressings.
A. Immerse the affected area in heated water at 40-46°C. Choice A is correct. The nurse should immerse the frostbitten area in heated water at 40.6 - 46.1°C to rewarm the area. Choice B is incorrect. Engaging the frostbitten part in 80 - 90 °C water is too hot and would cause burns to the patient. Therefore, the nurse should immerse the frostbitten area in heated water at 40.6 - 46.1°C to rewarm the area. Choice C is incorrect. The nurse should handle the frostbitten area gently, taking care not to burst the blood-filled blisters. Choice D is incorrect. Loose, sterile, bulky dressings should be applied, not snug or tight-fitting ones. 66% correct Subject Adult Health Lesson Integumentary Client Need Area Physiological Adaptation
The emergency department nurse is caring for a client exposed to inhalation anthrax. It would be essential for the nurse to take which action? A. Initiate continuous pulse oximetry B. Obtain a prescription for a chest radiograph C. Notify the public health department D. Prepare the client for a lumbar puncture 7787
A. Initiate continuous pulse oximetry Choice A is correct. Inhalation anthrax poses a serious threat because the progression of symptoms may be rapid and become life-threatening. Anthrax may cause hypoxia, and continuous pulse oximetry monitoring is essential. This would enable the nurse to determine if the client's condition is deteriorating and may allow the nurse to immediately apply supplemental oxygen. Choices B, C, and D are incorrect. These actions apply to caring for a client with inhalation anthrax, but they do not prioritize monitoring the client's oxygenation status, which may rapidly deteriorate. A chest x-ray will be obtained to determine any abnormalities in the lung, and a lumbar puncture will be performed to evaluate for meningitis. Anthrax is a bioterrorism agent, and the public health department must be notified promptly, but it does not prioritize over direct client care. 41% correct Subject Adult Health Lesson Infectious Disease Client Need Area Reduction of Risk Potential
The nurse is caring for a patient with dementia who exhibits increased confusion during the evenings and frequently attempts to get out of bed. Which interventions would be appropriate for the nurse to implement before resorting to physical restraints? Select all that apply. A. Initiate toileting schedule B. Place patient near the nurses' station C. Keep one bedrail fully up and the other side half up D. Implement electronic bed alarm 6856
A. Initiate toileting schedule B. Place patient near the nurses' station D. Implement electronic bed alarm Choices A, B, and D are correct. A: Patients with dementia often experience increased confusion during evenings (sundowning effect) and may not be able to effectively communicate their needs. Cognitively impaired patients who frequently try to get out of bed at night may be attempting to get to the bathroom. This nurse and other members of the patient's care team should implement a toileting schedule for this patient to reduce unsafe attempts and prevent incontinence. B: Placing this patient near the nurses' station would be appropriate since it would allow for faster assistance/alarm response and more frequent assessments. D: Electronic bed and chair alarms would be an appropriate, non-restraint intervention for this patient that would help to reduce the risk of falls by signaling to staff that the patient may be attempting to get out of bed. Choice C is incorrect. Full-length bedrails are a form of physical restraint when used to prevent the patient from getting out of bed. Confused patients may not recognize the bedrail as a reminder to stay in bed, and studies have shown that routine use of these barriers can increase the risk of falls and injury.
Your client has a stat order for a cooling or hypothermia blanket. After you call the appropriate department, the cooling blanket is delivered to your nursing care unit. What is the first thing you should do concerning this stat order? A. Inspect and run the equipment prior to use. B. Immediately use the cooling blanket for the client because it is a stat order. C. Ask the engineering department to perform preventive maintenance on it. D. Inspect the blanket for any frayed cords before to protect against fire.
A. Inspect and run the equipment prior to use. Choice A is correct. You must thoroughly inspect and run the equipment before use to ensure that it is appropriately functioning BEFORE it is used. This inspection should include an overall assessment for frayed electrical cords and documented evidence that the piece of equipment has had the mandated preventive maintenance and safety inspections according to the facility's policies and procedure. Choice B is incorrect. You would not immediately use the cooling blanket for the client just because it is a stat order because other preventive measures must be taken first before using it. Choice C is incorrect. You would not ask the engineering department to perform preventive maintenance because you should be able to see documented evidence that the preventive maintenance was done on the sticker that is affixed to the piece of equipment. Choice D is incorrect. You would not merely inspect the blanket for any frayed cords before use to protect against fire.
An 11-week pregnant client is complaining to the nurse about her hemorrhoids. The nurse understands that hemorrhoids occur because of pressure on the rectal veins from the bulk of the growing fetus. All of the following are measures to alleviate hemorrhoid pain, except: A. Instruct the client to use mineral oil to soften her stools. B. Rest in a side-lying position daily. C. Increase the client's fiber and water intake. D. Apply a cold compress to the area. 3302
A. Instruct the client to use mineral oil to soften her stools. Choice A is correct. Mineral oil is contraindicated in pregnancy as it decreases nutrient absorption in the mother. Choice B is incorrect. Sleeping in a side-lying position removes the weight of the fetus on the superior and inferior vena cava, promoting venous return and decreasing venous pressure. Choice C is incorrect. Increasing fiber and water intake promote the formation of bulkier stools. Preventing constipation and relieving rectal pain. Choice D is incorrect. Cold compresses relieve pain by vasoconstriction of the hemorrhoids.
A gastrointestinal disease of childhood where a piece of bowel goes backward inside itself forming an obstruction is called what? A. Intussusception B. Pyloric stenosis C. Hirschsprung's disease D. Omphalocele
A. Intussusception Choice A is correct. A gastrointestinal disease of childhood where a piece of bowel goes backward inside itself, forming an obstruction, is called intussusception. Choice B is incorrect. Pyloric stenosis is the enlargement and stiffening of the pylorus, the opening from the stomach into the duodenum. This prevents the passage of food into the duodenum and results in projectile vomiting. Choice C is incorrect. Hirschsprung's disease is a congenital anomaly that results in mechanical obstruction. Choice D is incorrect. Omphalocele is a congenital disability in which an infant's intestine or other abdominal organs are outside of the body, protruding through a hole in the umbilical region
The nurse is providing discharge instructions to a client prescribed nasal cannula oxygen. Which of the following instructions should the nurse include? Select all that apply. Correct A. Keep a pulse oximetry device readily available. B. Pad the tubing in areas that put pressure on the skin. C. Have a sign on your door indicating the presence of oxygen. D. I should use the oven and not the stovetop to cook. E. You may apply petroleum jelly to your nares to prevent drying. 7444
A. Keep a pulse oximetry device readily available. B. Pad the tubing in areas that put pressure on the skin. C. Have a sign on your door indicating the presence of oxygen. Choices A, B, and C are correct. A pulse oximetry device should be provided to the client, and they should be encouraged to log their oxygen saturations as directed. If the client experiences dyspnea or tachypnea, the client should be instructed to seek medical attention for a level less than 95% (unless otherwise directed). Padding the tubing around pressure ears (back of the ears) is recommended to avoid injury. A sign posted on the door should be visible to alert visitors of the oxygen and extinguish and open flames. Choices D and E are incorrect. Stovetop and oven cooking is highly discouraged as the presence of oxygen may accelerate any fire that may ignite. Rather, if cooking is to be done using heat or flames, another individual should do the cooking, and the oxygen should be greater than six feet away from the flame source. Petroleum jelly should not lubricate the nares as it may be aspirated. Water-soluble jelly is recommended. 33% correct Subject Adult Health Lesson Respiratory Client Need Area Physiological Adaptation
A nurse is caring for a client with pneumonia who is in bilateral wrist restraints. The client has developed confusion. The nurse should take which priority action? A. Obtain vital signs B. Release restraints and provide range of motion C. Auscultate lung sounds D. Assess skin integrity under each restraint 7731
A. Obtain vital signs Choice A is correct. A complication of pneumonia is acute respiratory distress syndrome (ARDS). The hallmark of ARDS is hypoxemia which may manifest as altered mental status. The nurse should obtain vital signs with an emphasis on assessing the client's respiratory rate and pulse oximetry. Choices B, C, and D are incorrect. The restraints inhibit the client from mobilizing, which is detrimental to the management of pneumonia. However, the nurse should immediately obtain vital signs to ascertain if hypoxia is causing this confusion. Auscultating lung sounds is not an essential action. This would not generate useful clinical data as it cannot reveal if the client is hypoxic. Assessing the skin integrity of the wrists and providing range of motion are not actions that would remedy the client's confusion.
The nurse is assessing a 4-year-old client who was sent to the emergency department from urgent care. Assessment reveals tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling. Vital signs are: Temp: 39 C HR: 188 RR: 46 O2: 82 % What is the priority action for the nurse to take at this time? A. Keep the child calm and call for emergency airway equipment B. Obtain IV access C. Assess the throat for a cherry red epiglottis D. Place the child on a high flow nasal cannula at 100% FiO2 6120
A. Keep the child calm and call for emergency airway equipment Choice A is correct. Based on the presenting symptoms, the nurse suspects that this child has epiglottitis. Any child presenting with excessive drooling, distress, and stridor is highly suspicious to have this medical emergency. In addition, this client is already showing signs of circulatory compromise including circumoral cyanosis and mottling. The priority nursing action in this emergency is keeping the child calm and calling for emergency airway equipment. The child is at risk of losing their airway and the airway is always the priority. Choice B is incorrect. It is inappropriate to attempt to obtain IV access on a child suspected of epiglottitis before emergency airway equipment is available. The priority action at this time is keeping the child calm and calling for emergency airway equipment. Choice C is incorrect. It is inappropriate to assess the throat for a cherry red epiglottis at this time. Although the presence of a cherry red epiglottis would confirm the diagnosis of epiglottitis, this child is at risk of losing their airway. The priority action will be to protect the airway before IV access is attempted. Choice D is incorrect. Placing the child on a high-flow nasal cannula at 100% FiO2 is not the priority at this time. This answer probably sounded right, because you see the O2 is 82% and they have circumoral cyanosis. Oxygen sounds like the right answer but this intervention addresses the "C" in the ABC's mnemonic - circulation but the priority is always the airway. This child is at risk of losing their airway, so all interventions need to wait until there is emergency airway equipment close by. If anything upsets the child, then their airway could spasm and obstruct completely, making it impossible to intubate them. That is why keeping the child calm and calling for emergency airway equipment is the priority in epiglottitis patients.
Which of the following statements about appendicitis are true? Select all that apply. A. McBurney's point tenderness is a sign of appendicitis. B. Appendicitis is more common among males. C. A low carbohydrate diet is a risk factor for appendicitis. D. Lower left quadrant pain is a sign of appendicitis.
A. McBurney's point tenderness is a sign of appendicitis.
A post-adrenalectomy client is admitted to the ICU and is on IV hydrocortisone. Which nursing intervention should be included in the client's plan of care? A. Monitor blood glucose levels frequently. B. Keep the client supine for 24 hours. C. Discontinue hydrocortisone once vital signs become stable. D. Educate the client on how to properly clean his wound at home. 2827
A. Monitor blood glucose levels frequently. Choice A is correct. Hydrocortisone promotes gluconeogenesis and elevates blood glucose levels. The nurse should monitor the client's blood glucose levels frequently. Choice B is incorrect. The nurse should frequently turn the client and change position, cough, and deep breathe to prevent post-operative complications. Choice C is incorrect. The nurse cannot discontinue the medication unless stipulated by the physician. Choice D is incorrect. Discharge teaching should start upon admission. It should not be started once the client has finished his operation.
Which of the following nursing actions can an LPN/LVN perform on a patient who has a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA)? A. Obtain wound cultures during dressing changes. B. Plan ways to improve the client's oral protein intake. C. Assess the risk for further skin breakdown. D. Educate the client about home care of the leg ulcer. 4586
A. Obtain wound cultures during dressing changes. Choice A is correct. LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound cultures. Choices B, C, and D are incorrect. Teaching, assessment, and planning of care are complex actions that should be carried out by a registered nurse. 84% correct
The nurse is caring for a client immediately following transsphenoidal hypophysectomy. It would be essential for the nurse to obtain a prescription for which medication? A. Ondansetron B. Methimazole C. Omeprazole D. Methylphenidate 7628
A. Ondansetron Choice A is correct. Prophylactic nausea and vomiting prevention is essential following this surgery. If the client were to vomit, this would put pressure on the operative site and cause wound disruption. Following this surgery, the client is instructed not to cough, blow their nose, or sneeze. Vomiting should be avoided because it exerts pressure on the operative site, which is detrimental. Choices B, C, and D are incorrect. Methimazole is an antithyroid medication used for hyperthyroidism. This is not indicated following hypophysectomy. Omeprazole is a PPI and indicated in the treatment of peptic ulcer disease. Methylphenidate is a psychostimulant indicated in the treatment of ADHD. 46% correct
The nurse is discussing the use of medications to prevent organ rejection with the health care provider. Which of the following medicines is not used to avoid organ rejection? A. Oxybutynin chloride B. Prednisone C. Tacrolimus D. Cyclosporine 4024
A. Oxybutynin chloride Choice A is correct. Oxybutynin chloride is an anti-cholinergic medication often used for overactive bladder. This medication is not used to prevent organ rejection. Choice B is incorrect. Prednisone, a glucocorticoid medication, is frequently used in conjunction with other medicines to prevent organ rejection. Choice C is incorrect. Tacrolimus is an immunosuppressive medication used to prevent organ rejection. Choice D is incorrect. Cyclosporine is an immunosuppressive medication used to prevent organ rejection. NCSBN client need Topic: Physiological Integrity, Pharmacological and Parenteral therapies
The nurse is caring for a group of premature infants. Which action is most important in preventing healthcare-acquired infection? A. Performing frequent hand hygiene B. Disinfecting commonly touched surfaces C. Screening visitors for illness D. Administer prophylactic antibiotics 8465
A. Performing frequent hand hygiene Choice A is correct. The most important action a nurse can take to prevent a healthcare acquired infection is to frequently wash their hands. Hand hygiene is a proven and effective measure to decrease the transmission of pathogens. The nurse should wash their hands when they are visibly soiled, before and after contact with the client. Alternatively, the nurse may use alcohol-based sanitizers. Choices B, C, and D are incorrect. These measures are useful in preventing disease transmission however, handwashing is critical to reducing the transmission of microorganisms. Prophylactic antibiotic use is often discouraged because of the exposure to adverse effects such as gastrointestinal illness and antibiotic resistance.
A 60-year old adult walks into the clinic with a forehead laceration. He was going 45 mph on his motorcycle when he skidded on the gravel and fell off his bike. He isn't sure if he hit his head. After checking for significant bleeding and apparent signs of injury, what is the first intervention the nurse should do? A. Place a c-collar on the patient's neck. B. Take the patient back to a procedure room to stitch the laceration. C. Palpate the patient's abdomen to check for internal bleeding. D. Check the patient's pupils. 4451
A. Place a c-collar on the patient's neck Choice A is correct. After checking for apparent signs of illness, this patient needs c-spine precautions placed immediately. This patient was going faster than 30 mph on a motorcycle. We are not sure if he was wearing a helmet, but with the mechanism of injury, he could have a possible c-spine injury. This is important in preventing any spinal cord damage from occurring. Choice B is incorrect. Even though this intervention needs to be performed at some point, it is not the most important thing to do. A laceration may need pressure to stop the bleeding, but it can wait to be sutured. Choice C is incorrect. This step comes later in the head-to-toe assessment. The emergency physician will utilize an ultrasound machine to assess for any internal bleeding or complications. Choice D is incorrect. This step comes later in the head-to-toe assessment. This will happen after airway/c-spine, breathing, and circulation are assessed. The pupils should be assessed in this situation because the patient isn't sure if he hit his head on the ground. This could result in possible brain injury, including illness.
The nurse and two unlicensed assistive personnel (UAP) are preparing to reposition a client who requires log rolling. Which actions would be appropriate? Select all that apply. A. Place a small pillow between the client's knees. B. Places the client's arms at their side. C. Fanfold a drawsheet along the backside of the client. D. Instruct the client to laterally flex the neck during the turn. E. Roll the client as one unit in a smooth, continuous motion. 7774
A. Place a small pillow between the client's knees. C. Fanfold a drawsheet along the backside of the client. E. Roll the client as one unit in a smooth, continuous motion. These actions are appropriate during the process of log rolling a client. It is appropriate for a client who is to be log rolled to have a pillow placed between the client's knees to prevent tension on the spinal column and adduction of the hip. Fanning out a draw sheet under the client enables staff to have strong handles to grip without slipping. The purpose of log rolling a client is to move the client in one smooth, continuous motion to prevent twisting of the spinal column. Choices B and D are incorrect. To prevent a client from injuring their arms, the client should cross their arms across their chest during the repositioning. Instructing the client to laterally flex the neck would defeat the purpose of log rolling as this causes twisting of the spinal column.
The registered nurse (RN) is observing licensed practical/vocational nurses (LPN/VN) care for assigned clients. Which of the following actions by the LPN would require the RN to intervene? Select all that apply. A. Positions an unconscious client semi-Fowlers for oral care. B. Administers a bronchodilator to a client with chronic asthma. C. Irrigates an indwelling urinary catheter with 30 ml of sterile saline. D. Removes and reapplies weight to a client's skin traction every two hours. E. Administers intramuscular (IM) ketorolac to a client with osteoarthritis. 6476
A. Positions an unconscious client semi-Fowlers for oral care. D. Removes and reapplies weight to a client's skin traction every two hours. Choices A and D are correct. An unconscious client should not be positioned semi-Fowler's for oral care. The client should be positioned on their side to prevent aspiration. When a client has skin traction, the weights should hang freely and not be removed unless prescribed by the physician. Intermittent removal and reapplication may be harmful to the client. Choices B, C, and E are incorrect. Administering a bronchodilator to a client with chronic asthma, irrigating an indwelling urinary catheter, and administering intramuscular anti-inflammatory medications such as ketorolac is all within the scope of an LPN. 24% correct
A nurse is caring for a client who has developed bradycardia. Which prescription should the nurse question? A. Propranolol B. Furosemide C. Spironolactone D. Valsartan 3857
A. Propranolol Choice A is correct. Propranolol is a non-selective beta-blocker. Propranolol is used in the management of hypertension and migraine prevention. While it reduces blood pressure, it can also decrease heart rate (bradycardia) by blocking beta-1 receptors. Therefore, if a client is experiencing bradycardia, the client should not receive any medications that can lower the heart rate further. Choices B, C, and D are incorrect. Furosemide, spironolactone, and valsartan lower blood pressure through different mechanisms, but they do not decrease heart rate. 77% correct
The nurse is teaching a parenting class on ways to prevent burn injuries in the home. Which of the following information should be included? Select all that apply. A. Protective guards should be installed in electrical outlets. B. Adjust your hot water heater to prevent scald burn injuries. C. If a liquid chemical burn occurs, do not rinse it with water D. Develop and practice a family escape plan in case of a fire. E. Pot handles should be turned toward the back of the stove. 7359
A. Protective guards should be installed in electrical outlets. B. Adjust your hot water heater to prevent scald burn injuries. D. Develop and practice a family escape plan in case of a fire. E. Pot handles should be turned toward the back of the stove. Choices A, B, D, and E are correct. Protective guards should be placed in the outlet and furniture, if possible, should be placed in front of electrical outlets. This prevents the child from inserting objects into the outlet, preempting a serious electrical injury. The hot water heater should be adjusted to 49°C (120°F) or lower to prevent burn injuries. A fire escape plan should be developed for the home and practiced in the event of a fire. Pot handles should be placed on the back end of the stove with the handles turned toward the back. Choice C is incorrect. The initial treatment for a chemical burn is that it is irrigated with a copious amount of water. This should occur before touching the burn to prevent further injury to the individual rendering care.
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 Choice A is correct. 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. Choices B, C, and D are incorrect. All of these options violate the client's right to privacy and confidentiality. 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. 35% correct
The nurse is teaching a group of unlicensed assistive personnel (UAPs) concepts of client identification. Which situation would require two client identifiers? Select all that apply. A. Providing a meal tray B. Changing bed linens C. Replacing a suction cannister D. Obtaining vital signs E. Providing range of motion exercises 7776
A. Providing a meal tray D. Obtaining vital signs E. Providing range of motion exercises Choices A, D, and E are correct. Anytime the nurse or unlicensed assistive personnel (UAP) engages directly with the client, two identifiers (name and date of birth) should be asked. This prevents misidentification and mitigates errors related to care delivery. Providing a meal tray will require the identifiers because diets vary by client and are prescribed by the primary healthcare provider (PHCP). Obtaining vital signs requires the two identifiers so the nurse (or UAP) may accurately record these vital signs. Finally, providing range of motion requires two identifiers as it is a task directly involving the client. Choices B and C are incorrect. These tasks do not involve the client, nor is there a risk for client harm when these tasks are executed. They do not require two client identifiers.
The nurse is planning a staff development conference about medications utilized in an emergency. Which of the following information should the nurse include? Select all that apply. Correct A. Sodium bicarbonate is prescribed for severe cases of metabolic acidosis. B. Diphenhydramine should be administered before epinephrine for anaphylaxis. C. Glucagon may be prescribed to treat calcium channel blocker toxicity. D. Calcium gluconate is prescribed to treat dysrhythmias associated with hypokalemia. E. Magnesium sulfate is the prescribed treatment for torsades de pointes
A. Sodium bicarbonate is prescribed for severe cases of metabolic acidosis. C. Glucagon may be prescribed to treat calcium channel blocker toxicity. E. Magnesium sulfate is the prescribed treatment for torsades de pointes Choices A, C, and E are correct. Sodium bicarbonate may be used to treat severe metabolic and respiratory acidosis. Glucagon is an approved treatment for calcium channel and beta-blocker toxicity. Magnesium sulfate is the treatment for torsades de pointes, a fatal ventricular dysrhythmia. This should be combined with defibrillation if the client is hemodynamically unstable with torsades de pointes. Choices B and D are incorrect. Epinephrine is the priority treatment over diphenhydramine in anaphylaxis because of its ability to relieve upper airway obstruction or hypotension. Calcium gluconate is utilized to protect the myocardium from the irritability caused by hyperkalemia - not hypokalemia.
The nurse is caring for a client with the below laboratory result. Which early vital sign change would the nurse expect to support this finding? hgb 5.6 hct 16.8 A. Tachycardia B. Bradycardia C. Hypotension D. Bradypnea
A. Tachycardia
While working in an outpatient clinic, you take vital signs for a woman who expresses her interest in using herbal therapies to treat her chronic back pain. As a nurse, you know that herbal therapies can be safe when used properly, but should be closely monitored. You review the following teaching points with her to ensure her safe use of any herbal therapies. A. Tell your health care provider about any herbal therapies you are using. B. Only take the recommended dose of the herbal therapy to avoid any toxicity. C. Continue taking your prescribed medications from your healthcare provider; never stop taking a medication without talking to your health care provider. D. Using herbal remedies is acceptable for any condition as long as they are supervised by a healthcare provider. 3792
A. Tell your health care provider about any herbal therapies you are using. B. Only take the recommended dose of the herbal therapy to avoid any toxicity. C. Continue taking your prescribed medications from your healthcare provider; never stop taking a medication without talking to your health care provider. Choices A, B, and C are correct. The nurse should teach the patient to tell her healthcare provider about any and all herbal therapies she is using. It is important for the patient to understand that these therapies should be treated as seriously as any medication and that her healthcare provider will need to know everything she is taking to prevent any side effects or adverse reactions. Herbal therapies used in doses higher than what is recommended can quickly become toxic and the client should be instructed on this. Discontinuing a prescribed medication, even if adding an herbal therapy, is never recommended and could be dangerous. The client should be educated never to do this. Choice D is incorrect. Herbal remedies are not appropriate for all conditions. For example, in serious medical conditions such as heart disease or stroke, herbal remedies are not appropriate treatments.
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. Choice A is correct. 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. Rehabilitation by PT often will focus on learning to use the non-paralyzed portions of the body to regain varying levels of autonomy. Upon successful treatment, survivors of injuries at the C6/C7 level may be able to drive a modified car with hand controls. The C6 and C7 cervical vertebrae (and the C8 spinal nerve) form the lowest levels of the cervical spine and directly impact the arm and hand muscles. The C6/C7 injury has the potential to change everything below the top of the ribcage, resulting in quadriplegia or paraplegia. Physical therapy is an essential part of recovery. The patient will need to maintain any function not lost by the cord damage, as well as try to regain function.In acute rehabilitation of C6/C7 SCI patients, the focus is on strengthening the upper extremities to the maximal level in patients with complete paraplegia. Empowering exercises for shoulder rotation are proposed for using crutches, swimming, electric bicycles, and walking. At the end of the acute phase, strong upper extremities are needed for the independent transfer from the bed. For this purpose, active and resistance exercises to strengthen the muscles of the upper extremity should be initiated at the earliest possible period. The wheelchair is an essential tool for SCI patients to be mobile and participate in social life. Choices B and C incorrect. A client with C6-C7 Spinal cord injury with complete paraplegia loses control over leg and foot movement completely. These statements by the client indicate that she may need counseling regarding coping with her injuries. Choice D is incorrect. 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. 49% correct Subject Adult Health Lesson Neurologic Client Need Area Physiological Adaptation
The nurse is planning a staff development conference about diabetic ketoacidosis (DKA). Which of the following information should the nurse include? A. The goal is to lower blood glucose by 50 to 75 mg/dL/hr. B. Dextrose 5% should be available for hypoglycemia symptoms. C. Hypovolemia caused by DKA may be treated with 3% saline. D. The urine output would increase once regular insulin is initiated.
A. The goal is to lower blood glucose by 50 to 75 mg/dL/hr. Choice A is correct. DKA treatment aims to lower the blood glucose by 50 to 75 mg/dL/hr. This is accomplished by the prescribed regular insulin, which is given intravenously. Choices B, C, and D are incorrect. Dextrose 50% should be available in the event of severe hypoglycemia. Dextrose 5% is not sufficient to treat hypoglycemia. The treatment goal for the hypovolemia caused by DKA is isotonic saline, not hypertonic saline. Urine output would decrease with the infusion of regular insulin as correcting the hyperglycemia would treat the polyuria, which is a symptom of hyperglycemia.
The registered nurse works with others inside and outside their immediate work environment to achieve goals and make decisions that are best for individual clients or groups of clients. Out of the following choices, which best describes the role the nurse is fulfilling in this capacity? A. The nurse as a collaborator B. The nurse as a team leader C. The nurse as a delegator D. The nurse as a manager 2453
A. The nurse as a collabo Choice A is correct. A nurse fulfills the role of a collaborator when the registered nurse works with others inside and outside of their immediate work environment to achieve goals and make decisions that are best for an individual client or group of clients. Choice B is incorrect. Leadership is the ability to inspire others to achieve a desired outcome. Although team leadership may occur in various forms, a registered nurse working with others inside and outside their immediate work environment to achieve goals and make decisions that are best for the individual client or group of clients does not necessarily signify that the nurse is fulfilling a team leadership position. Although Choice B could arguably be considered, the question asks for the answer which best describes the role the nurse is fulfilling. Choice C is incorrect. Nurses serve as delegators when they delegate and assign roles or specific duties to others. As a delegator, the registered nurse transfers authority and responsibility to an appropriate team member to complete a task while retaining accountability. Nurses serve as delegators when they delegate and assign roles or specific duties to others. As a delegator, the registered nurse transfers authority and responsibility to an appropriate team member to complete a task while retaining accountability. Based solely on the information contained within the question, there is no indication that delegation is occurring. Choice D is incorrect. The nurse as a manager takes on more of an administrative than a clinical role. Some typical nurse manager responsibilities include planning (i.e., budgeting), organizing, staffing, directing, and controlling (i.e., resource allocation). While part of this position may occur outside of their immediate work environment, the majority of the position will occur within their immediate work environment. 67% correct
The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who A. has atrial fibrillation and a heart rate of 112/minute. B. has glomerulonephritis with a blood pressure of 137/86 mm Hg. C. is receiving amphotericin b, and the most recent temperature is 100.4°F (38°C). D. has chronic obstructive pulmonary disease (COPD) with an oxygen saturation of 91% on room air.
A. has atrial fibrillation and a heart rate of 112/minute. Choice A is correct. The client with atrial fibrillation and has two treatment goals. 1. The prevention of a stroke 2. Rate control between 60-100. The client with atrial fibrillation with an elevated heart rate requires priority follow-up because the increased rate likely means the client has atrial fibrillation with a rapid ventricular response. The client with this type of arrhythmia requires medications such as diltiazem or amiodarone to achieve rate control. Choices B, C, and D are incorrect. These clients are experiencing expected findings and do not require follow-up. A client with glomerulonephritis will have elevated blood pressure, proteinuria, and hematuria. An infusion of amphotericin b would cause a client to experience fever and chills and does not require imminent follow-up. This side effect can be avoided by the client being premedicated with isotonic fluids and acetaminophen. An oxygen saturation of 88% or greater is optimal for a client with COPD.
Which of the following is an example of the implementation step of the nursing process? A. The nurse carefully removes the bandages from a burn victim's arm. B. The nurse assesses a patient to check her nutritional status. C. The nurse forms a nursing diagnosis for a patient with a seizure disorder. D. The nurse repositions a bed-bound patient every two hours to prevent decubitus ulcers. E. The nurse checks the client's insurance coverage at the initial interview. F. The nurse verifies community resources for a patient with dementia. 5130
A. The nurse carefully removes the bandages from a burn victim's arm. D. The nurse repositions a bed-bound patient every two hours to prevent decubitus ulcers F. The nurse verifies community resources for a patient with dementia. Choices A, D, and F are correct. The nursing process involves 5 steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation ( ADPIE). During the implementation step of the nursing process, nursing actions planned in the previous steps ( according to the care plan) are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes, promote and restore health, and facilitate coping with altered functioning. By implementing the care plan, the nurse aims to assure continuity of care for the patient during hospitalization and in preparation for discharge. Choices B, C, and E are incorrect. The assessment step of the nursing process includes obtaining not only physiological data, but also psychological, sociocultural, spiritual, economic, and lifestyle data as well. The nursing diagnosis step includes not just primary diagnosis but also formulating diagnoses. The North American Nursing Diagnosis Association (NANDA) defines nursing diagnosis as "a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community." The diagnosis is the basis for the nurse's care plan. Often a nursing diagnosis is based on Maslow's Hierarchy of Needs pyramid and helps prioritize treatments. For example, physiological needs (such as food, water, and sleep) are more fundamental to survival than love and belonging, self-esteem, and self-actualization, so they prioritize nursing interventions. Based on nursing diagnoses, the nurse plans the goals ( planning, step 3) to address the patient's diagnosis/ problems through nursing implementation ( step 4). Assessing a patient for nutritional status ( Choice B) or insurance coverage ( Choice E) occurs in the assessment step, and formulating nursing diagnoses ( Choice C) occurs in the diagnostic step.
Your client had an appendectomy 4 to 5 days ago. He is tolerating an oral diet. Which of the following assessment findings would be a priority? Select all that apply. A. WBC count B. Hydration status C. Temperature D. Pulses 5895
A. WBC count C. Temperature Choices A and C are correct. Monitoring the patient's WBCs is an essential consideration after an appendectomy. The patient is at risk of infection, so monitoring for a rising WBC count will assist in identifying any disease early. The most common complication after appendectomy is wound infection and it occurs about 4-5 days following the surgery (Choice A). Monitoring the patient's temperature is an important consideration after an appendectomy. The patient is at risk of infection, so monitoring for fever will assist in identifying any disease early (Choice C). Choice B is incorrect. While monitoring hydration status is vital in all patients, it is not the priority for a 4-day status-post appendectomy patient who is tolerating an oral diet. The primary risk after this surgery is an infection, so monitoring for signs and symptoms of the disease is the priority. Choice D is incorrect. While monitoring pulses is vital in all patients, it is not the priority for a postoperative appendectomy patient. The primary risk after this surgery is an infection, so monitoring for signs and symptoms of the disease is the priority.
Which of the following are appropriate to include in a teaching plan for a teen with acne? Select all that apply. A. Wash the skin twice daily with a mild cleanser and warm water. B. Use cosmetics liberally to cover blackheads. C. Use emollients on the affected areas. D. Squeeze blackheads as soon as they appear. E. Keep hair off the face and wash hair daily. F. Avoid sun-tanning booths and use sunscreen.
A. Wash the skin twice daily with a mild cleanser and warm water. E. Keep hair off the face and wash hair daily. F. Avoid sun-tanning booths and use sunscreen. Choices A, E, and F are correct. Washing the skin removes oil and debris. Hair should be kept away from the face and washed daily to help prevent oil from the hair from getting on the forehead. Sunbathing should be avoided when using acne treatments. Acne is a condition that is characterized by clogged pores caused by dead skin cells and sebum sticking together in the orifice. Inside the pore, the bacteria have a perfect environment for multiplying very quickly. With a large number of bacteria inside, the pore becomes inflamed. If the inflammation goes deep into the skin, an acne cyst or nodule appears. Acne can appear on the face, back, chest, neck, shoulders, upper arms, and buttocks. Treatment includes avoiding squeezing or picking the infected areas, as this may spread the infection and cause scarring. The face should be washed twice daily with a mild cleanser and warm water. Oil-free, water-based moisturizers and make-up should be used. Choices B, C, and D are incorrect. Liberal use of cosmetics and emollients can clog pores. Squeezing blackheads is always discouraged because it may lead to infection.
The emergency department charge nurse was notified of a mass shooting at a nearby shopping mall. The charge nurse should take which action to prepare for the surge in clients? Select all that apply. A. Work to arrange timely discharge and admission for appropriate clients. B. Establish a holding area for discharged clients not able to go home. C. Modify the nurse/client ratio to accommodate the surge levels. D. Instruct staff to switch from electronic to paper documentation. E. Prepare to provide frequent updates to local media. 7977
A. Work to arrange timely discharge and admission for appropriate clients. B. Establish a holding area for discharged clients not able to go home. C. Modify the nurse/client ratio to accommodate the surge levels. Choices A, B, and C are correct. During an external disaster such as a mass shooting, it is reasonable for the nurse to anticipate a surge in clients. To accommodate the surge of individuals, the nurse should advocate for the timely disposition of clients (either admission or discharge) to clear up necessary space. If a client is discharged but cannot leave until the transportation is arranged, they should be placed in a designated discharge area. The charge nurse will need to modify the nurse/client ratio as the influx in clients will require more staffing resources. Choices D and E are incorrect. Switching documentation methods from electronic to paper would jeopardize client safety. This also would decrease efficiency. This would be an inappropriate action. The charge nurse should not be responsible for frequently updating the media. This would be the responsibility of the facilities administration.
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. 6045
A. hyperemesis gravidarum. Choice A is correct. Hyperemesis gravidarum is a pregnancy complication characterized by severe nausea, vomiting, weight loss, and possibly dehydration. 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. Choice B is incorrect. A client with renal failure will be at risk for hyperkalemia, not hypokalemia. The kidneys will be unable to excrete potassium as they usually do, and there will be a build-up of potassium in the blood leading to hyperkalemia. Choice C is incorrect. A client in diabetic ketoacidosis (DKA) will be at risk for hyperkalemia, not hypokalemia. When a client is in diabetic ketoacidosis, glucose cannot be transported into cells due to the lack of insulin. The body resorts to breaking down fat cells for energy, producing ketones, and driving blood pH down. Due to the blood's acidity and high glucose content, fluid and potassium are forced out of the cells and into the blood, causing hyperkalemia. If the client were experiencing alkalosis, they would be at risk for hypokalemia. Choice D is incorrect. 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. 51% correct Subject Adult Health Lesson Urinary/Renal/Fluid and Electrolytes Client Need Area Physiological Adaptation
The nurse is caring for assigned clients. The nurse should recognize which client is at risk of developing hypoglycemia? Select all that apply. A client: A. with diabetic ketoacidosis receiving continuous regular insulin intravenously. B. receiving methylprednisolone for an exacerbation of asthma. C. with pancreatitis and is receiving total parenteral nutrition (TPN). D. who is nothing by mouth (NPO) status following a coronary artery bypass graft (CABG). E. who received six units of lispro insulin one hour ago and has not eaten. 6582
A. with diabetic ketoacidosis receiving continuous regular insulin intravenously. E. who received six units of lispro insulin one hour ago and has not eaten. Choices A and E are correct. A client with diabetic ketoacidosis (DKA) receiving regular insulin intravenously is at significant risk for hypoglycemia because regular insulin (given intravenously) peaks within fifteen to thirty minutes. This is why the client has their glucose taken every hour. Lispro insulin is a rapid-acting insulin, and if the client has not eaten within ten to fifteen minutes of getting the insulin, they run the risk of hypoglycemia. Choices B, C, and D are incorrect. Methylprednisolone is a corticosteroid that causes hyperglycemia. This client would need more aggressive glucose control while they are receiving this medication. TPN may cause hyper- or hypoglycemia; however, the risk of hyperglycemia is much higher, especially if the client has pancreatitis. The client who has had a CABG will likely have hyperglycemia because of the stress associated with the surgery. Following major surgery, the adrenal glands discharge cortisol which raises blood glucose. It will be important for the client to have good post-operative glucose control, which is associated with better outcomes. 15% correct Subject Adult Health Lesson Endocrine Client Need Area Reduction of Risk Potential
The nurse is preparing morning medications for a client with a nasogastric tube connected to low-intermittent wall suction. Which actions does the nurse take to ensure proper administration of this client's medications? Select all that apply. A. Position the client in Trendelenburg position. B. Verify correct placement of the tube before medication administration. C. Turn off the suction during medication administration. D. Return the NG tube to low-intermittent wall suction after administering the medication. 6017
B is correct. Before medication or food administration, it is crucial always to verify the correct placement of the nasogastric tube ( NGT). The gold standard to verify tube placement is visualization on an x-ray. The American Association of Critical-Care Nurses (AACN) guidelines recommend confirming the position of NGTs by X-ray. However, given the risks of radiation exposure with X-rays and delayed feeding, alternative options are often used to verify the tube placement before feeding or giving medications to the client. The most commonly used first-line verification method is measuring the pH of the NG tube aspirate to make sure it falls in line with that of gastric contents. Most guidelines recommend that the pH of an NGT aspirate should be ≤5.5 (acidic) to confirm proper placement. An alkaline pH ( >7.0) often indicates a lung aspirate rather than gastric. A false-negative pH reading greater than 5.5 may be seen with the use of antacids and proton pump inhibitors. If the pH is greater than 5.5, an X-ray must be performed as a second-line test. After the placement has been initially verified, the nurse may mark where the tube is located at the nare of the client so that the nurse can assess that the tube has not moved and remains in the stomach before each feed. C is correct. It is appropriate to turn off the suction during medication administration. If the client remained on low-intermittent wall suction, the medication would be evacuated from the stomach via suction before it could be absorbed. The nurse should stop the suction and clamp the nasogastric tube for 30 minutes after administering the medications to allow them to absorb fully. Choice A is incorrect. It would be highly inappropriate to place a client in the Trendelenburg position before administering medications through a nasogastric tube. To prevent aspiration, the nurse should sit the patient up as much as tolerated, raising the head of the bed at least 30 degrees. This will allow gravity to help the medication flow into the stomach for absorption. Choice D is incorrect. Returning the NG tube to low-intermittent wall suction is not appropriate after administering the medication. This process would prevent the medications from wholly absorbing. The nurse should clamp the nasogastric tube for 30 minutes after medication administration to allow for medication absorption. Then the nurse may return the NG tube to low-intermittent wall suction. 44% correct Subject Adult Health Lesson Gastrointestinal/Nutrition Client Need Area Reduction of Risk Potential
You are the nurse performing education for a patient with AIDS at the community clinic. Which of the following statements is an example of appropriate teaching? A. "Do not wash your dishes with your roommate's dishes." B. "Clean all utensils and dishes before reusing them." C. "Do not use the same shower or toilet as your roommate." D. "Hand sanitizer is not necessary unless you plan on touching someone else." 4175
B. "Clean all utensils and dishes before reusing them." Choice B is correct. Stagnant water and food particles can be a breeding ground for pathogenic microorganisms. A patient with an AIDS diagnosis is susceptible to contracting illness/infections more quickly due to the deficiency in his/her immune system. The focus of education should include measures to protect the patient from contracting illnesses from others. Choices A and C are incorrect. Washing dishes with someone else's or sharing bathroom facilities does not protect the patient or the roommate from illness or spread of disease. Choice D is incorrect. Using hand sanitizer is recommended for all people to help prevent the spread of germs.
The nurse is caring for four newborns during her shift in the unit. After performing an assessment, which newborn should the nurse give her attention to? A. A 24-hour old newborn that has not yet passed meconium. B. A 3-day old infant with mild jaundice and a bilirubin of 3 mg/dL. C. A 3-hour old infant that has just passed meconium. D. A 5-day old infant with a positive Babinski reflex.
B. A 3-day old infant with mild jaundice and a bilirubin of 3 mg/dL.
The nurse has educated a client scheduled to have an endoscopic retrograde cholangiopancreatography (ERCP). Which of the following client statements would indicate the need for additional teaching by the nurse? Select all that apply. A. "I will not be able to eat or drink anything for six to eight hours before this procedure." B. "I will have to do a bowel prep before this procedure." C. "Someone will have to drive me home after this procedure." D. "I should expect that I will have abdominal pain and distention for one or two days following this procedure." E. "I can expect to have white stools one to two days following this procedure." 9921
B. "I will have to do a bowel prep before this procedure." D. "I should expect that I will have abdominal pain and distention for one or two days following this procedure." E. "I can expect to have white stools one to two days following this procedure." Choices B, D, and E are correct. Bowel prep would be required for a barium enema or a colonoscopy. Abdominal pain and distention one to two days following this procedure requires follow-up as post-procedure pancreatitis may adversely occur. This complication has deterred many providers from pursuing this procedure. Choices A and C are incorrect. These statements are factual and do not require follow-up. To prevent aspiration, the client will have nothing by mouth status (NPO) six to eight hours before this procedure. This procedure involves the client being moderately sedated with medications such as lorazepam, propofol, midazolam, or fentanyl. The residual sedation puts the client at risk for a motor vehicle accident. Thus, the client must not drive following this procedure. 11% correct Subject Adult Health Lesson Gastrointestinal/Nutrition Client Need Area Reduction of Risk Potential
A nurse is instructing a client about prescribed risperidone. Which statements, if made by the client, require follow-up? A. "I should report any abnormal movements that I develop." B. "I will need to have weekly tests to monitor my white blood cells." C. "If I get muscle stiffness, I should notify my physician." D. "I will need to chew sugarless gum if I develop a dry mouth. 6450
B. "I will need to have weekly tests to monitor my white blood cells." Choice B is correct. Risperidone is a second-generation antipsychotic used in delirium, schizophrenia, and some childhood disorders. Weekly white blood cell tests are not required with risperidone as this is appropriate for an individual receiving clozapine. Choices A, C, and D are incorrect. Risperidone is a second-generation antipsychotic which may adversely cause movement disorders such as dystonia or tardive dyskinesia. The client should report any abnormal movements to the provider. Neuroleptic Malignant Syndrome (NMS) is a potentially fatal adverse reaction manifested by muscle rigidity, fever, and tachycardia. This must be reported promptly. Finally, the client should use special mouthwashes and sugar-free gum for dry mouth because of the anticholinergic properties associated with this drug.
Which of the following statements made by an elderly client indicate the achievement of ego integrity? Select all that apply. A. "I wish I could change some things in my past." B. "I'd like to volunteer at the youth center a few days a week." C. "I'm thinking of helping people learn to read and write." D. "I signed up for an art class at the senior center." 4103
B. "I'd like to volunteer at the youth center a few days a week." C. "I'm thinking of helping people learn to read and write." D. "I signed up for an art class at the senior center." Choices B, C, and D are correct. Ego integrity signs are manifested by tasks or statements that help bring all previous phases of the life cycle together. Symptoms of successful ego integrity include continuing to learn, helping others, and volunteering. Choice A is incorrect. Ego Integrity vs. Despair is the final stage of Erikson's Psychosocial Development. Signs of self-disgust or despair are manifested when the older adult believes life has been too short or if he/she wants a chance to do things over in life.
The nurse teaches a client about their newly applied halo fixator device with a vest. Which of the following statements should the nurse make? Select all that apply. A. "You should ride a bicycle instead of driving a car." B. "Report any fever or drainage at the pin sites." C. "Always keep the wrench taped to the front of the vest." D. "When you are getting out of bed, roll to the side and push on the mattress." E. "Wear a cotton t-shirt under the vest to absorb any moisture." 9395
B. "Report any fever or drainage at the pin sites." C. "Always keep the wrench taped to the front of the vest." D. "When you are getting out of bed, roll to the side and push on the mattress." E. "Wear a cotton t-shirt under the vest to absorb any moisture." Choices B, C, D, and E are correct. This device is an external fixator and has pins directly into the skull. Any signs or symptoms of infection should be reported immediately, as these manifestations may suggest osteomyelitis. The wrench of the device should always be kept affixed to the front of the vest in the case of the need to perform CPR. It would be correct for the client to get out of bed by pushing against the mattress. Cotton clothing should be worn under the vest to absorb any excess moisture and prevent skin breakdown. Choice A is incorrect. These statements are incorrect. Driving a vehicle and riding a bicycle are prohibited while in this device because of the client's inability to turn from side to side to view traffic.
What is the term that is used to describe a human's innate biological clock relating to daytime and nighttime wakefulness and activity? A. REM sleep B. Circadian rhythm C. Diurnal activity D. Nocturnal activity 3063
B. Circadian rhythm Circadian rhythm is defined as our 24-hour biological clock that is primarily one that functions best with daytime wakefulness/activity and nighttime sleep. When clients are in synchrony with their biological clock, humans function optimally because many of our essential rational physiological and mental functions like blood pressure, body temperature, and levels of alertness/performance are at their optimal levels.
You have offered one of your newly admitted clients a partial bed bath. The client states, "I took a bath at home three days ago. I do not need a bath for another 3 or 4 days." How should you respond to this client? You should respond by saying: A. "Would it be okay with you if I teach you about the benefits of and the need for daily bathing?" B. "That is fine. At what time of the day do you prefer to bathe and do you prefer a shower or tub bath?" C. "A once a week bath is not good. You have to bathe at least every other day to protect against infection." D. I am sorry but we have rules here. All clients must be bathed at least every other day. Let's start the bath." 3054
B. "That is fine. At what time of the day do you prefer to bathe and do you prefer a shower or tub bath?" Choice B is correct. You would respond with, "That is fine. At what time of the day do you prefer to bathe, and do you prefer a shower or tub bath?" when one of your newly admitted clients refuses a partial bed bath by stating, "I took a bath at home three days ago. I do not need a bath for another 3 or 4 days." This response acknowledges the fact that the frequency of bathing, bathing routines, and practices vary among individuals and cultures. Clients should be assessed for their bathing needs in preferences of their type of bathing and time of bathing. Additionally, a bath once a week is acceptable as long as the client remains clean, without bodily odors, and is still hygienic. Choice A is incorrect. You would not respond with, "Would it be okay with you if I teach you about the benefits of and the need for daily bathing?" because a daily bath is not always necessary and a bath once a week is acceptable as long as the client remains clean, without bodily odors, and is still hygienic.
The nurse is teaching a parenting class on car seat safety. Which statements should the nurse include? Select all that apply. A. "Place the car seat rear-facing in the back seat and at 90 degrees." B. "The car seat straps should fit snugly over the shoulders." C. "Infants should ride in a rear-facing, in the back seat, until six months." D. "Rolled blankets may be needed between the crotch and legs to prevent slouching." E. "You may add padding underneath the infant to increase their comfort." 9386
B. "The car seat straps should fit snugly over the shoulders." D. "Rolled blankets may be needed between the crotch and legs to prevent slouching." Choices B and D are correct. The car seat straps should be placed snugly over the infant's shoulders. Further, rolled blankets may be placed on each side of the infant to prevent lateral movements and slouching. Choices A, C, and E are incorrect. The car seat should be rear-facing in the back seat of the car. The car seat should be positioned at 45 degrees to prevent slouching and airway obstruction. The infant or toddler should never be positioned in the passenger seat. Infants and toddlers should also utilize the car seat until two years old or until they reach the highest weight or height recommended by the car seat manufacturer. Padding should not be added to the car seat as slack in the harness, leading to the possibility of the child's ejection from the seat in the event of a crash.
During the middle of her busy day shift, the nurse has several tasks that need to be completed. Which of the following patient assignments would be appropriate for unlicensed assistive personnel? A. A 65-year-old male requiring sterile dressing changes. B. A 26-year-old female requiring a one-person assist in ambulating to the restroom. C. An 80-year-old male who is receiving enteral feedings continuously through an NG tube. D. A 16-year-old female who is 4 hours post-cardiac catheterization. 5953
B. A 26-year-old female requiring a one-person assist in ambulating to the restroom. Choice B is correct. A 26-year-old female requiring a one-person assist in ambulating to the restroom would be an appropriate assignment for unlicensed assistive personnel (UAP). The UAP is skilled in assisting clients with ambulation and this is within their scope of practice. Choice A is incorrect. A 65-year-old male requiring sterile dressing changes would not be an appropriate assignment for unlicensed assistive personnel. Simple dressing changes are not performed by unauthorized personnel. The UAP does not have the requisite knowledge and experience for this task. Choice C is incorrect. An 80-year-old male who is continuously receiving enteral feedings through an NG tube would not be an appropriate assignment for unlicensed assistive personnel. Administering tube feedings is not performed by unauthorized personnel. Choice D is incorrect. A 16-year-old female who is 4 hours post-cardiac catheterization would not be an appropriate assignment for unlicensed assistive personnel. The client recovering from a cardiac catheterization will require close monitoring for frequent changes and should be assigned to an experienced healthcare team member. 98% correct
A registered nurse (RN) and a licensed practical nurse (LPN) are working together in a psychiatric ward. Which of the following clients may the RN assign to the LPN? A. A client taking amitriptyline, now swinging his jaw and grimacing. B. A client with dementia that is confused and disoriented. C. A client with bipolar disorder and a lithium level of 2.0 mEq/L. D. A client with a history of chronic alcoholism experiencing delirium tremens. 2707
B. A client with dementia that is confused and disoriented. Choice B is correct. Clients with advanced dementia are expected to be confused and disoriented. In the absence of any new or acute changes in the mental status, the LPN is fully qualified to take care of this client. Choice A is incorrect. A client receiving amitriptyline, swinging his jaw, and grimacing is showing signs of acute dystonia, a potentially serious condition arising from taking antipsychotic medications. Acute dystonic reactions must be treated right away. This patient should be handled by a qualified psychiatric nurse. Choice C is incorrect. A client with a lithium level of 2.0 mEq/L is having severe lithium toxicity. This client should be taken care of by a registered nurse. A safe blood level for lithium is 0.6 mEq/L to 1.2 mEq/L. A level of 1.5 mEq/L or greater is considered toxic. Severe toxicity may occur at a level greater than 2.0 mEq/L, which can be life-threatening. Choice D is incorrect. Delirium tremens is a sign of severe alcohol withdrawal. It is associated with rapid onset of confusion and is sometimes characterized by hyperthermia and/or seizures. Such patients demonstrate unpredictable and unstable outcomes. Handling patients with delirium tremens need frequent assessments and critical thinking. Such patients should not be assigned to an LPN.
A nurse manager of a home health nursing agency is completing client assignments for the nursing staff. Which client should be assigned to the most experienced registered nurse? A. A recovering Guillain-Barre syndrome client complaining of constant fatigue B. A client with stage 3 and 4 pressure injuries present on the sacral area C. A 2-week postoperative laryngectomy client due to laryngeal cancer D. A client due for discharge from home health services in the coming week 2602
B. A client with stage 3 and 4 pressure injuries present on the sacral area Choice B is correct. A client with stage 3 and 4 pressure injuries present on the sacral region requires extensive wound care from an experienced nurse capable of properly assessing and caring for the client's pressure injuries. The nurse manager should assign this client to the experienced registered nurse for various reasons. First, accurate assessment and documentation of pressure injuries requires experience. Second, dressing stage 3 and 4 pressure injuries often requires complex, time-consuming methods. Third, this client will need to undergo a head-to-toe assessment for additional pressure injuries and areas at risk for pressure injuries, with all applicable areas documented and addressed. Fourth, the client (and any applicable caregivers) will require significant education on pressure points, the need to rotate every two hours, how moisture affects skin breakdown, etc. Therefore, this client is appropriate for the experienced registered nurse. Choice A is incorrect. Fatigue is an anticipated complaint in clients with Guillain-Barre syndrome (GBS). Studies have demonstrated that fatigue is one of the most disabling symptoms in GBS clients, often lingering for months or years following the onset of symptoms. Complaints of fatigue from a GBS client do not warrant using the most experienced nurse. Choice C is incorrect. A client who is two weeks postoperative following a laryngectomy would not warrant the expertise of the most experienced registered nurse at the home health nursing agency. At this point in the postoperative period, many of the risks the client faced in the immediate postoperative period are no longer a concern. Additionally, the client no longer requires extensive postoperative teaching or comprehensive nursing care. Therefore, this client does not require the most experienced registered nurse. Choice D is incorrect. From the time a client is admitted to a home health service, the goal of the home health service is to discharge the client. The primary method to accomplish this goal is client education. As such, the client education process begins upon the client's admission. Here, the client is due for discharge within the coming week, meaning the client possesses the requisite amount of applicable client education and has improved to the point of being eligible for discharge from home health services. Based on this information, this client does not require the services of the agency's most experienced registered nurse. 45% correct
Select the diet that would most likely be ordered for a client who is edentulous? A. A low sodium diet to prevent edema and excessive fluid. B. A mechanical soft diet to facilitate mastication. C. A renal diet to prevent fluid retention and edema. D. A high fiber diet to prevent constipation secondary to edema. 3000
B. A mechanical soft diet to facilitate mastication. Choice B is correct. A mechanical soft diet to facilitate mastication would most likely be ordered for a client who is edentulous. This diet would help the client who is without teeth (edentulous) to chew, or gnaw, their food with their gums. Other diets do not meet this nutritional and safe eating need. Choice A is incorrect. A low sodium diet to prevent edema and excessive fluid is indicated for clients affected with edema, renal disease, and heart disease, but not edentulous clients. Choice C is incorrect. A renal diet to prevent fluid retention and edema is indicated for clients affected with renal disease and kidney failure, but not edentulous clients. Choice D is incorrect. A high fiber diet is indicated for clients at risk for and that are constipated, but it is not indicated for clients who are edentulous. 59% correct Subject Adult Health Lesson Gastrointestinal/Nutrition Client Need Area Basic Care and Comfort
A nursing student in a pediatric unit at a hospital asks the clinical nurse educator about a nurse's legal responsibilities in cases of suspected child abuse. Which of the following would be the most appropriate response by the nurse educator? A. A nurse is required to collect additional data to support their suspicion before taking further action. B. A nurse is required to directly report their suspicions to the local child protection agency and/or law enforcement agency. C. A nurse is required to talk to a child's parents regarding any suspected abuse. D. A nurse is required to talk to the health care provider (HCP) regarding their suspicions of child abuse. 2540
B. A nurse is required to directly report their suspicions to the local child protection agency and/or law enforcement agency. Choice B is correct. A nurse's legal responsibility is to immediately report any suspected child abuse to the relevant authorities according to state and local law(s). Once any suspicion forms, the nurse is required to report the suspicion to the appropriate investigative agency or agencies per applicable law, which then assumes the investigation. Choice A is incorrect. The data which has led the nurse to suspect child abuse should be sufficient to prompt the nurse to report the suspicions to the authorities. The nurse should not waste additional time or resources accumulating additional information, as the additional time used to collect those resources will lead to delayed intervention. Choice C is incorrect. This step should be avoided. Speaking to the suspected victim's/pediatric client's patients will likely aggravate the parents, resulting in additional negative repercussions against the child. Furthermore, the situation may worsen (i.e., increased abuse, the family may suddenly relocate, etc.). Choice D is incorrect. Discussion with the HCP does not guarantee notification of the authorities of this case. Child abuse reporting is not something you "pass up the chain of command." While the nurse may discuss the issue with the HCP, this discussion does not negate the nurse of their duty to report their suspicions under the law. 69% correct
The nurse is teaching a group of students about medications and fall prevention. The nurse would be correct to identify which of the following medications that can increase the risk for falls? Select all that apply. A. Naproxen B. Alprazolam C. Bumetanide D. Verapamil E. Allopurinol F. Thiamine 6555
B. Alprazolam C. Bumetanide D. Verapamil Medications that may hasten the risk for falls and included benzodiazepines such as alprazolam. This medication causes drowsiness and may impair judgment. Bumetanide is a loop diuretic; this medication may cause a client to experience orthostatic hypotension and the urgency to use the bathroom. Both of which pose a fall hazard. Verapamil is a calcium channel blocker and is utilized in the management of migraines and hypertension. This medication causes vasodilation; therefore, it will allow the client to become orthostatic if they do not shift positions slowly.
Which of the following clients is at greatest risk for developing malnutrition? A. A 72-year-old woman in a nursing home B. An 81-year-old widow who lives alone C. A 65-year-old with poor dentition who is married D. A 79-year-old widower who receives food from 'Meals on Wheels'
B. An 81-year-old widow who lives alone Choice B is correct. This patient has two risk factors, which make her a higher risk for developing malnutrition. Malnutrition refers to deficiencies, excesses, or imbalances in a person's intake of energy and nutrients. The term malnutrition addresses three broad groups of conditions: Undernutrition, which includes wasting (low weight-for-height), stunting (low height-for-age), and underweight (low weight-for-age) Micronutrient-related malnutrition, which includes micronutrient deficiencies (a lack of important vitamins and minerals) or micronutrient excess Overweight, obesity, and diet-related non-communicable diseases (such as heart disease, stroke, diabetes, and some cancers) Women, infants, children, and adolescents are at particular risk of malnutrition. Optimizing nutrition early in life—including the 1000 days from conception to a child's second birthday—ensures the best possible start in life, with long-term benefits. Poverty amplifies the risk of, and threats from, malnutrition. Poor people are more likely to be affected by different forms of malnutrition. Also, hunger increases health care costs, reduces productivity, and slows economic growth, which can perpetuate a cycle of poverty and ill-health. Choices A, C, and D are incorrect. While each of these clients may experience poor nutrition and develop malnutrition, if untreated, the patient in answer choice B has two risk factors which make her the highest risk for developing malnutrition. 79% correct
Select the barrier to effective medication use among the elderly population that is accurately paired with an effective corrective nursing intervention. A. Poverty and the lack of health insurance: Discontinue medications and suggest over-the-counter remedies B. Arthritis affecting the hands: Suggest non-child proof medication containers C. Poor fine motor coordination: Suggest an eye examination D. Severe confusion and poor memory: Write up a chart for medications 3560
B. Arthritis affecting the hands: Suggest non-child proof medication containers Choice B is correct. The barrier to effective medication use among the elderly population that is accurately paired with an effective corrective nursing intervention is suggesting non-childproof medication containers for elderly clients who have arthritis due to their poor manual dexterity and poor fine motor coordination; non-child proof medication containers are very helpful for these patients. Choice A is incorrect. Poverty and the lack of health insurance are not a reason to discontinue medications and suggest over-the-counter remedies; instead, suggest less expensive alternatives to the ordering physician, contact social services, and also contact pharmaceutical manufacturers for assistance. Choice C is incorrect. Poor fine motor coordination interferes with the client's ability to open childproof medication containers and perhaps even take pills or capsules out of them; however, you could suggest an occupational therapist rather than an eye examination. Choice D is incorrect. Writing up a chart for medications is most likely of little use for clients who are affected with severe confusion and poor memory; assistance with drugs should, therefore, be suggested.
A client requests to change rooms after overhearing that their roommate is positive for the human immunodeficiency virus (HIV). The nurse should take which appropriate action? A. Relocate the client to a private room B. Ask the client to elaborate on their concern C. Notify the risk manager of the request D. Place an additional divider in-between the two beds 8689
B. Ask the client to elaborate on their concern Choice B is correct. Asking the client to elaborate on their concern is the most logical and therapeutic action. The client is likely misinformed about the disease transmission of HIV, and the nurse should encourage the client to verbalize their concerns. It also is appropriate for the nurse to respond to any misconceptions the client may have with compassion and facts. Choices A, C, and D are incorrect. These actions are incorrect. Based on the information provided, the client should not be relocated to a private room. Additionally, if the client were to be relocated, a private room would not be necessary, as another semi-Private room would be appropriate. The risk manager does not need to be notified of the request. This request would be irrelevant to a risk manager. Finally, an additional divider is unnecessary because this would further fuel the hysteria surrounding HIV. A client with HIV can be roomed with another individual, and standard precautions should be utilized.
An emergency department (ED) nurse establishes continuous cardiac monitoring for a client. The following tracing is observed on the monitor (sinus bradycardia). The nurse should take which initial action? See the image below. A. Establish vascular access and request a prescription for atropine B. Assess the client's blood pressure and level of consciousness C. Obtain and review the client's current medications D. Document the findings and reassess the client in one hour 7900
B. Assess the client's blood pressure and level of consciousness Choice B is correct. The nurse should prioritize assessing the client's vital signs and level of consciousness. This tracing reflects sinus bradycardia. While sinus bradycardia may be benign, if the client should experience unstable blood pressure or have dizziness, the nurse will need to act by establishing vascular access and administering atropine. However, this is predicated on the client's overall stability which can only be discerned by assessment. Choices A, C, and D are correct. These actions are plausible but do not prioritize assessing the client and their overall condition. Reviewing the client's current medications may determine the origin of the bradycardia but will not yield clues as to the client's current level of stability. Documentation should only occur once the nurse has determined that the client is stable.
Which of the following are substantial nursing interventions for a patient who is one-hour post-op from a cardiac catheterization? Select all that apply. A. Administer their regularly scheduled metformin on time. B. Assess the pulse of the extremity distal to the puncture site. C. Position them supine with the head of bed at 45 degrees. D. Monitor for hematoma formation at the puncture site. 4882
B. Assess the pulse of the extremity distal to the puncture site. Choices B and D are correct. The nurse must perform a thorough assessment of the perfusion status of the extremity distal to where the puncture was. In a cardiac cath, a sheath is inserted through an artery and snaked up into the heart. This sheath occluded blood flow during the procedure. So, we must monitor the extremity through which they placed the sheath to ensure perfusion returns properly. This includes assessing the pulse, capillary refill, the color of the extremity if there is any pain or numbness, and movement of the extremity. Usually, a femoral artery is used, so we must monitor the perfusion of the foot on the leg that was accessed (Choice B). Monitoring for hematoma formation over the access site is a critical nursing intervention. The most common complication after a cardiac catheterization is bleeding, and the creation of a hematoma shows bleeding under the skin. The nurse should notify the health care provider if she notes a hematoma forming so that they may evaluate the patient. Be sure to monitor for other signs of bleeding as well, especially around the access site (Choice D). Choice A is incorrect. If the patient who is postoperative from a cardiac catheterization has metformin scheduled, the dose should be held for 48 hours post-op. Iodinated contrast used for cardiac catheterization may cause kidney failure. Should such acute kidney failure occur, metformin metabolites can accumulate and cause lactic acidosis. Therefore, metformin should always be held for 48 hours after any procedure that involves iodinated contrast. Choice C is incorrect. Positioning is critical after a cardiac catheterization. For 4 to 6 hours post-op, the head of the bed should be flat or slightly elevated but no more than 30 degrees. Such positioning prevents bleeding and helps the access site from the cardiac catheterization ultimately heal. It is also essential to educate the patient about this so that they will be still and not try to stand up on their own before they are allowed to.
Select an appropriate nursing diagnosis for your client who is affected with hyperalgesia. A. At risk for inadvertent narcotic overdoses related to hyperalgesia. B. At risk for abnormal and irreversible pain related to hyperalgesia. C. At risk for somatic pain related to hyperalgesia. D. At risk for visceral pain related to hyperalgesia. 3664
B. At risk for abnormal and irreversible pain related to hyperalgesia. Choice B is correct. "At risk for abnormal and irreversible pain related to hyperalgesia" is an appropriate nursing diagnosis for a client who is affected with hyperalgesia. Hyperalgesia, which is synonymous with hyperpathia, is abnormal pain processing that can lead to the appearance of neuropathic pain that is irreversible if left untreated. Choice A is incorrect. "At risk for inadvertent narcotic overdoses related to hyperalgesia" is not an appropriate nursing diagnosis for a client who is affected with hyperalgesia. Hyperalgesia is abnormal pain processing that is not associated with inadvertent narcotic overdosages. Choice C is incorrect. "At risk for somatic pain related to hyperalgesia" is not an appropriate nursing diagnosis for a client who is affected with hyperalgesia. Hyperalgesia can lead to neuropathic pain, but not somatic nociceptive pain. Choice D is incorrect. "At risk for visceral pain related to hyperalgesia" is not an appropriate nursing diagnosis for a client who is affected with hyperalgesia. Hyperalgesia can lead to neuropathic pain, but not visceral nociceptive pain. 25% correct, Subject Adult Health Lesson Neurologic Client Need Area Physiological Adaptation
Which of the following is the definition of death established in the Uniform Determination of Death Act of 1981? A. Either irreversible cessation of circulatory and respiratory functions; or irreversible cessation of all functions of the entire brain including the brain-stem. B. Both irreversible cessation of circulatory and respiratory functions as well as the irreversible cessation of all functions of the entire brain including the brain-stem. C. Irreversible cessation of circulatory and respiratory functions only. D. Irreversible cessation of all functions of the entire brain including the brain-stem only.
B. Both irreversible cessation of circulatory and respiratory functions as well as the irreversible cessation of all functions of the entire brain including the brain-stem.
A 55-year old female has a complete knee replacement on her left knee. Which symptom would be the most likely to indicate a severe adverse reaction after surgery? A. Inability to move the leg B. Capillary refill 5+ for the left foot C. Severe pain at the left knee incision site D. Ability to move the toes 4467
B. Capillary refill 5+ for the left foot Choice B is correct. Assessments after knee surgery should include the 5 P's: pain, pallor, pulse, paralysis, and paresthesia. Capillary refill should be assessed during the pallor assessment. A normal capillary refill is less than two seconds. The capillary refill, in this case, is 5 seconds, which is indicative of a problem. Choice A is incorrect. This patient may not be able to move her leg due to pain after the surgery. Choice C is incorrect. This patient will have pain at the surgery incision site. If the patient continues to have severe and uncontrollable pain in the entire leg, the nurse should worry about compartment syndrome. Choice D is incorrect. This is a normal finding. Subject Adult Health Lesson Musculoskeletal Client Need Area Reduction of Risk Potential 61% correct
You work in a community clinic in a large city. There has been a recent outbreak of meningococcal meningitis at the local university and students who have been in contact with the sick students have been advised by public health officials to obtain prophylactic treatment. Which of the following would be helpful in preventing this disease? Select all that apply. A. Amoxicillin B. Ciprofloxacin C. Rifampin D. Meningococcal conjugate vaccine 4436
B. Ciprofloxacin C. Rifampin D. Meningococcal conjugate vaccine Choices B, C, and D are correct. Meningococcal meningitis is transmitted through respiratory droplets from infected individuals. After exposure, symptoms will usually appear within 3 to 4 days. The CDC does not recommend universal prophylaxis during an outbreak, but prophylactic treatment should be provided for individuals in close contact with the infected patients. A single dose of ciprofloxacin or four doses of rifampin over two days can be useful in preventing the acquisition of the disease. Meningococcal conjugate vaccine (MCV4) is the preferred vaccine for at-risk individuals in this group. College students often receive this vaccination before attending school. Choice A is incorrect. Amoxicillin is not a treatment that will provide chemoprophylaxis.
Which of the following findings would lead you to suspect non-accidental trauma in your 1-year-old burn victim patient? Select all that apply. A. Scalding on the anterior trunk B. Circumferential burns on the feet C. Same thickness of skin damage throughout the burn D. Burns to the soles of the feet 5357
B. Circumferential burns on the feet C. Same thickness of skin damage throughout the burn Choices B and C are correct. B is correct. Circumferential burns on the feet would lead you to suspect non-accidental trauma in a 1-year-old. As a mandatory reporter, you are required to report these suspicions. Circumferential burns are full-thickness burns affecting the entire circumference of an area. They are very dangerous and can cause serious complications. In this case, it is unlikely a one-year-old could inflict a circumferential burn of the feet to themselves accidentally. This burn pattern can be caused by holding the child's feet in scalding water. C is correct. A burn that has the same thickness of skin damage throughout the burn is suspicious for non-accidental trauma. In an accident where something such as boiling water was spilled, the water will cool as it moves and leaves different levels of tissue damage in different areas. Likewise, if the child splashes in a bathtub with water that is too hot, areas will be affected differently. If the burn has the same thickness of skin damage throughout, it is suspicious for being non-accidental. Choice A is incorrect. It is more likely for a 1-year old to spill something on their anterior trunk accidentally. If they pull down on anything, such as a pot on the stove, it can spill onto their torso and burn them. Burns on the posterior surface of a one-year-old would be suspicious for non-accidental trauma. Choice D is incorrect. Burns to the soles of the feet are not necessarily a concern for non-accidental trauma. The child could have stepped onto something hot causing the burns accidentally. Areas of suspicion should include the back, buttocks, inside of the thighs, and genitalia.
Which of the following foods is contraindicated when the client is taking a monoamine oxidase inhibitor (MAO) for depression? A. Calves' liver B. Citrus fruits C. Milk D. Kale
B. Citrus fruits
When making patient care assignments, the nurse delegates care activities to nursing assistive personnel [NAP]. What factors must the nurse consider? Select all that apply. A. Patient gender and ethnicity B. Complexity of the tasks C. Knowledge and skills of the NAP D. Scope of practice for the NAP 3751
B. Complexity of the tasks C. Knowledge and skills of the NAP D. Scope of practice for the NAP Choices B, C, and D are correct. When delegating patient care activities to nurse assistive personnel (NAP), the RN must be aware of patient needs, the complexity of the tasks to be assigned, the knowledge/skills of the individual NAP, and which jobs are appropriate to delegate according to the scope of practice for NAPs. Choice A is incorrect. Patient gender and ethnicity are not primary concerns.
You are providing education on home safety to a group of new parents. Which of the following educational points are important to include? Select all that apply. A. Use stair gates to keep children off the stairs until they are in kindergarten. B. Cover the electrical outlets by the time your infant is 7 months old. C. Place locks on toilet lids by the time your infant is 7 months old. D. Move items on coffee tables to areas that cannot be reached before your child is a year old. 4822
B. Cover the electrical outlets by the time your infant is 7 months old. C. Place locks on toilet lids by the time your infant is 7 months old. Choices B and C are correct. It is important to teach parents that electrical outlets should have plug covers in place by the time their child is 7-months-old. At this age, the infant will be able to crawl and will be reaching out to touch unfamiliar things. This is when electrical outlets start to pose a risk and should therefore be covered (Choice B). It is important to teach parents that toilet lids should have locks on them by the time their child is 7 months old. At this age, the infant will be able to crawl and will be reaching out and pulling themselves up on things. This is when toilets start to pose a risk and should have locks placed on their lids so that they cannot fall into them (Choice C). Choice A is incorrect. It is not necessary to use stair gates until the child is in kindergarten, as they should be able to safely navigate stairs on their own by 3 to 4 years of age. Advise parents to use stair gates until their child is 3 to 4 years old and is able to walk up and down the stairs without their support. Choice D is incorrect. This should be done by the time the child is 7 months old. A child who is developing normally will be crawling, reaching, and pulling themselves up on things by the time they are 7 months old, so this is when items on tables should be moved for their safety.
Which of the following is the final step that is used during the physical assessment of the abdomen? A. Inspection B. Deep palpation C. Percussion D. None of the above 4200
B. Deep palpation Choice B is correct. Deep palpation is cautiously done after light palpation when necessary because the client's responses to deep palpation may include their tightening of the abdominal muscles. When this occurs, it could make light palpation less effective, particularly if an area of pain or tenderness has been palpated. A complete health assessment may be conducted starting at the head and proceeding systematically downward (head-to-toe evaluation). However, the procedure can vary according to the age of the individual, the severity of the illness, the preferences of the nurse, the location of the examination, and the agency's priorities and procedures. Choice A is incorrect. Inspection is typically the first step of an assessment. Choice C is incorrect. Percussion of the abdomen should be done before any palpation, especially deep palpation. Choice D is incorrect. Since choices A and C are incorrect, choice D is also wrong.
The nurse is preparing to administer medications to a client. The nurse notices that his heart rate is at 51 beats per minute. Which medication should the nurse withhold? A. Amlodipine 5 mg PO B. Diltiazem 60 mg PO C. Ibuprofen 500 mg PO D. Ciprofloxacin 500 mg PO
B. Diltiazem 60 mg PO Choice B is correct. The client is experiencing bradycardia. Therefore, it is important to withhold medications that may exacerbate bradycardia. Diltiazem is a non-dihydropyridine calcium channel blocker (CCB). Diltiazem is more cardioselective compared to dihydropyridine CCBs. Because of its cardiac depressant (negative chronotropic and negative inotropic) properties, diltiazem reduces the heart rate and contractility. Because of negative chronotropic action, it can cause bradycardia. For this reason, therapeutic uses of diltiazem include atrial arrhythmia and paroxysmal supraventricular tachycardia. When the client has baseline bradycardia, it is important to hold the diltiazem and notify the healthcare provider for further orders or dosage modification. Choice A is incorrect. Amlodipine is a dihydropyridine CCB that is more selective to vascular smooth muscle calcium channels. Therefore, it causes vasodilation and can be used to treat hypertension. Amlodipine does not cause bradycardia. The client is experiencing bradycardia but not hypotension. Amlodipine need not be held if there is asymptomatic bradycardia without hypotension. Side effects of dihydropyridine CCBs (amlodipine, felodipine, nifedipine) include hypotension, flushing, peripheral edema/ ankle edema, headache, and reflex tachycardia. Choice C is incorrect. Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID). NSAIDs do not affect the client's heart rate and can, therefore, be given regardless of their heart rate. Choice D is incorrect. Ciprofloxacin is a fluoroquinolone antibacterial and can be given even if the client's heart rate is low. Ciprofloxacin's most reported cardiac side effects include QTc prolongation and torsades de pointes (ventricular arrhythmias). Bradycardia is unusual.
A nurse is reinforcing education regarding home fire safety to the parents of a 5-year-old. Which of the following would be accurate to include in the teaching plan? Select all that apply. A. Most fatal fires occur when people are cooking. B. Most people who die in fires die of smoke inhalation rather than burns. C. Less than 60% of U.S. fire deaths occur in the home. D. About 60% of fire deaths occur in a home without a smoke detector. E. More fires occur in homes occupied by single parents. F. In the event of a fire, quickly call the fire department and then exit home.
B. Most people who die in fires die of smoke inhalation rather than burns D. About 60% of fire deaths occur in a home without a smoke detector. Choices B and D are correct. Most people who die in home fires indeed die of smoke inhalation rather than burns (Choice B). Smoke inhalation is the most common cause of death in a house fire. Symptoms of smoke inhalation include coughing, nausea, vomiting, drowsiness, and confusion. If a fire victim has difficulty breathing, singed nostril hairs, and burns to their nose, mouth, or face, then immediate medical attention is warranted because this may indicate the individual has inhaled scorching air, which can cause burns in the respiratory tract. More than 50 percent of people with severe burns and smoke inhalation die. Fire, while burning, consumes the oxygen in an enclosed space leaving little oxygen for occupants to breathe and maintain consciousness. Lack of oxygen may cause impaired consciousness quickly and occupants are often not able to reach the exits. In addition to this, toxic gases like carbon monoxide replace the oxygen and can be fatal even in small amounts. Fire experts often recommend conducting a family fire drill twice a year, which may include practicing to get out of the house while blindfolded. The family should be taught to exit first since time is of the essence during a fire, and exiting should not be delayed searching for a phone or calling a neighbor/fire department for help. Such calls should be made after exiting. Studies have found that about 60% of home fire deaths occur in a home without a smoke detector. So, a nurse needs to reinforce the education regarding smoke alarms and the client should make sure these alarms are working. Choice A is incorrect. Most fatal fires occur when people are sleeping, not while cooking. Choice C is incorrect. it is not less than 60%. 85% of fire-related deaths occur in the home, not in public places. Choice E is incorrect. Being a single parent does not increase the risk of experiencing a fire in the home. Choice F is incorrect. In the event of a fire, first, exit home and then call for help from the fire department or neighbor. Since smoke can quickly overcome an occupant, time is of the essence, and the occupant should exit the home STAT.
A nurse is caring for a client who has Lyme disease. The nurse should anticipate a prescription for which medication? A. Finasteride B. Doxycycline C. Valacyclovir D. Diphenhydramine
B. Doxycycline Choice B is correct. Lyme disease is a disease that is caused by the bacteria, Borrelia burgdorferi, which is carried by deer ticks. Symptoms of Lyme disease include a localized rash progressing to generalized symptoms. Doxycycline is one of the antibiotics used to treat this infection. Choice A is incorrect. Finasteride is indicated for benign prostatic hypertrophy. Choice C is incorrect. Valacyclovir is an anti-viral indicated for herpes infections Choice D is incorrect. Diphenhydramine is indicated for seasonal allergies.
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 3703
B. Equianalgesia Choice B is correct. 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. Choice A is incorrect. Morphine equivalency relates to the equivalency of an opioid analgesic when compared to parenteral morphine. Choice C is incorrect. Morphine equivalent relates to the equivalency of an opioid analgesic when compared to parenteral morphine. Choice D is incorrect. The morphine factor is the term that elements in the power of parenteral morphine.
The nurse is preparing to administer a prescribed infusion of oxytocin to a client with labor dystocia. During the infusion, the nurse plans to monitor which of the following? Select all that apply. A. Deep tendon reflexes (DTR) B. Fetal heart rate (FHR) patterns C. Uterine activity (UA) D. Blood pressure (BP) E. Urine specific gravity (USG) 9160
B. Fetal heart rate (FHR) patterns C. Uterine activity (UA) D. Blood pressure (BP) Choices B, C, and D are correct. FHR patterns, UA, and BP are three monitoring parameters essential to monitor an infusion of oxytocin. Oxytocin may cause nonreassuring FHR patterns such as tachycardia, bradycardia, decreased variability, and pathologic (late, variable, or prolonged) decelerations. Oxytocin may cause excessive uterine activity (UA) (tachysystole, hypertonus, inadequate relaxation time). Rapid infusion of oxytocin may cause maternal hypotension. BP monitoring is recommended. Choices A and E are incorrect. DTRs are not necessary to monitor during an oxytocin infusion. This would be applicable for the infusion of magnesium sulfate as magnesium sulfate is a muscle relaxant. USG has no relevance to the infusion of oxytocin.
After reporting to her usual adult medical-surgical floor, the LPN is told she must float to the mother-baby unit. The LPN has never cared for this patient population before. Which of the following actions is most appropriate? A. Refuse the assignment. B. Float to the mother-baby unit and identify tasks within her training that she can safely perform. C. Call the nurse manager. D. Float to the mother-baby unit and ensure no one knows about her inexperience. 5946
B. Float to the mother-baby unit and identify tasks within her training that she can safely perform. Choice B is correct. Floating to the mother-baby unit and identifying tasks within her training that she can safely perform is the correct action. This promotes patient safety and benefits both the nurse and the unit. Choice A is incorrect. It is not appropriate to refuse the assignment. Nurses may be asked to float to another unit, depending on the hospital census, and it is not beneficial to refuse to take an assignment if asked to float. Choice C is incorrect. It is not appropriate to call the nursing manager. Floating is an acceptable legal practice used by the hospital to solve understaffing. Choice D is incorrect. Floating to the mother-baby unit and ensuring not to let anyone there know she does not have experience in this area is not appropriate and does not promote patient safety. The nurse should identify tasks that she can safely perform.
The nurse is discussing ocular disorders with a group of nursing students. Which of the following statements would be correct for the nurse to make? Select all that apply. A. Cataracts are caused by increased ocular pressure (IOP). B. Graves' disease may cause exophthalmos. C. Macular degeneration is manifested by loss of peripheral vision. D. Angle-closure glaucoma is manifested by headache and eye pain. E. Hyphema results in increased aqueous humor in the anterior chamber.
B. Graves' disease may cause exophthalmos. D. Angle-closure glaucoma is manifested by headache and eye pain. Choice B and D are correct. Graves' disease may cause a client to develop exophthalmos. Angle-closure glaucoma is a medical emergency where the IOP is greater than 30 mmHg, and the client has manifestations such as eye pain, headache, blurred vision, and reddened eye appearance. Choices A, C, and E are incorrect. Increased IOP is a central feature of glaucoma. Cataracts is a disorder of the lens as it causes the client to have difficulty discriminating colors and seeing in low light. Opacities can commonly be seen in the affected eye. Macular degeneration causes central vision loss, not vision loss in the peripheral fields. A hyphema is caused by blood in the eye's anterior chamber.
The oncoming nurse is receiving a report on a pregnant patient with HELLP syndrome. This nurse knows that HELLP syndrome, a severe progression of preeclampsia stands for: A. Half Eclipsed Lipase Levels and Preeclampsia B. Hemolysis, elevated liver enzymes, and lowered platelets C. Hematocrit elevation, low lipase, and pancreatitis D. Hemoglobin, elevated lipids, and low plasma
B. Hemolysis, elevated liver enzymes, and lowered platelets Choice B is correct. HELLP syndrome stands for Hemolysis, elevated liver enzymes, and low platelets. HELLP syndrome is a condition in which hemolysis of the red blood cells occurs creating elevated liver enzymes and low platelets. Generally, complications are prevented by delivering the fetus as soon as symptoms develop. Choices A, C, and D are incorrect. These are not associated with HELLP syndrome. NCSBN client need Topic: Physiological Adaptations, alterations in body function 82% correct
Which of the following findings would prompt immediate investigation when performing an assessment of a patient on a medical/surgical unit? A. Bowel sounds of 14 per minute B. High-pitched bowel sounds at a rate of 4 per minute C. Bowel sounds greater than 60 per minute D. Low-pitched bowel sounds at a rate of 30 per minute 5008
B. High-pitched bowel sounds at a rate of 4 per minute Choice B is correct. Bowel sounds less than 5 per minute may indicate blockage and should be evaluated. Bowel sounds are high-pitched, occasional gurgles, or clicks that last from one to several seconds. They occur every 5 to 15 seconds in the average adult. Choice A is incorrect. Bowel sounds of 14 per minute are considered normal. Choice C is incorrect. Although bowel sounds that are more than 30 per minute are considered hyperactive, it is not as immediate a concern as choice B. Choice D is incorrect. Bowel sounds usually are high-pitched. However, the rate of bowel sounds is within normal limits. This answer choice does not pose as much concern as choice B.
You ask your 32-year-old female client about her hobbies. The client tells you that they thoroughly enjoy reading, making pottery, hiking, and rock climbing in the mountains. Which of these interests would you primarily focus on and encourage A. Making pottery because this avocation is relaxing and not hazardous. B. Hiking because this avocation is a good and low-impact exercise. C. Reading because this avocation is relaxing and not hazardous. D. Rock climbing because this avocation is a good and low-impact exercise. 2399
B. Hiking because this avocation is a good and low-impact exercise. Choice B is correct. You would primarily focus on and encourage hiking because hiking is not only a hobby and interest for the client, but it is an excellent form of exercise that is low impact and relatively safe in comparison to other hazardous hobbies like rock climbing. Choice A is incorrect. Making pottery is not the activity or hobby that you would focus on and encourage because pottery is a sedentary and solitary activity; not one that provides enjoyable outdoor exercise and social interactions with others. However, it can be relaxing and with minimal hazards. Choice C is incorrect. Reading is not the activity or hobby that you would focus on and encourage because it is a sedentary and solitary activity; not one that provides any exercise and social interactions with others, although it can be relaxing. Choice D is incorrect. Rock climbing is not the activity or hobby you would focus on and encourage because rocking climbing is exceptionally hazardous, although it is an excellent and high-impact exercise. 45% correct
The nurse is reviewing newly prescribed medications for a client taking lithium. Which medication requires further follow-up? A. Venlafaxine B. Hydrochlorothiazide C. Gabapentin D. Verapamil 6436
B. Hydrochlorothiazide Choice B is correct. A client taking lithium should be instructed to avoid dehydration and hyponatremia. Lithium is a salt, and when the client has decreased fluid volume, the drug will accumulate and raise the lithium level. HCTZ is a thiazide diuretic and is contraindicated for a client taking lithium because of its ability to decrease fluid and sodium levels. Choices A, C, and D are incorrect. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor and has no contraindication with lithium. Further, gabapentin and verapamil have no contraindications as gabapentin is indicated for neuropathy, and verapamil is indicated for hypertension.
The nurse is evaluating a patient with symptoms of metabolic acidosis. Which of the following is not a cause of metabolic acidosis? A. Severe diarrhea B. Hyperventilation C. Starvation D. Diabetes mellitus 4186
B. Hyperventilation Choice B is correct. Hyperventilation due to asthma, anxiety, or high altitude may lead to respiratory alkalosis. Unless it is quickly corrected, acidosis and alkalosis can have severe or fatal consequences. The nurse needs to understand possible causes and identify symptoms as soon as possible. Note: Acidosis and alkalosis are not diseases, but instead signs of an underlying disorder. The primary treatment of acid-base disorders is targeted at correcting the underlying cause. Choices A, C, and D are incorrect. These are all possible causes of metabolic acidosis. Therefore, not the answers to the question.
Which of the following are appropriate secondary prevention strategies to teach your patient for cancer prevention? Select all that apply. A. Eliminate alcohol intake B. Pap smears C. Rehabilitation programs D. Colonoscopies
B. Pap smears D. Colonoscopies
The nurse is caring for several geriatric clients. Which of the following should the nurse include in the teaching plan for older clients with altered immune responses? Select all that apply. A. It is normal to run a slightly higher than normal temperature. B. If arthritis pain begins to bother you, the doctor can prescribe something for pain. C. I'd like to talk to you about ways to manage stress. D. It is very important to eat a well-balanced diet. 4102
B. If arthritis pain begins to bother you, the doctor can prescribe something for pain. C. I'd like to talk to you about ways to manage stress. D. It is very important to eat a well-balanced diet. Choices B, C, and D are correct. Many elderly clients suffer from chronic pain ( for example; arthritic pain). Chronic pain and continuous stress can negatively affect the immune system. Uncontrolled and persistent pain can trigger a stress response. Stress is associated with an increase in cortisol. Chronic cortisol elevation causes reduced immune response. Therefore, the nurse should discuss the strategies to manage pain and stress appropriately. Additionally, the nurse should also educate the elderly clients to maintain a well-balanced diet to promote a healthy immune system Choice A is incorrect. The elderly often experience masked signs of infection and inflammation. These masked signs mean that the client with an infection may not present with noticeably elevated temperature or increased white blood count, unlike a younger client. It's essential for the nurse to observe for masked signs of infection and to encourage elderly patients to contact their physician, even if their fever is "low-grade." Subject Adult Health Lesson Immune Client Need Area Health Promotion and Maintenance 43% correct
The nurse is performing a verbal hand-off report for a client. Which essential information should the nurse include in the report? A. Current medication list B. Involuntary admission status C. Food and mealtime preferences D. The presence of family at the bedside 6568
B. Involuntary admission status Choice B is correct. Admission status is essential information provided in the hand-off report because involuntary admission requires the client to stay in the healthcare facility. This status is typically required when a client may pose a threat to themselves or others. This type of involuntary admission status also may raise the risk of the patient eloping. This should be communicated because if a client is involuntarily admitted, they may not have a rational thought process which may raise the risk of self-injury if they do successfully elope. Choices A, C, and D are incorrect. The current medication list is generally not communicated during the hand-off report. Hand-off reports should include new prescriptions or prescriptions pertinent to the client's care. The oncoming nurse may easily obtain this list by accessing the medication administration record. Food and mealtime preferences are important to delivering client-centered care but do not prioritize the client's admission status. Finally, the presence of family at the bedside may be irrelevant unless pertinent family dynamics impact care. 39% correct
The nurse is caring for a client with the following clinical data. The nurse should expect the primary healthcare provider (PHCP) to prescribe what medication? BP: 224/123 Pulse: 118 A. Enalapril B. Labetalol C. Amiodarone D. Nitroglycerin 6933
B. Labetalol Choice B is correct. Labetalol is an alpha- and beta-adrenergic blocking agent used to treat a hypertensive emergency. Considering that this client is both hypertensive and tachycardic, labetalol would be a good choice. Choices A, C, and D are incorrect. Enalapril is an ACE inhibitor that may be given intravenously. However, this medication would have no effect on the client's tachycardia. Thus, this would be an inappropriate recommendation. Amiodarone is an umbrella drug used to manage atrial and ventricular dysrhythmias. This medication is not indicated for a hypertensive emergency. While utilized in treating a hypertensive emergency, nitroglycerin would not be efficacious for the client's tachycardia. It would make the tachycardia worse as this drug causes reflex tachycardia as the blood pressure is decreased. Subject Adult Health Lesson Cardiovascular Client Need Area Pharmacological and Parenteral Therapies
You are taking care of a client who is taking warfarin and lovastatin. Which statement about the interaction warfarin and lovastatin should you incorporate into your plan of care? A. Lovastatin decreases the effects of the warfarin. B. Lovastatin increases the effects of the warfarin. C. Lovastatin has no known effects on the warfarin. D. Combining lovastatin and warfarin causes respiratory depression. 3396
B. Lovastatin increases the effects of the warfarin. Choice B is correct. Lovastatin increases the effects of warfarin, so the nurse should incorporate this knowledge related to an increased influence of the anticoagulant, warfarin, into the plan of care.
Which of the following activities can be delegated to unlicensed assistive personnel (UAPs)? Select all that apply. A. Performing initial client assessments B. Making client beds C. Giving clients bed baths D. Administering client medications E. Ambulating clients F. Assisting clients with meals
B. Making client beds C. Giving clients bed baths E. Ambulating clients F. Assisting clients with meals
The nurse is caring for an 18-month-old toddler with a cough and fever. Which is the most appropriate play activity for the nurse to offer the toddler? A. Toy puzzles B. Miniature cars C. Finger painting D. Comic book reading
B. Miniature cars
The nurse is caring for a client newly prescribed ropinirole. The nurse understands that this medication is prescribed to treat which condition? A. Multiple Sclerosis B. Parkinson disease C. Schizophrenia D. Guillain-barré syndrome 8084
B. Parkinson disease
While caring for a client who requires a mechanical ventilator for breathing, the high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A. Disconnect the client from the ventilator and use a manual resuscitation bag. B. Perform a quick assessment of the client's condition. C. Call the respiratory therapist for help. D. Press the alarm reset button on the ventilator. 4168
B. Perform a quick assessment of the client's condition. Choice B is correct. Several situations can cause the high-pressure alarm to sound. An assessment of the client will tell the nurse whether the alert was triggered by something simple, such as the patient coughing, or by a more difficult situation that might require using a manual resuscitation bag and calling the respiratory therapist. Several things can trigger pressure alarms on mechanical ventilators. Some of the most common causes of high-pressure alarm triggers include water in the ventilator circuit, increased or thicker mucus or other secretions blocking the airway (caused by not enough humidity), bronchospasm, coughing, gagging, or "fighting" the ventilator breath. Regardless of the cause of the triggered alarm, the priority for nurses is to evaluate the patient's status first. Choice A is incorrect. If the patient is struggling for air, the nurse should disconnect the ventilator and use a manual resuscitation bag. This will be evident when the patient is assessed, which is the first nursing action that should be taken. Choice C is incorrect. Although the respiratory therapist may need to be called, this should not be the nurse's first response. Choice D is incorrect. The reset button may need to be engaged. However, the patient's status should be the nurse's priority
The nurse is obtaining vital signs for a client who has acquired immune deficiency syndrome (AIDS). Prior to entering the room, the nurse should do which of the following? A. Wear gloves and a gown. B. Perform hand hygiene. C. Review the client's viral load. D. Obtain a disposable stethoscope.
B. Perform hand hygiene. Choice B is correct. When caring for a client who has AIDS, the nurse should maintain standard precautions. Applying PPE such as a gown, pair of gloves, and mask would be inappropriate. Standard precautions require appropriate hand hygiene and other PPE as needed. Choices A, C, and D are incorrect. The diagnosis of AIDS requires standard precautions which mandate appropriate hand hygiene. It would be inappropriate for gowns or gloves to be worn during client care. Assessing the client's viral load prior to obtaining vital signs would not change the fact that this client requires standard precautions. A disposable stethoscope and blood pressure cuff may be useful for a client with contact precautions, but it would not be necessary for a client with AIDS.
A male patient, one-day post-CVA, is showing signs of left-sided neglect. To begin the rehabilitation process, the nurse caring for this patient should add the following interventions to the patient's plan of care. Select all that apply. A. Sit on the unaffected side when interacting with the patient. B. Place the phone on the patient's affected side. C. Encourage the patient to touch the affected hand with the unaffected hand. D. Place a favorite object into the hand on the affected side. 4429
B. Place the phone on the patient's affected side. C. Encourage the patient to touch the affected hand with the unaffected hand. D. Place a favorite object into the hand on the affected side Choices B, C, and D are correct. Rehabilitation should start as early as possible for the stroke victim with unilateral neglect. In this side effect of a stroke, the patient is not aware of one side of the body. In this scenario, the patient would ignore the left side of the body and might be unaware of anything happening to his left. The key to this question is the phrase "to begin the rehabilitation process." In this case, the purpose of rehab is to help the patient become aware of the side he is currently ignoring. These answer choices will all force the patient to acknowledge his left side. Sitting on the unaffected side will allow the patient to continue to ignore the left side; thus, the nurse should encourage visitors to interact with the patient from his left side. This may mean that the visitor will have to turn the patient's head physically to the left. Choice A is incorrect. 20% correct
The nurse is teaching a class on acid-base imbalances. It would be correct for the nurse to identify which of the following would cause respiratory acidosis? Select all that apply. A. Aspirin overdose B. Pneumothorax C. Opioid overdose D. Anxiety E. Renal disease 4699
B. Pneumothorax C. Opioid overdose Choices B and C are correct. Respiratory acidosis is caused by the inability to expel carbon dioxide either through obstruction in the airway or decreased ventilation. A pneumothorax causes shallow breathing, which causes the retention of CO2 (an acid). Opioids are central nervous system depressants. When the client is exposed to toxic levels, the effect causes hypoventilation and the retention of CO2. Choices A, D, and E are incorrect. An aspirin overdose stimulates causes metabolic acidosis because excessive ingestion leads to an increase in the hydrogen ion concentration. Renal disease also causes metabolic acidosis because of the kidneys inability to recycle bicarbonate in the body. 31% correct, I put A B & E Subject Adult Health Lesson Urinary/Renal/Fluid and Electrolytes Client Need Area Physiological Adaptation
The nurse is caring for a client two days post-op total knee replacement with a continuous passive motion (CPM) device at the bedside. The nurse would recognize that the primary purpose of this machine is to: A. Stabilize the knee joint during ambulation B. Promote knee flexion C. Reduce post-surgical swelling D. Prevent blood clots 6889
B. Promote knee flexion Choice B is correct. Maintaining joint flexion and mobility is a high priority for the post-op total knee replacement (TKR) client. The continuous passive motion (CPM) device would be worn intermittently while the client is in bed to flex and extend the knee, reduce scar tissue formation, and help the client maintain optimal joint mobility. Choice D is incorrect. Although leg exercises would reduce the client's risk of DVT, the primary purpose of the CPM machine is to promote flexion and mobility of the joint, not to prevent blood clots.
While monitoring the administration of intravenous heparin to a patient. The nurse asks the physician to order which medication in case of an emergency? A. Potassium chloride B. Protamine sulfate C. Vitamin K D. Naloxone 4052
B. Protamine sulfate
An infant is currently stable but has just been diagnosed with cystic fibrosis. Which of the following would be the priority nursing goal for the family? A. Stabilize the child B. Provide emotional support C. Arrange for financial assistance D. Formulate long-term goals 8463
B. Provide emotional support Choice B is correct. The family needs emotional support when a chronic condition is newly diagnosed in a family. The parents need to follow up on genetic counseling, treatment options, prognosis, and resources. Choice A is incorrect. The infant has already been stabilized, so there is no longer a need to adjust care for the infant. Choice C is incorrect. This is a long-term goal for the family. Choice D is incorrect. This is a long-term goal for the family. 58% correct
A client with Raynaud's disease has just been prescribed ephedrine. What is the nurse's most appropriate action? A. Provide dietary instructions to the client. B. Question and discuss the prescription with the physician. C. Instruct the client regarding adverse effects. D. Administer the medication initially to the client. 3482
B. Question and discuss the prescription with the physician. Choice B is correct. Clients with Raynaud's disease or any other peripheral vascular disease are contraindicated to receive ephedrine or any other adrenergic agonist as these diseases could be exacerbated by systemic vasoconstriction. The nurse should question the physician regarding this prescription. Choice A is incorrect. Providing dietary instructions to the patient is an inappropriate action as this medication is contraindicated for the patient's existing disease. Choice C is incorrect. The nurse's most appropriate action would be to question the physician's prescription as the medication is contraindicated in the patient's present condition. Choice D is incorrect. The nurse should not administer the initial dose of a medication that he/she knows will do the patient harm. The nurse should question and discuss with the physician regarding the prescription. 43% correct Subject Adult Health Lesson Immune Client Need Area Pharmacological and Parenteral Therapies
The nurse is providing education to the mother of an 8-year-old boy scheduled to receive a scratch skin test to assess for the presence of allergies. The nurse would be correct in encouraging the mother to do which of the following actions to prepare for the test? A. Administer a single dose of anti-histamine medication one day before the test to prepare for any discomfort. B. Refrain from administering systemic steroids to the child in the 5 days preceding the exam. C. Scrub the child's skin vigorously before the exam. D. Maintain NPO status for twelve hours before the test. 3981
B. Refrain from administering systemic steroids to the child in the 5 days preceding the exam. Choice B is correct. The nurse providing education to this mother would be most accurate in reminding the mother to refrain from administering systemic steroids to the child in the five days prior to the exam. Systemic corticosteroids, as well as anti-histamine medications, may interfere with the test results by reducing reactions and giving false-negative results. Choice A is incorrect. Anti-histamines should not be given in five days before the exam. Choice C is incorrect. This child can bathe as normal and should not have their skin cleaned vigorously before the exam. Choice D is incorrect. NPO status, or nothing by mouth, is not necessary for this exam. Children should eat like usual and encourage them to eat small meals if they are nervous. 80% correct
The nurse is observing a newly hired nurse apply bilateral wrist restraints to a client. Which action by the newly hired nurse requires follow-up? A. Secures the restraint to the frame of the bed. B. Repositions the client from semi-Fowlers to prone. C. Provides easy access to the quick release buckle. D. Assesses the radial pulse every two hours.
B. Repositions the client from semi-Fowlers to prone. Choice B is correct This action is not appropriate and requires follow-up. A client in physical restraints should not be positioned prone, which may lead to suffocation. Additionally, a client should not be positioned supine because this makes the client feel vulnerable. Choices A, C and D are incorrect. These actions by the newly hired nurse are appropriate and do not require follow-up. Physical restraints should not be secured to the side rails as this may result in physical injury to the client. Securing the restraint with a knot is no longer acceptable clinical practice and the nurse should engage a quick release buckle that is anchored to the bed frame. Part of the assessment of a client in bilateral wrist restraints includes the client's radial pulses to determine the client's neurovascular status.
The nurse is assessing a client with pancreatitis. Which of the following type of pain would be expected? A. Burning, aching pain in the left lower quadrant radiating to the hip. B. Severe pain in the mid-epigastric area radiating to the back. C. Burning, aching pain in the epigastric area radiating to the umbilicus. D. Severe pain in the left lower quadrant radiating to the groin. 3474
B. Severe pain in the mid-epigastric area radiating to the back. Choice B is correct. Pain in pancreatitis is described as severe and maximal in intensity. It begins mid-epigastrium and radiates to the back; sometimes, it radiates to the chest, flanks, and lower abdomen. Choice A is incorrect. Pain in pancreatitis is described as severe pain, not burning or aching pain. Choice C is incorrect. Pain in pancreatitis is described as severe pain, not burning or aching pain. Choice D is incorrect. Pain in pancreatitis starts in the mid-epigastric area and radiates to the back, chest, and lower abdomen. It does not radiate to the groin. This disorder commonly causes a client to experience intense epigastric pain radiating to the back, nausea/vomiting, and sometimes jaundice. 58% correct, GI, physiological adaptation
A patient being treated for hypertension is assessed by the nurse and found to have poor gait and impaired balance. What would the nurse's appropriate action be? A. Do nothing as this has nothing to do with why the patient was hospitalized. B. Speak with the attending physician about his concerns and request a referral to physical therapy. C. Speak with the attending physician about his concerns and request a referral for the patient to go to the hospital gym. D. Add this issue to the nursing care plan and have daily gait/balance training as an intervention. 4576
B. Speak with the attending physician about his concerns and request a referral to physical therapy. Choice B is correct. Nurses need to be aware of the patient's needs even if they do not pertain to the reason for hospitalization and treatment. Observation is a crucial nursing skill. The nurse should always be alert for any changes in a patient's condition, regardless of the initial diagnosis. Being aware of the patient's status will equip the nurse to be a better advocate for patients and to request referrals when concerns or issues arise during care. Choice A is incorrect. Any changes in a patient's status should be reported, even if it has nothing to do with the reason for admission. Choice C is incorrect. A referral to go to the hospital gym is not necessary. Physical Therapy can assist the client with balance and gait issues. Choice D is incorrect. The nursing care plan should include safety measures related to gait/balance impairment. However, gait training will be provided by physical therapy.
what is the acronym for right sided hf s/s
BACONED Bloating Anorexia Cyanosis Oliguria Nausea Edema Distended neck veins
Which of the following symptoms are indicative of autonomic dysreflexia in a client who has experienced spinal cord injury? Select all that apply. A. Hypotension B. Sudden headache C. Flushed face D. Nasal congestion 4565
B. Sudden headache C. Flushed face D. Nasal congestion Choices B, C, and D are correct. All of these answer choices are symptoms of autonomic dysreflexia. Autonomic dysreflexia (AD) is a condition in which the involuntary nervous system overreacts to external or bodily stimuli. It's also known as autonomic hyperreflexia. This reaction causes: A dangerous spike in blood pressure Bradycardia Constriction of your peripheral blood vessels Other changes in your body's autonomic functions The condition is most commonly seen in people with spinal cord injuries above the sixth thoracic vertebra, or T6. It may also affect people who have multiple sclerosis, Guillain-Barre Syndrome, and some head or brain injuries. AD can also be a side effect of medication or drug use. AD is a severe condition that's considered a medical emergency. It can be life-threatening and result in: Stroke Retinal hemorrhage Cardiac arrest Pulmonary edema The symptoms of AD may include: Anxiety and apprehension Nasal congestion High blood pressure with systolic readings often over 200 mmHg A pounding headache Flushing of the skin Profuse sweating, particularly on the forehead Lightheadedness Dizziness Confusion Dilated pupils Choice A is incorrect. Hypotension is not a symptom of autonomic dysreflexia. Instead, hypertension is indicative of autonomic dysreflexia. 21% correct
A patient is about to get a Salem sump NG tube inserted. Which position should the nurse place the patient in? A. Supine, with the head of the bed elevated at 30° - 45° B. Supine, with the head of the bed elevated at 60° - 90° C. Knee-chest position D. Prone position 3620
B. Supine, with the head of the bed elevated at 60° - 90° Choice B is correct. A supine position with a 60° - 90° elevation facilitates swallowing of the patient and lets gravity help in the movement of the tube down the GI tract. Choice A is incorrect. The nurse should position the patient so that the insertion of the NG tube is facilitated. An elevation of 30° - 45° is not enough to facilitate the movement of the tube down the GI tract. Choice C is incorrect. A knee-chest position does not facilitate the movement of the tube down the GI tract. Choice D is incorrect. A prone position does not facilitate the insertion of the NG tube. 58% correct Subject Adult Health Lesson Gastrointestinal/Nutrition Client Need Area Basic Care and Comfort
The nurse is preparing to administer a medication to a client. They check the following information: Name and DOB of the client Name of the medication Dosage Route Date and time of the medication order Frequency of the medication What other information should the nurse verify before administering the medication? A. The client's ethnicity B. The concentration of the medication C. The client's room number D. The brand name of the medication
B. The concentration of the medication Choice B is correct. The nurse should also verify the concentration of the drug before administering. This is an important right of medication administration. Many drugs come in different concentrations, and if the nurse does not verify this they may inadvertently administer the wrong dosage of the drug. Choice A is incorrect. The client's ethnicity is not relevant to the administration of their prescribed medication. Choice C is incorrect. The client's room number is not an appropriate patient identifier. The nurse correctly verified this patient's identity with their name and DOB. Other appropriate identifiers include the MRN or patient telephone number. Choice D is incorrect. The name brand of the medication does not need to be verified prior to administration. This is not a right of medication administration.
A 14-year-old was taken to the emergency department after stepping on a broken piece of glass. The wound is cleansed and a dressing was applied. The nurse asks the adolescent to receive a tetanus shot. He responds by saying that all his immunizations are up to date. All the other antibiotics were given and the client is sent home with instructions to return whenever changes in the wound occur. After a few days, the client was admitted to the hospital due to tetanus. What is the nurse's legal responsibility in this situation? A. The nurse displayed adequate judgment and the client was treated accordingly. B. The nurse performed an incomplete assessment. C. Tetanus was not foreseen because of the clients' complete immunization status. D. The nurse should have routinely given the Tetanus shot after such an injury.
B. The nurse performed an incomplete assessment. Choice B is correct. The nurse's assessment was inadequate and incomplete, thus leading to inadequate judgment regarding the situation. The nurse should have asked for the date the last tetanus immunization was received. Choice A is incorrect. The nurse's assessment was incomplete, thus leading to inadequate judgment regarding the situation. The nurse should have asked for the date the last tetanus immunization was received. Choice C is incorrect. The clients' wound would have alerted the nurse to ask more regarding tetanus immunizations since a puncture wound is a "tetanus-prone" wound. Choice D is incorrect. The function of a nurse does not include giving orders for tetanus immunization. The nurse should have assessed further by asking for the immunization date. 38% correct
Which of the following lipid levels are out of range and should be reported to the physician? A. Triglycerides: 75 mg/dL B. Total cholesterol: 6.5 mmol/L C. High-density lipoprotein (HDL): 60 mg/dL D. Low-density Lipoprotein (LDL): 95 mg/dL 4133
B. Total cholesterol: 6.5 mmol/L Choice B is correct. Lipid profile helps physicians determine the patient's risk of developing heart disease. It is recommended that individuals have a lipid profile done at least every five years as part of a regular medical exam. 6.5 mmol/L exceeds the "high normal" total cholesterol level. The average total cholesterol level is 3.5 to 5.0 mmol/L. In milligrams, total cholesterol of 200 milligrams per deciliter (mg/dL) or less is considered desirable for adults Choices A, C, and D are incorrect. The normal lipid levels for these tests include: Triglycerides: 50-150 mg/dL High-density lipoprotein (HDL): 40-80 mg/dL Low-density lipoprotein (LDL): 85-125 mg/dL 46% correct
The nurse is participating on a committee that is changing the hospital security plan. Which of the following statements by the nurse would be appropriate to make? Select all that apply. A. Open visitation should be implemented in the newborn nursery. B. Visitors should always wear a badge while in the hospital. C. Oral temperatures should be obtained for all visitors. D. Hand sanitizing stations should be offered throughout the facility. E. Disaster drills should be conducted to ensure staff competency.
B. Visitors should always wear a badge while in the hospital. E. Disaster drills should be conducted to ensure staff competency. Choices B and E are correct. Proper visitor identification is essential in keeping a hospital secure. This allows for rapid identification and a log of all visitors within the facility. Disaster drills should be conducted to ensure that staff is competent with procedures related to certain threats such as mass bioterrorism or fire. Choices A, C, and D are incorrect. Open visitation should not be implemented in a newborn nursery because of this risk of infant abduction. Visitors may learn the hospital's layout and certain procedures, therefore, enabling a more inconspicuous abduction. Checking the oral temperatures of visitors and providing hand sanitizing stations is essential in infection prevention, but they are not pertinent to the hospital's security plan.
The nurse is caring for a client with bulimia nervosa. Which newly prescribed medication requires clarification with the primary healthcare provider (PHCP)? A. fluoxetine B. bupropion C. sertraline D. fluvoxamine 7355
B. bupropion Choice B is correct. Bupropion is contraindicated in the treatment of bulimia because of its weight negative effects. Weight loss is not a treatment goal for a client with bulimia nervosa, and thus, this medication should not be utilized. Choice A, C, and D are incorrect. Serotonergic agents such as fluoxetine are primarily utilized to manage bulimia nervosa. Fluoxetine is the only approved medication for bulimia nervosa. Other SSRIs such as sertraline or fluvoxamine may be used if this medication is not tolerated. Medications such as bupropion should be avoided. ssris are good for bulimia
The nurse is teaching a group of students on incident reports. Which of the following situations would require an incident report? Select all that apply. A client A. requesting to view their medical record. B. complaining about poor care from a nurse. C. leaving against medical advice (AMA). D. requesting an increase in pain medication. 6594
B. complaining about poor care from a nurse. C. leaving against medical advice (AMA). E. threatening a nurse with bodily harm. Choices B, C, and E are correct. Incident (sometimes termed occurrence or event) reporting is required when any activity deviates from the norm. Events such as client complaints regarding their care, leaving against medical advice (AMA), and threatening a nurse with bodily harm are all examples of incidents requiring factual reporting. Choices A and D are incorrect. Incident reporting would be inappropriate for clients requesting to view their medical records. This is a right afforded to them. A request for an increase in pain medication or even a request for pain medication does not require reporting.
The nurse is counseling a client who has prediabetes. The nurse understands that the client is meeting the treatment goal as evidenced by A. total cholesterol of 215 mg/dL. B. hemoglobin A1C of 5.4%. C. fasting blood glucose 128 mg/dL. D. random blood glucose of 210 mg/dL.
B. hemoglobin A1C of 5.4%. Choice B is correct. This is an optimal hemoglobin A1C as it is less than 5.7%. A hemoglobin A1C of 5.7% to 6.4% is prediabetes. This is a concerning finding as the client is on a negative trajectory toward diabetes mellitus. A hemoglobin A1C of 6.5% is the diagnosis of diabetes mellitus. Choices A, C, and D are incorrect. Total cholesterol of 215 mg/dL is a concerning finding. The goal is to have total cholesterol of less than 200 mg/dL. Elevated total cholesterol contributes to metabolic syndrome, which is the driver of diabetes mellitus. Fasting blood glucose of 128 mg/dL is elevated (this is impaired fasting glucose), and a level greater than 126 mg/dL requires further testing for diabetes mellitus. Random blood glucose of 210 mg/dL is concerning as this is a provisional diagnosis for diabetes mellitus.
The nurse is caring for assigned clients. The nurse should immediately follow up with the client who A. has influenza and their most recent temperature was 102°F (39°C). B. is recovering from a thoracentesis and reports a nagging cough. C. reports reddish-brown sputum immediately following a bronchoscopy. D. has pulmonary tuberculosis and is wearing a surgical mask while ambulating to radiology. 8072
B. is recovering from a thoracentesis and reports a nagging cough. a nagging cough indicates possible pneumothorax. Manifestations of a pneumothorax that are concerning include a nagging persistent cough, increased heart and respiratory rate, dyspnea, and potentially a feeling of air hunger.
The nurse is providing education to a group of nursing students regarding the causes of hypercalcemia. Which of the following information should be included? Select all that apply. A. hypoparathyroidism. B. thiazide diuretics. C. malignancy. D. end-stage kidney disease. E. crohn's disease. 4691
B. thiazide diuretics. C. malignancy. Choices B and C are correct. Thiazide diuretics cause calcium retention, making their administration a potential cause of hypercalcemia. Malignancy, especially malignancies with metastasis involving the bones, may induce hypercalcemia from the breakdown of the bone. This causes the calcium to transition into the bloodstream. Choices A, D, and E are incorrect. Hyperparathyroidism can cause hypercalcemia, not hypoparathyroidism. There is too much parathyroid hormone (PTH) when a client has hyperparathyroidism. PTH functions to pull calcium stores from the bones and put it into the serum, increasing the serum calcium. It is usually released when serum calcium is low and the client needs more. End-stage kidney disease commonly causes hypocalcemia because of the body's inability to recycle vitamin D and have it absorb the calcium. Additionally, high phosphorus levels drive down calcium levels (inverse relationship). Crohn's disease may cause malabsorption of vitamins and minerals, and a clinical feature of Crohn's disease is hypocalcemia. 11% correct
The nurse is teaching a client about newly prescribed tamsulosin. Which of the following statements should the nurse include? A. "This medication may turn your urine reddish/orange." B. "You will urinate more often with this medication." C. "Change positions slowly while you take this medication." D. "Avoid calcium-containing foods while on this medication." 6486
C. "Change positions slowly while you take this medication." Choice C is correct. Tamsulosin is an alpha-1 antagonist medication indicated in the treatment of benign prostatic hypertrophy. This medication causes vasodilation, and the biggest side effect is orthostatic hypotension. The nurse should educate the client to change positions slowly while taking this medication to reduce the risk of orthostasis. Choices A, B, and D are incorrect. Tamsulosin does not cause urine to change colors. This effect is more consistent with rifampin or phenazopyridine. The client will not urinate more often with this medication as it is not a diuretic. Rather, the client should urinate less often because of the ability for him to empty his bladder. Calcium-containing foods do not need to be avoided while a client takes this medication.
A family unit you are caring for is experiencing a situational crisis that has led to dysfunctional communication within the family. You have recommended that the entire family and members of the extended family who live in the family's home begin family therapy. The grandparents tell you that their grandson, who is addicted to prescription painkillers, is the cause of the problem. Since he is not their son, they feel that they do not have to participate in this group therapy. How should you respond to these grandparents? A. "You should try to come to a few sessions at least because they may be very informative to you." B. "You are probably correct. This really is not your problem." C. "Despite the fact that it is your grandson's drug addiction, situations such as this affect all members of the family, including grandparents who live in the home." D. "You should attend because the doctor has ordered family therapy for you as extended family members." 4221
C. "Despite the fact that it is your grandson's drug addiction, situations such as this affect all members of the family, including grandparents who live in the home." Choice C is correct. You should respond to the grandparents' statement with, "Despite the fact that it is your grandson's drug addiction, situations such as this affect all members of the family, including grandparents who live in the home." After this statement, you should also educate the grandparents about the fact that group and family therapy is often indicated when the family unit is affected with stressors and dysfunction because family members may not fully understand the need for the entire family unit to participate when only one member of the family is adversely affected with a stressor and poor coping; in reality, all family members are affected. Choice A is incorrect. You would not state, "You should try to come to a few sessions at least because they may be very informative to you" since these sessions are therapeutic and not educational. Choice B is incorrect. You would not state, "You are probably correct. This really is not your problem" since this statement is not true. Choice D is incorrect. You should not state, "You should attend because the doctor has ordered family therapy for you as extended family members" since this is not the real reason why attending these sessions is needed.
Your client, who is taking an anticonvulsant medication, is also using herbs and other alternative therapies at home. The client tells you that some of these substances include "ginkgo biloba, garlic supplements, and evening primrose." How should you respond to this client's statement? A. "You are really wasting your money on these things. None of them work." B. "Garlic supplements can lower your seizure threshold when you are taking your anticonvulsant medications." C. "Evening primrose can lower your seizure threshold when you are taking your anticonvulsant medications." D. "Ginkgo biloba can decrease your clotting time and increase the clotting risk" 3398
C. "Evening primrose can lower your seizure threshold when you are taking your anticonvulsant medications." Choice C is correct. Evening primrose oil is a rich source of omega-3 fatty acids. Although its effects are unproven, patients use it widely for self-treating inflammatory disorders. Some reports indicate evening primrose may lower the seizure threshold. When the seizure threshold is reduced, there is a higher risk of seizures. This mechanism of primrose may cause it to interact with anticonvulsant medications, thereby reducing therapeutic efficacy. Choice A is incorrect. This statement is confrontational, judgmental, and not necessarily true. To respond to the client that they are wasting money on these things and sounding judgmental is inappropriate. Choice B is incorrect. Garlic supplements do not lower the seizure threshold. Garlic, however, can reduce blood pressure and potentiate the action of antihypertensive medications. Choice D is incorrect. Ginkgo biloba does not decrease clotting time; instead, it increases the bleeding time. Ginkgo biloba is a widely available herbal supplement. Patients commonly use it for early-stage dementia (early Alzheimer's disease), tinnitus, and to treat intermittent claudication pain of peripheral vascular disease. Ginkgo does not interact with anticonvulsants, but it may increase the bleeding risk if combined with warfarin and antiplatelet agents (aspirin). Ginkgo affects platelet aggregation and increases the bleeding time. Since it increases the bleeding risk, Ginkgo should be discontinued before surgical procedures.
A 63-year-old male is being seen in the clinic for his annual exam. Before performing a digital rectal exam. Which of the following questions should the nurse ask? A. "Are you exercising regularly?" B. "Has your diet changed dramatically in the past year?" C. "Have you had any difficulty starting a stream of urine when you attempt to use the toilet?" D. "Are you currently experiencing constipation?" 3887
C. "Have you had any difficulty starting a stream of urine when you attempt to use the toilet?" Choice C is correct. Health care practitioners perform digital rectal exams (DRE) to check their aging male patients for benign prostatic hyperplasia (BPH) or prostate enlargement. Patients experiencing BPH may have difficulty starting a stream of urine or completely emptying their bladder. Choice A is incorrect. While asking clients about exercise is a general question asked during most yearly exams, this question does not have an impact on digital rectal examinations. Choice B is incorrect. Dietary questions are common at yearly examinations, especially for aging patients. However, dietary changes should not impact digital rectal exams. Choice D is incorrect. Health care staff may ask the patient about their bowel health during an annual exam if they have complained about any discomfort or concerns. Still, this question does not impact the reasons behind digital rectal examinations
The client's nephew walks up to the nurse's station and asks if he can see his uncle's file. The nephew states, "It's okay, I'm a nurse as well. I just want to take a quick look and see how my uncle is doing." What is the nurse's most appropriate response? A. "You can take a look for only 5 minutes." B. "Let me get an approval from the attending physician." C. "I will need permission from your uncle first." D. "Non-hospital employees cannot view the patient's file."
C. "I will need permission from your uncle first." Choice C is correct. According to the Health Insurance Portability and Accountability Act (HIPAA), the nurse must first obtain consent from the client to allow the relative to view their file. Choice A is incorrect. According to the Health Insurance Portability and Accountability Act, the nurse must first obtain consent from the client in order for the relative to view their file. In the absence of the client's permission, allowing the nephew to view the data even for 5 minutes is not legal. Choice B is incorrect. The physician is not the one that decides who can view the client's file. The client's consent is necessary under HIPAA provisions. Choice D is incorrect. Non-employees can view the client's file once the client has given consent for them to see his health information. 58% correct
The nurse is performing an assessment on a client. The client tells the nurse, "You people are part of the government plotting to destroy me." The nurse should respond with which appropriate statement? A. "Would you like me to come back later for your assessment?" B. "I believe you and think we should explore why you feel this way." C. "Tell me more about someone trying to destroy you." D. "Let us talk about your current medication and how it can help with those thoughts." 8201
C. "Tell me more about someone trying to destroy you." Choice C is correct. Exploring the content of the client's delusion is important because this assessment will determine if the delusion has any logic (unlikely) and will help foster a therapeutic relationship with the client. Helping the client come to the realization that the delusion is just that; a delusion can be a challenge. This challenge is often mitigated when a therapeutic rapport is established. Choices A, B, and D are incorrect. Diverting the assessment shows avoidance and is a missed opportunity in intervening in a delusion that may cause a client to react with violence. Avoidance is never therapeutic. Stating that you believe the client is not appropriate. While it is important to explore the client's thought content, validating that someone is after the client, etc., further reinforces the delusion. The nurse should only validate the delusion if it is real. Discussing the treatment plan, while important, does not explore the content of the delusion, which is important.
As the charge nurse on 3 East, you have assigned a nursing assistant to transfer a client from the bed to the chair using a mechanical lift. This is something that is within the scope of practice and in the job description for nursing assistants. When the nursing assistant sees the written assignment, the nursing assistant says, "I don't know how to use our mechanical lift." How should you respond to this nursing assistant? A. "It is your responsibility to be able to use it. You have been taught about its proper and safe use; this is part of your job description." B. "I have looked at your competency checklist and you were deemed competent to use mechanical lifts during your orientation." C. "Thank you for letting me know. I will work with you as we transfer the client safely and properly with the mechanical lift." D. "Oh, that is okay. I will assign the transfer of this client using a mechanical lift to another nursing assistant." 3736
C. "Thank you for letting me know. I will work with you as we transfer the client safely and properly with the mechanical lift." Choice C is correct. The nurse should respond to the nursing assistant by saying, "Thank you for letting me know. I will work with you as we transfer the client safely and properly with the mechanical lift." This statement allows the nurse to reeducate the nursing assistant about the use of a mechanical lift and determine the nursing assistant's ability and competency to use it. Choice A is incorrect. The nurse would not respond with a statement such as, "It is your responsibility to be able to use it. You have been taught about its proper and safe use; this is part of your job description." This statement does not address the underlying learning need of the nursing assistant. Choice B is incorrect. The nurse would not respond with a statement such as, "I have looked at your competency checklist, and you were deemed competent to use mechanical lifts during your orientation." This statement does not address the underlying learning need for retraining and education about the use of a mechanical lift. Choice D is incorrect. The nurse would not respond with a statement such as, "Oh, that is okay; I will assign the transfer of this client using a mechanical lift to another nursing assistant." This statement does not address the underlying learning need for retraining and education about the use of a mechanical lift. 96% correct
The nurse is administering phosphate excreting medications to her patient with hypocalcemia because she understands what core information about calcium and phosphorous? A. As phosphorous exits the body so does calcium. B. Calcium is managed by the excretion of phosphorous. C. When serum phosphorous decreases, serum calcium increases. D. Phosphorous must be above 4.5 mg/dL before calcium can increase.
C. When serum phosphorous decreases, serum calcium increases.
While working in the emergency department, the nurse sees each of the following clients. As a mandated reporter, the nurse knows which client is at highest risk for elder abuse? A. A 70-year old female with orthostatic hypotension. B. An 86-year old female with glaucoma. C. A 92-year old male with late-stage Alzheimer's disease. D. A 75-year old male with leukemia. 6135
C. A 92-year old male with late-stage Alzheimer's disease. Choice C is correct. A 92-year old male with late-stage Alzheimer's disease is at very high risk for elder abuse. This can include both physical and psychological abuse. Elders with late-stage Alzheimer's disease are at very high risk because of the memory loss and confusion that occurs with this disease. Choice A is incorrect. A 70-year old female with orthostatic hypotension may be at risk for elder abuse, but there is another answer choice with a higher risk individual. Choice B is incorrect. An 86-year old female with glaucoma may be at risk for elder abuse, but there is another answer choice with a higher risk individual. Choice D is incorrect. A 75-year old male with leukemia may be at risk for elder abuse, but there is another answer choice with a higher risk individual.
The nurse is preparing to discharge clients from the nursing unit. Which client has the greatest need to be referred for outpatient community services? A. A client newly diagnosed with skin cancer that lives with family. B. A client recovering from a stroke and is discharged to inpatient rehab. C. A client who is homeless and has a substance use disorder. D. A client leaving against medical advice for the treatment of cellulitis. 6947
C. A client who is homeless and has a substance use disorder. Choice C is correct. Individuals with difficulty obtaining and sustaining housing have high rates of treatment non-adherence. Lack of adequate housing poses a serious threat to treatment adherence because of the lack of privacy, storage of medications, and a sense of detachment from the community. This client should be referred for outpatient services because they are homeless and have a substance use disorder. Both are issues that may be mitigated with community services. Choices A, B, and D are incorrect. Cancer support groups are essential for a client coping with the illness. This would be an appropriate referral, but not the greatest need of a referral considering the client lives with family, which can be viewed as a support system. A client recovering from a stroke requires many interdisciplinary resources and would not need a referral for community services because they are going to inpatient rehab. A client leaving AMA would not require a referral; the serious cellulitis diagnosis is acute and will resolve with antibiotics. 76% correct
The nurse is caring for a patient who is six hours post-operative from a laparoscopic appendectomy. Which of the following findings would be essential for the nurse to follow-up? A. Incisional pain level of "6" on a 1-10 scale B. An oral temperature of 99.5 degrees Fahrenheit. C. A heart rate of 112 beats-per-minute (BPM). D. Hypoactive bowel sounds in all four quadrants. 3867
C. A heart rate of 112 beats-per-minute (BPM). Choice C is correct. Immediately following abdominal surgery, shock (distributive, hypovolemia) is a concern to the nurse. A heart rate of 112 would indicate tachycardia, which is one of the earliest manifestations of shock, and the nurse needs to assess the client further. Choice B is incorrect. A low-grade temperature is an expected finding following surgery because of the inflammation. Choices A and D are incorrect. Incisional pain and hypoactive bowel sounds are all expected findings in the immediate post-operative period. Subject Adult Health Lesson Gastrointestinal/Nutrition Client Need Area Reduction of Risk Potential 56 correct-know
Which healthcare team member is paired with the primary function related to their role? A. An occupational therapist assisting with gait exercises. B. A physical therapist offers the provision of assistive devices to be used with activities of daily living. C. A speech or language therapist addressing swallowing disorders. D. An RN case manager ordering therapies and medications. 4121
C. A speech or language therapist addressing swallowing disorders. Choice C is correct. Speech/language therapists assess and treat patients with swallowing disorders as well as communication and speech problems that occur following a stroke. Understanding the role of each member of the healthcare team is essential. It helps foster accountability within the organization and also helps to ensure that each person acts within his/her role. Choice A is incorrect. Occupational therapists assist clients with ADLs and provide assistive devices. Choice B is incorrect. Physical therapists perform restorative and rehabilitative care including helping clients with balance/gait exercises and ambulation. Choice D is incorrect. Case managers coordinate care along the continuum of care and they manage insurance reimbursements. Physicians order medications and therapies. 65% correct
The nurse is administering digoxin to an infant when she notes that her pulse is 85 beats per minute. What should be the nurse's most appropriate action? A. Administer the medication. B. Extract blood for serum digoxin levels. C. Withhold the medication and check again after an hour. D. Administer the medication intramuscularly. 3490
C. Withhold the medication and check again after an hour. If the pulse is less than 90 beats/min in an infant, the nurse should withhold the medication and check again in an hour. A consistently low pulse rate may indicate digoxin toxicity.
The nurse is planning to assist a respiratory therapist in performing a chest physiotherapy procedure. Which of the following is the initial action by the nurse before the process? A. Place a gown or fabric between the hands or percussion device and the client's skin B. Walk with the patient for a few laps around the unit to aid in percussion C. Administer a prescribed bronchodilator D. Call the physician to confirm x-ray results 4041
C. Administer a prescribed bronchodilator The nurse should make sure that the patient receives a prescribed bronchodilator about 15 minutes before their chest physiotherapy procedure. Chest physiotherapy is used to loosen secretions trapped in the lungs. When administered before this procedure, a bronchodilator helps to dilate the bronchioles and liquify secretions. Choice A is incorrect. A gown or piece of fabric should be placed between the hands or percussion device right before the procedure. However, this should be done just before the process. Another option (administering bronchodilator 15 minutes prior) exists in the choices and is the initial action. Choice B is incorrect. Walking with the patient before the procedure is not necessary before chest physiotherapy. Choice D is incorrect. Calling the physician to confirm the x-ray results is not necessary at this time and does not alter the plan for chest physiotherapy.
The nurse is caring for a patient with suspected bowel perforation. Which of the following would be contraindicated for this patient? A. Administering gastrografin for an upper GI x-ray. B. An exploratory laparotomy procedure. C. Administering milk of magnesia following an upper GI study. D. An abdominal CT scan. 4303
C. Administering milk of magnesia following an upper GI study. Choice C is correct. Milk of magnesia is a cathartic agent used to promote the excretion of barium sulfate following an upper GI study. Since barium sulfate would not be appropriate for this patient due to bowel perforation, gastrografin would be used instead. Gastrografin may cause diarrhea, which would be exacerbated by giving this patient milk of magnesia. Choice A is incorrect. Water-soluble gastrografin is an osmotic cathartic and is indicated for patients with bowel perforation who require upper GI x-ray studies. Gastrografin is used instead of barium sulfate. Choice B is incorrect. Surgical intervention (i.e. exploratory laparotomy) is commonly used to diagnose and determine the cause of bowel perforation. This procedure would be indicated for this patient unless other issues are present that would prevent the patient from tolerating surgery, such as severe congestive heart failure or multiorgan failure. Choice D is incorrect. Bowel perforation is not a contraindication for a CT scan. CT imaging may be more useful than x-ray in locating bowel perforation due to more sensitive imaging/results.
Which of the following healthcare providers are responsible for documenting care provided to a patient? A. The LPNs should document the care that they provided and the care that was given by unlicensed assistive staff. B. The registered nurse must document all of the care that is provided by the nursing assistants because they are accountable for all care. C. All staff members should document all of the care that they have provided. D. All staff should document all of the care that they have provided but since the registered nurse is the only independent practitioner, the RN signs it. 4572
C. All staff members should document all of the care that they have provided. Choice C is correct. All staff members, including unlicensed assistive staff like nursing assistants, document and sign all of the care that they have personally provided. For example, the nursing assistants will document the vital signs that they have taken; the licensed practical nurses will document all of the treatments and medications that they have given to the patient, and the registered nurse will document nursing diagnoses and assessments that they have completed. There is an old saying among healthcare professionals that have been passed on to new generations. The saying is, "I don't care what you did; if you didn't document it, you didn't do it." Documentation is an essential part of patient care. A patient's complete medical record is a legal document. Proper documentation means 1. The person who provided care should document what care/treatment/medication was given and how the patient responded. 2. If care is delegated to another person, it should be noted to whom the responsibility was assigned; proper documentation AND follow-up should be done. Choice A is incorrect. Each person providing care should personally document the attention that he/she provided. Choice B is incorrect. Although the RN or charge nurse is responsible for making sure tasks are delegated to the appropriate personnel, only the person who performs the care should document the care that was provided. Choice D is incorrect. The person providing care should document the care followed by his/her signature.
You are caring for a client who states they have a health care proxy. Which of the following most accurately describes a health care proxy? A. The client's legal designation to their spouse or significant other allowing them to have a voice in health care treatment options as the client ages B. An individual designated by the client to assist in medical decision-making who also becomes responsible for a minimum of one-half of all medical bills accrued by the client C. An individual the client legally designates to make medical decisions when the client is no longer capable of doing so D. A specific designation specifying who can receive and discuss the client's privileged healthcare information 2447
C. An individual the client legally designates to make medical decisions when the client is no longer capable of doing so Choice C is correct. A health care proxy is an individual named in a written legal document designated to make medical decisions for the client when the client is no longer able to make decisions for themself. Choice A is incorrect. Although a client may designate their spouse or significant other as their health care proxy, an official health care proxy requires the completion of legal paperwork and a copy of the documents to be provided to the hospital or healthcare provider. Without doing so, the significant other or spouse cannot be the legally designated health care proxy. Choice B is incorrect. Health care proxies make decisions about healthcare. In general, if the health care proxy follows the client's pre-discussed wishes, there are no financial implications for the health care proxy. Choice D is incorrect. A health care proxy designation and a designation to receive confidential information protected under HIPAA are two distinct designations.
A Pap smear is recommended to screen for which of the following conditions? A. Ovarian cancer B. Endometrial cancer C. Cervical cancer D. Vaginal cancer 4797
C. Cervical cancer Choice C is correct. A Pap smear is an excellent screening tool to detect precancerous or cancerous cells of the cervix. There is a long lag time between the appearance of precancerous cells and the development of invasive cervical cancer. Therefore, early detection of precancerous lesions by PAP smear and addressing them promptly with localized treatments help prevent cervical cancer. Choice A is incorrect. Tests and procedures used to diagnose ovarian cancer include a pelvic exam. During a pelvic exam, the provider performs a bimanual exam while simultaneously pressing on the abdomen to palpate pelvic organs. Imaging and blood tests may also be ordered, but they are not accurate for "screening" purposes. Choice B is incorrect. An endometrial biopsy is done to determine endometrial cancer. Choice D is incorrect. A vaginal biopsy determines the presence of cancerous vaginal tissue cells.
There have been reports circulating about an impending terrorist attack involving anthrax in the local news. The nurse manager in the ER understands that anthrax can be countered by which of the following medications? A. Acyclovir B. Zidovudine (Retrovir) C. Ciprofloxacin D. Oseltamivir 3292
C. Ciprofloxacin Choice C is correct. Anthrax is a bacterial infection treated with antibiotics such as penicillin, doxycycline, and ciprofloxacin. Inhaled anthrax is most effectively treated with a combination of ciprofloxacin and another antibiotic (i.e. penicillin, clindamycin, chloramphenicol). Antibiotics are usually given for 60 days because it takes that long for spores to germinate. Choice A is incorrect. Acyclovir is an antiviral used to treat herpes. Antiviral medications do not affect anthrax, which is a bacterial infection. Choice B is incorrect. Zidovudine (Retrovir) is an anti-retroviral medication that is used for the treatment of HIV. Antiviral drugs do not affect anthrax, which is a bacterial infection. Choice D is incorrect. Oseltamivir is an antiviral drug used to treat influenza. Antiviral medications do not affect anthrax, which is a bacterial infection.
The nurse manager receives a complaint from a client's family member regarding the client's care provided by a specific nurse. Which initial action should the nurse manager take? A. Tell the night charge nurse to ensure the night shift nurse performs the assigned duties appropriately B. Speak with the night shift nurse regarding the complaint and discuss the care provided C. Contact the client's family member who made the complaint to discuss the situation D. Take note of the complaint and place it in the applicable employee's file 9144
C. Contact the client's family member who made the complaint to discuss the situation Choice C is correct. Assuming the family member rendering the complaint is listed on the client's HIPAA release form, the nurse manager's initial action should be to contact this individual to let them know they have been heard. Additionally, this point of contact allows the nurse manager to ask additional questions regarding the complaint to ultimately help in determining whether the complaint holds merit. Once the manager has determined how reliable the information from the client's family member is, the nurse manager may speak with the client (if the client is capable) before speaking with the nurse in question. Choice A is incorrect. Although the nurse manager may have a discussion with the night charge nurse at some point, this is not the nurse manager's most appropriate initial action. Choice B is incorrect. Here, the question asks for the nurse manager's most appropriate initial action. While the nurse manager will undoubtedly speak with the night shift nurse regarding the complaint and discuss the care provided, this conversation is not the nurse manager's most appropriate initial action. Choice D is incorrect. Taking note of an unverified complaint and placing it in an employee's file would be an inappropriate and unethical action by the nurse manager. The incident may go into the nurse's file, but not without investigating the matter first.
A patient in the prenatal clinic has stated her intention to choose formula feeding for her infant. Identify which action by the nurse is most appropriate in being a patient advocate. A. Remind the patient of why breast feeding is the best method of infant feeding. B. Request a referral to the lactation consultant. C. Determine the patient's knowledge base related to infant feeding options. D. Accept the patient's decision without further discussion
C. Determine the patient's knowledge base related to infant feeding options.
The nurse is caring for a client demonstrating avolition. The nurse would expect to observe the client have which of the following? A. Loss of balance B. Full range of affect C. Diminished expression D. Lack of motivation
C. Diminished expression
Which of the following infection control activities should be delegated to an experienced nursing assistant? A. Asking clients about the duration of antibiotic therapy. B. Demonstrating correct handwashing techniques to client and family. C. Disinfecting blood pressure cuffs after clients are discharged. D. Screening clients for upper respiratory tract symptoms. 4587
C. Disinfecting blood pressure cuffs after clients are discharged. Choice C is correct. Nursing assistants can follow agency protocol to disinfect items that come in contact with intact skin by cleaning with chemicals such as alcohol. In nursing, delegation refers to indirect care. The intended outcome is achieved through the work of someone supervised by the nurse. It involves defining the task, determining who can perform the job, describing the expectation, seeking agreement, monitoring performance, and providing feedback to the delegate regarding performance. While some nursing assistants may be proficient in tasks or be familiar with symptoms of diseases or disorders, clinical tasks such as assessments and education should always be assigned to a licensed nurse. Choice A, B, and D are correct. These should be carried out by a licensed nurse.
The nurse is providing discharge teaching to a patient receiving sulfamethoxazole. Which of the following instructions should be given during this teaching? A. Discontinue taking this medication when symptoms are alleviated B. Restrict fluid intake to prevent hypertension C. Drink plenty of fluids D. Go to the emergency department if the urine turns a dark brown or yellow 4025
C. Drink plenty of fluids Choice C is correct. Sulfamethoxazole (SMX) is used to treat urinary tract infections and should be taken with plenty of water. Each dose should be taken with a full glass of water. Choice A is incorrect. Antibiotics should not be discontinued until the entire prescribed course is completed. Choice B is incorrect. This medication should be taken with plenty of fluids to prevent adverse effects. Choice D is incorrect. Dark brown urine is a common side effect of using sulfamethoxazole and does not warrant a visit to the emergency department. NCSBN client need Topic: Physiological Integrity, Pharmacological and Parenteral therapies
The most effective way to perform hand hygiene is : A. Washing hands after gloves are removed and following any patient care. B. Using hand sanitizer and rubbing hands together for at least 20 to 30 seconds. C. Either wash hands for 20 seconds in warm, soapy water or use hand sanitizer if hands are not visibly soiled. D. Holding hands down after washing to prevent water from rolling down your arm while drying. 5033
C. Either wash hands for 20 seconds in warm, soapy water or use hand sanitizer if hands are not visibly soiled. Choice C is correct. Either technique is the evidence-based practice of hand hygiene and has proven to kill more germs than other methods. The CDC recommends handwashing for at least 20 seconds. Hand sanitizer can be used if hands are not visibly soiled. Choice A is incorrect. Although simply washing hands after gloves are removed and following patient care is essential, it is not the "most effective way to perform hand hygiene". Hands must be washed for 20 seconds. Choices B and D are incorrect. These are not the most effective way to perform hand hygiene.
Which of the following actions is most effective at reducing the incidence of health-care-associated infections? A. Screen all newly admitted clients for colonization or infection with MRSA. B. Develop policies that automatically start antibiotic therapy for clients colonized by multi-drug resistant organisms. C. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital. D. Require nursing staff to wear gowns to change wound dressings for all clients. 4094
C. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital. Choice C is correct. Since the hands of healthcare workers are the most common means of transmission for infection from one client to another, the most effective method of preventing the spread of disease is to make supplies for hand hygiene readily available for staff to use. Reducing the risk of healthcare-associated infections is the responsibility of every healthcare worker. Following standard precautions for all patients is the easiest and most effective way of preventing the spread of disease. Choice A is incorrect. Although some hospitals have started screening newly admitted clients for MRSA, there is no evidence that this decreases the spread of infection. Choice B is incorrect. Because the administration of antibiotics to individuals who are colonized by bacteria may promote the development of antibiotic resistance, antibiotic use should be restricted to clients who have clinical manifestations of infection. Choice D is incorrect. Wearing a gown to care for clients who are not on contact precautions is unnecessary.
The process of absorbing drugs before elimination after they have been excreted into bile and delivered to the intestines is called: A. Hepatic clearance B. Total clearance C. Enterohepatic cycling D. First-pass effect 4637
C. Enterohepatic cycling Choice C is correct. Drugs and drug metabolites with molecular weights higher than 300 may be excreted via the bile, stored in the gallbladder, delivered to the intestines by the bile duct, and then reabsorbed into the circulation. This process reduces the elimination of drugs and prolongs their half-life and duration of action in the body. Before drugs can be clinically useful, they must be absorbed. Absorption is the process of a drug moving from its site of delivery into the bloodstream. The chemical composition of a drug, as well as the environment into which a drug is placed, work together to determine the rate and extent of drug absorption. Absorption can be accomplished by administering the drug in a variety of different ways (orally, rectally, intramuscularly, subcutaneously, inhalation, topically, etc.). If a drug is administered intravenously, the need for absorption is bypassed entirely. For drug absorption to be most efficient, the properties of the drug itself and the pH of the environment where the drug is located must be considered. Most drugs are either weak acids or weak bases. Drugs that are weak acids will pick up a proton when placed in an acidic environment and will be un-ionized. Other factors that also impact drug absorption include the following: Physiologically, a drug's absorption is enhanced if there is a large surface area available for absorption (villi/microvilli of the intestinal tract) and if there is a large blood supply for the drug to move down its concentration gradient. The presence of food/other medications in the stomach may impact drug absorption - sometimes enhancing absorption and other times, forming insoluble complexes that are not absorbed (it depends on the specific drug). Some drugs are inactivated before they can be absorbed by enzymes, acidity, bacteria, etc. Choice A is incorrect. Hepatic clearance is the amount of drug eliminated by the liver. Choice B is incorrect. Total clearance is the sum of all types of removal, including renal, hepatic, and respiratory. Choice D is incorrect. The first-pass effect is the amount of drug absorbed from the GI tract and then metabolized by the liver; thus, reducing the amount of medicine, making it into the circulation. 32% correct Subject Adult Health Lesson Gastrointestinal/Nutrition Client Need Area Physiological Adaptation, NCSBN Client Need Topic: Physiological Integrity, Pharmacological therapies
Due to a recent flood, the only staff that were able to make it to work are two nursing assistants and one licensed practical nurse with the nurse manager. Knowing the different nursing delivery systems, which system should the nurse manager implement to care for the 20 clients admitted in their ward? A. Primary nursing B. Team nursing C. Functional nursing D. Case management 3609
C. Functional nursing Choice C is correct. In functional nursing, each caregiver on a specific nursing unit is given specific tasks that fall into their scope of practice. In this situation, the nurse manager may administer medications to the entire group, while a licensed practical nurse performs treatments, and the client care attendants provide physical care. Choice A is incorrect. A registered nurse plans and organizes care for a group of clients and cares for this group during their entire hospitalization. This type of care delivery cannot be useful in this situation. Choice B is incorrect. An RN leads nursing staff who work together to provide care for a specific number of clients. The team typically consists of RNs, LPNs, and client care attendants. The team leader assesses client needs, plans client care, and revises the care plan based on changes in the client's condition. The leader assigns tasks to team members as needed. This cannot be done in this situation, as this requires too many staff members. Choice D is incorrect. Case management is a form of primary nursing that involves a registered nurse who manages the care of an assigned group of clients. This nurse coordinates care with the entire health care team. There is only one RN in the situation. Therefore, it cannot be used.
The nurse is teaching a group of nursing students infectious diseases that are reportable to the local health department. Which of the following conditions should be reported? Select all that apply. A. Bacterial vaginosis B. Herpes simplex virus (HSV) C. Human immunodeficiency virus (HIV) D. Hepatitis A E. Syphilis F. Human Papilloma Virus infection (HPV)
C. Human immunodeficiency virus (HIV) D. Hepatitis A E. Syphilis Choices C, D, and E are correct. Infectious conditions are reportable to the local health department including Human immunodeficiency virus (Choice C), Hepatitis-A (Choice D) and Syphilis (Choice E). Other reportable conditions include chlamydia, pulmonary tuberculosis, rabies, chickenpox, influenza, and gonorrhea. Healthcare providers have the responsibility to report these to the state/local health departments. Choice A is incorrect. Bacterial vaginosis is a common infection that does not require reporting. Choice B is incorrect. Herpes simplex virus (HSV) is spread by multiple methods and thus is not reportable. Genital herpes need not be reported. Choice F is incorrect. Human Papillomavirus (HPV) is not a reportable disease. Human Papillomavirus (HPV) infection and other HPV-associated clinical conditions are not nationally notifiable or required by the CDC. Some states and jurisdictions require specific HPV associated conditions reported (cervical cancer, cervical pre-cancer) but not infection itself. 16% correct Subject Adult Health Lesson Infectious Disease Client Need Area Health Promotion and Maintenance
The nurse caring for a patient with Guillain-Barre syndrome is gathering supplies to keep near the patient's bedside. The patient is experiencing paralysis up to his waist. Which of the following instruments is of the highest priority? A. Blood pressure cuff B. Pulse oximeter C. Intubation tray D. Stethoscope 4014
C. Intubation tray Choice C is correct. Ascending paralysis is an attribute of Guillain-Barre syndrome; therefore, these patients are at risk for respiratory failure. An intubation tray should be kept near the patient's bedside. Choice A is incorrect. A blood pressure cuff is helpful to have on hand but not the highest priority in a patient with ascending paralysis related to Guillain-Barre syndrome. Choice B is incorrect. A pulse oximeter is helpful to have on hand but not the highest priority in a patient with ascending paralysis related to Guillain-Barre syndrome. Choice D is incorrect. A stethoscope is helpful to have on hand but not the highest priority in a patient with ascending paralysis related to Guillain-Barre syndrome.
The nurse is providing discharge instructions to a client prescribed lisinopril. Which of the following instructions should the nurse include? Select all that apply. A. You will need to take your pulse for one minute before each dose. B. You may notice the need to go to the bathroom more often. C. Limit your intake of foods such as avocados and apricots. D. You may notice a decrease in your ability to taste foods. E. The goal of this medication is to lower your cholesterol. 7611
C. Limit your intake of foods such as avocados and apricots. D. You may notice a decrease in your ability to taste foods. Choices C and D are correct. Lisinopril is an ACE inhibitor (ACE-I) and may cause hyperkalemia. It would be correct for the nurse to instruct the client to limit their intake of potassium-rich foods such as avocados, bananas, apricots, and legumes. The client decreasing their potassium intake could decrease the likelihood of developing dangerously high potassium. ACE-I's may also cause a client to have decreased taste sensation. This may make the client more likely to use salt, worsening hypertension. Thus, it is appropriate to instruct the client to season their food more naturally. Choices A, B, and E are incorrect. ACE-Is effectively lowered blood pressure and reduced congestive heart failure mortality. These medications do not lower pulse, and therefore, it would be inappropriate for the client to take their pulse prior to taking the medication. ACE-I do not have a diuretic effect and it would be inaccurate to advise the client that they may need to use the bathroom more frequently. Finally, ACE-I lower blood pressure, not cholesterol.
The nurse is caring for a patient who is 1-day postoperative following a left total knee replacement. Which assessment data would indicate to the nurse that the patient is progressing as expected? A. T 99.2 degrees F, HR 102, RR 18, BP 89/40 mm Hg B. Urine output of 200 mL in the past 8 hours C. Lung bases are clear upon auscultation D. The patient consistently rates left knee pain as 9/10 4304
C. Lung bases are clear upon auscultation Choice C is correct. Clear lung bases indicate adequate gas perfusion and suggest normal progression of postoperative recovery. Inadequate gas perfusion would increase the risk of complications and slows healing. Choice A is incorrect. The patient's temperature and heart rate are slightly elevated, whereas the blood pressure is low. This abnormal data should be investigated. Etiology includes infection; dehydration, or sepsis with shock. Choice B is incorrect. Urine output should be at least 30 mL/hour, or 240 mL/8 hours. A urine output of 200 mL for 8 hours would be too low, which indicates that intervention is needed. Provider should be notified so that the potential causes of decreased urinary output ( eg; dehydration, acute renal failure) can be explored. Choice D is incorrect. Localized pain is expected following total knee replacement surgery, but should not be consistently at the 9/10 level. Such assessment data would indicate ineffective pain management. Pain control should be optimized.
The nurse is assessing a client with a chest tube for a pneumothorax. The nurse assesses a crackling sensation beneath the fingertips around the chest tube insertion site. The nurse should take which action? A. Document the finding as normal B. Clamp the chest tube C. Notify the primary healthcare provider (PHCP) D. Apply nasal cannula oxygen 8068
C. Notify the primary healthcare provider (PHCP) Choice C is correct. Notifying the PHCP is essential because this assessment indicates crepitus which is air trapped in and under the skin, known as subcutaneous emphysema. The PHCP needs to be notified because this is a complication, and measures such as increasing the suction on the chest tube need to be considered. Choices A, B, and D are incorrect. These actions are not appropriate. Documenting the finding as normal is inappropriate because this is a complication of chest tube therapy. Chest tubes should rarely be clamped; if they are clamped, they should be for a very brief period. This is not an oxygen issue; thus, applying nasal cannula oxygen is inappropriate and unnecessary.
The nurse is caring for a neonate experiencing cold stress. The nurse should also assess the neonate for A. hyperglycemia. B. increased muscle tone. C. hypoglycemia. D. metabolic alkalosis.
C. hypoglycemia. Choice C is correct. When a neonate develops hypoglycemia, norepinephrine is released, causing tachycardia which causes an increase in glucose metabolism. This increase in glucose metabolism depletes the neonate's reserve of glucose. If a neonate is experiencing cold stress, the nurse should warm the neonate by applying warm clothes, removing the neonate from any drafts, and ensuring the neonate is dry. The nurse should assess the neonate for hypoglycemia via heel stick once the neonate's temperature stabilizes. Choices A, B, and D are incorrect. Cold stress would deplete glucose stores because of the sympathetic response. Thus, hyperglycemia would not occur. Manifestations of hypoglycemia include poor muscle tone and a weak, jittery cry. Metabolic acidosis would develop due to cold stress because the lack of glucose would cause fat to be the fuel source, causing metabolic acidosis. 81% correct
A patient recovering from a transient ischemic attack can walk but is having difficulty going upstairs. What professional should visit them to help work through this issue? A. Case manager B. Nurse practitioner C. Occupational Therapist D. Respiratory therapist
C. Occupational Therapist Choice C is correct. Occupational therapists are excellent resources for helping patients suffering from gait and movement problems. Occupational therapists help patients transition from their hospital life to their homes. While physical therapists are mostly involved in specific gait related issues, occupational therapists also assist to help improve functional mobility so that the patients can perform their activities of daily life ( ADL). Choice A is incorrect. Case managers work with patients and their families to organize their care and to discuss resources available outside of the hospital to meet the patient's needs. They do not resolve gait issues. Choice B is incorrect. While they work with a patient to treat various disorders, nurse practitioners are best utilized to prescribe treatments and monitor a full caseload. They are not the best option to help with physical movement. Choice D is incorrect. A respiratory therapist focuses on improving a patient's oxygen saturation. There may be circumstances where an occupational therapist and respiratory therapist may work together; for example, a patient with COPD who has a low oxygen saturation and is deconditioned from a long-term hospital stay. 85% correct
The nurse in the pediatric unit is caring for a 5-year old child diagnosed with dehydration. The child is reluctant to drink water because she is afraid of vomiting. Which action by the nurse would be most effective in ensuring her fluid intake? A. Call the physician to insert a nasogastric tube. B. Ask the help of the child's parents to force her to drink. C. Offer the child a popsicle. D. Offer her bubbles. 3628
C. Offer the child a popsicle
An infant is admitted to the pediatric floor to rule out cystic fibrosis. The nurse assesses the infant's stool, concluding the stool is consistent with a diagnosis of cystic fibrosis. Which of the following would describe this infant's stool? A. Small, hard, pellet-like stool B. Green, malodorous stool C. Oily, odorous, bulky stool D. Loose, yellow stool 2553
C. Oily, odorous, bulky stool Choice C is correct. This disease process frequently affects the pancreas, intestines, and hepatobiliary systems, resulting in the malabsorption of fats, fat-soluble vitamins, and protein in 85 to 95% of cystic fibrosis patients. As a result, gastrointestinal manifestations include the frequent passage of bulky, foul-smelling, oily stools. Choice A is incorrect. Small, hard, pellet-like stools are not characteristic stools produced by cystic fibrosis clients. Choice B is incorrect. Malodorous bowel movements are a clinical manifestation of cystic fibrosis clients; however, these bowel movements are not traditionally described as "green" in color. Choice D is incorrect. Loose, yellow bowel movements are not traditionally associated with cystic fibrosis patients.
The nurse is preparing to administer prednisone 5 mg to a client with hyperparathyroidism. The nurse understands that prednisone is given to the client because: A. Prednisone increases the client's immune function B. Prednisone increases the client's Vitamin D levels C. Prednisone decreases GI absorption of calcium D. Prednisone decreases the release of calcium by the bones 3209
C. Prednisone decreases GI absorption of calcium Choice C is correct. Prednisone decreases the absorption of calcium in the gastrointestinal system thereby reducing serum calcium levels in the patient with hyperparathyroidism. Choice A is incorrect. Prednisone is an immunosuppressant. It does not promote immune function. Choice B is incorrect. Prednisone does not have any effect on Vitamin D levels. Choice D is incorrect. Etidronate (Didronel) and calcitonin are drugs that prevent the release of calcium from the bones, not prednisone.
The nurse is caring for a patient with a medical diagnosis of scleroderma who reports fingertips tingling and turning white in response to cold or stress. The nurse would recognize these symptoms as which problem? A. Sjögren's Syndrome B. Sclerodactyly C. Raynaud's phenomenon D. Telangiectasia 6884
C. Raynaud's phenomenon Choice C is correct. This patient's symptoms are consistent with Raynaud's phenomenon. This condition is characterized by sudden or intermittent vasospasms in the fingertips and toes in response to cold temperatures or stress, resulting in decreased blood flow and blanching of the skin in these areas. This phase is typically followed by a blue phase, when hemoglobin releases oxygen into these tissues, and a red phase, when the areas are rewarmed. Sensations of tingling and numbness are common during these episodes. Choice A is incorrect. Sjögren's syndrome describes a condition of dry eyes and dry mouth that is experienced by approximately 20% of patients with scleroderma. Choice B is incorrect. Sclerodactyly describes the tightening of the skin of fingers and toes. Choice D is incorrect. Telangiectasia describes the presence of red spots on the hands, forearms, palms, face, and lips due to capillary dilation. 81% correct Subject Adult Health Lesson Musculoskeletal Client Need Area Physiological Adaptation
The charge nurse reviews staff assignments for one registered nurse (RN) and one licensed practical/vocational nurse (LPN/VN) on the nursing unit. To maximize staff resources, which client assignments require modification to be congruent with each nurse's scope of practice? Select all that apply. room 1- 67 yo taking abx for cystitis - given to LPN room 2- 22 yo 3 days postop laproscopy - given LPN room 3-55 yo with ST changes on the heart monitor- given to LPN room 4-49 yo 3 hrs postop thyroidectomy-given to RN room 5- 44 yo with insulin titrations for dka- given to RN room 6-59 yo with chronic wound care and dressing changes-given to RN A. Room 1 B. Room 2 C. Room 3 D. Room 4 E. Room 5 F. Room 6 6575
C. Room 3 F. Room 6 Choices C and F are correct. The client with angina and ST-segment changes should be assigned to the RN because of this client's clinical unpredictability. Angina accompanied by ST-segment changes is a worrisome sign of acute coronary syndrome. A 59-year-old requiring chronic wound care and the insertion of an indwelling catheter is more appropriate for the LPN to ensure an evenly divided client assignment. These are skills (wound care and indwelling catheter insertion) within the scope of an LPN. While an RN may assume this client, to maximize staff resources, this client should be assigned to the LPN. Choices A, B, D, and E are incorrect. Antibiotic administration is within the scope of an LPN, and the LPN may be assigned predictable client diagnoses such as cystitis. A client who is three days post-operative following a laparoscopic procedure is low acuity and, therefore, may be assigned to the LPN. This contrasts with the client three hours post-operative following a thyroidectomy which should be assigned to the RN. This client has the risk of developing laryngeal edema. Insulin titration is not within the scope of an LPN, and the RN is responsible for titrating medications based on client assessment. 40% correct
The nurse is caring for a patient that has just been diagnosed with primary hyperparathyroidism. With knowledge regarding this disease, the nurse should expect which laboratory value to be present? A. Serum potassium level of 4.1 mEq/L B. RBC of 5.2 x million/uL C. Serum calcium level of 11.2 mg/dL D. Serum sodium level of 120 mmol/L 2881
C. Serum calcium level of 11.2 mg/dL A calcium level of 11.2 mg/dL is high and indicates hypercalcemia. Normal serum calcium level is between 8.6 and 10.3 mg/dL. In primary hyperparathyroidism, serum calcium level is usually elevated. Often, primary hyperparathyroidism results in the removal of calcium from the bones and thereby, results in increased serum calcium levels. Removing calcium from bones results in demineralization and consequently, osteoporosis. A. K of 4.1 is normal B. hyperparathyroidism has nothing to do with RBCs D. hyponatremia is not a manifestation of primary hyperparathyroidism. Hyponatremia is seen with hypothyroidism, adrenal insufficiency, diuretic use, and syndrome of inappropriate anti-diuretic hormone (SIADH) secretion.
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 Choices C and D are correct. 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 (Choice C). Anticholinergics are rescue medications used for the relief of acute bronchospasm. Examples include ipratropium and tiotropium (Choice D). Choice A is incorrect. 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. Choice B is incorrect. Leukotriene modifiers are long term control medications used to prevent bronchospasm and inflammatory cell infiltration. They are often used as prophylactic agents before a triggering event, for example, in exercise-induced asthma. They are not useful as a "rescue" once bronchospasm occurs. For example, montelukast is indicated to be used "as needed" before exercising in patients who do not require a daily bronchodilator. Montelukast is taken at least two hours before the initiation of exercise.
The nurse is caring for a client with a breast tumor. The client reports trouble breathing, a puffy face/neck, nasal congestion, and a raspy voice. The nurse would suspect which of the following? A. Spinal cord compression B. Non-Hodgkin's Lymphoma (NHL) C. Superior vena cava syndrome D. Shock 3970
C. Superior vena cava syndrome Choice C is correct. This patient's tumor originates in the breast. Breast cancer may spread locally into the chest wall and lymph nodes. Due to its proximity to the superior vena cava (SVC), a locally advanced tumor or metastatic lymph node enlargement in the chest may obstruct blood flow to and from the superior vena cava. Such an obstruction results in venous congestion (puffiness in the face/ neck) and jugular-venous distension. Frequent clinical features of venous congestion in superior vena cava syndrome include blurred vision, hoarse voice, stridor, dyspnea, and nasal congestion. Choices A, B, and D are incorrect. These do not explain the patient's presentation. Spinal cord compression (choice A) may present with motor and sensory deficits, not puffy face and dyspnea. Non-Hodgkin's lymphoma (choice B) may cause SVC obstruction. However, the client has breast cancer, likely responsible for the SVC obstruction, not an occult lymphoma. Shock (choice D) presents with hypotension and impaired perfusion, not a puffy face and stridor. 52% correct
Following treatment for a fracture, a client is now undergoing rehabilitation. His regimen involves performing isometric exercises. Which action is evidence that the client has fully understood the proper technique? A. The client exercises both extremities simultaneously B. The client knows that his heart rate should be monitored while exercising C. The client practices forced resistance against stable objects D. The client swings his limbs through their full range of motion 2662
C. The client 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. Choices A, B, and D are incorrect. Isometric exercises do not include the simultaneous use of the extremities and neither does the swinging of limbs. Heart rate monitoring is done with aerobic exercises.
Which of the following expected outcomes is appropriate for a client with heart disease who is complaining of chest pain? A. The client will be free of neuropathic pain related to angina. B. The client will be free of hyperalgesia pain related to angina. C. The client will be free of visceral pain related to angina. D. The client will be free of somatic pain related to angina. 3665
C. The client will be free of visceral pain related to angina. Choice C is correct. "The client will be free of visceral pain related to angina" is an appropriate expected outcome for a client with heart disease who is complaining of chest pain. Chest pain is an example of visceral pain. Other cases of physical pain are cramping secondary to irritable bowel syndrome and labor pain. Choice A is incorrect. "The client will be free of neuropathic pain related to angina" is not an appropriate expected outcome for a client with heart disease who is complaining of chest pain. Chest pain is not neuropathic pain. Choice B is incorrect. "The client will be free of hyperalgesia pain related to angina" is not an appropriate expected outcome for a client with heart disease who is complaining of chest pain. Chest pain is not hyperalgesia. Choice D is incorrect. "The client will be free of somatic pain related to angina" is not an appropriate expected outcome for a client with heart disease who is complaining of chest pain. Chest pain is not bodily pain.
Select the age group that is accurately paired with a physiological characteristic that places them at risk for adverse effects, contraindications, side effects, and/or interactions related to medications. A. Neonates: Acidic gastric acids that affect absorption B. Toddler: Immature hepatic functioning that affects distribution C. The elderly: Decreased renal perfusion that affects excretion D. Adolescents: An underdeveloped blood-brain barrier 3412
C. The elderly: Decreased renal perfusion that affects excretion Choice C is correct. The elderly population, as the result of the regular changes occurring in the aging process, is at a higher risk for adverse medication effects, contraindications, side effects, and interactions. Among these frequent changes of the aging process include decreased renal perfusion and functioning, decreased hepatic perfusion and functioning, lowered bodily water, reduced gastric acid production, increased adipose tissue, and polypharmacy as the result of multiple chronic diseases and disorders. This also increases the elderly's risk for adverse effects, contraindications, side effects, and/or interactions. A is incorrect because they have alkaline gastric acids B is incorrect because Neonates and infants less than one year of age have immature hepatic functioning that affects distribution (not toddlers). Choice D is incorrect. Neonates and infants less than one year of age have an underdeveloped blood-brain barrier (not adolescents).
The mother is concerned about a 2 cm, red rash on her two-month-old infant's back, which blanches with pressure. What teaching should the nurse discuss with the mother regarding this type of lesion? A. Treatment is non-invasive and consists of yellow light laser ablation. B. This marking is due to excessive proliferation of mature capillaries. C. This immature hemangioma requires no intervention. D. The marking is a sign of an infected hair follicle. 4265
C. This immature hemangioma requires no intervention. Choice C is correct. The description is consistent with an immature hemangioma (capillary hemangioma, superficial hemangioma). Because of their bright-red appearance, they are often referred to as "strawberry nevi." They blanch with pressure, which can help differentiate these lesions from port-wine stains. Immature hemangiomas are common, harmless tumors of blood vessels that occur within the first year of life. They do not require any treatment and typically resolve on their own by 5-7 years of age. They commonly appear on the face, scalp, chest, or back. Occasionally, some immature hemangiomas can interfere with vision or cause other symptoms based on their location. Such hemangiomas may be treated with medications or laser surgery. Choice A is incorrect. Ablation with a yellow light laser is indicated for a port-wine stain, not for an immature hemangioma. A port-wine stain is typically a large, flat, dark, and macular patch that does not blanch with pressure. Choice B is incorrect. The proliferation of immature capillaries causes immature hemangiomas which are bright red and blanchable. A mature (cavernous) hemangioma presents as a reddish-blue colored, deep, spongy mass of blood vessels. Choice D is incorrect. The description of this lesion is not consistent with an infected hair follicle (furuncle). A furuncle would present as a localized, swollen, tender area of inflammation.
The nurse is preparing to remove a central venous catheter. It would be appropriate to place the client in which position for this procedure? A. Reverse Trendelenburg B. Left lateral C. Trendelenburg D. High-Fowler's
C. Trendelenburg Choice C is correct. Placing the client supine or Trendelenburg for this procedure would be appropriate. One of these two positions is acceptable to decrease the risk of air embolism. The client should not have their head elevated for this procedure. Choice A, B, and D are incorrect. The positioning of a client is essential to avoiding an air embolism. Thus, having a client high-Fowler's, lateral, or reverse Trendenlenberg would be contraindicated. If a client experiences an air embolism, turning the client to the left-lateral position would be appropriate, but not for the procedure of removing a central line itself.
What ethical principle below is accurately paired with a way that ethical principle is applied to nursing practice A. Beneficence: Doing no harm during the course of nursing care. B. Justice: The obligation to be fair; equally dividing time and other resources among a group of clients. C. Veracity: Fully answering the client's questions without any withholding of information. D. Fidelity: Upholding the American Nurses Association's Code of Ethics 4217
C. Veracity: Fully answering the client's questions without any withholding of information.
The nurse is providing discharge instructions to a client with a skin abscess that has tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following instructions should the nurse include? A. Avoid using alcohol hand-based sanitizers. B. Use disposable dishes and utensils for all meals. C. Wear a surgical mask when you are out in public. D. Keep the wound covered with a dry bandage.
C. Wear a surgical mask when you are out in public.
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. 8392
C. moves the nitroglycerin patch from the torso to the back. Choice C is correct. 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. Choices A, B, and D are incorrect. An MRI questionnaire is always completed before this exam to ensure client safety. MRI units can produce sounds up to 120 decibels, resulting in hearing damage. MRIs do not use radiation; this imaging exam uses magnets to create 3D cross-sectional images of the body. 46% correct
The nurse cares for a client with a potassium of 5.7 mEq/L. The nurse understands that this potassium level may be caused by Select all that apply. A. Cushing's disease. B. nasogastric tube suctioning. C. salt substitutes. D. hyperinsulinism. E. adrenal insufficiency.
C. salt substitutes. E. adrenal insufficiency Choices C and E are correct. The client's high potassium level, 5.7 mEq/L is concerning. Salt substitutes contain potassium which makes them more palatable. Excessive intake may lead to hyperkalemia. Adrenal insufficiency causes hyperkalemia because of the insufficient amount of aldosterone, which causes potassium elimination. Less aldosterone, and less potassium elimination, equates to hyperkalemia. Choice A, B, and D are incorrect. Cushing's disease is likely to cause hypokalemia, not hyperkalemia. In this disease, the adrenal glands produce too much aldosterone. Aldosterone causes the body to excrete potassium, putting clients with Cushing's disease at risk for excessive potassium losses leading to hypokalemia. The client with an NG tube to continuous suction will likely experience hypokalemia, not hyperkalemia. NG tube suction removes all of the gastric contents, which are rich in potassium. With those excessive potassium losses, the client becomes hypokalemic. Hyperinsulinism is likely to experience hypokalemia, not hyperkalemia. Insulin facilitates the movement of insulin into cells. With it comes potassium, and therefore when there is too much insulin as there is in hyperinsulinism, too much potassium is moved into the cells, and the serum potassium level drops, causing hypokalemia.
The school nurse is attending to a student who got a chemical cleaner in her eyes. In which order should the following actions be performed? Document the occurrence Call the child's parent Irrigate the eye from the inner canthus to the outer canthus Assess the visual acuity Check the pH of the eye 4080
Check the pH of the eye Irrigate the eye from the inner canthus to the outer canthus Assess the visual acuity Document the occurrence Call the child's parent Ocular chemical injuries (alkaline or acidic substances) can cause permanent damage and vision loss. Therefore, a chemical eye injury is considered a medical emergency. When a chemical injury is sustained, the school nurse should check the pH and immediately irrigate the student's eye. Sterile water or 0.9% saline can be used for eye irrigation. In an emergency, tap water can be used initially. The steps involved in eye irrigation include: Check the pH of the eye (check pH of both eyes. Alkaline substances penetrate the ocular surface more and cause more damage than acids). If the pH testing is not immediately available, this should not delay irrigation. Get the infusion set ready to regulate the flow of irrigation fluid. Position the patient with the cheek of the affected side pressed against a kidney dish. Irrigate the eye from the inner canthus to the outer canthus. This direction is used so that the chemical does not get into the other eye. Assess the child's visual acuity. Visual acuity testing should not precede eye irrigation since delaying the treatment is dangerous in chemical eye injury. Document the occurrence and the procedure. This documentation should include pH readings, the amount of irrigation fluid used, and the duration of the procedure. Call the child's parents to inform them of the occurrence, actions taken, and the outcome. A procedure note regarding the irrigation should be documented first. Following this, the nurse can call the parents and document the verbal/phone call communication in a separate note.
The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)? A. Alprazolam B. Rifaximin C. Lactulose D. Spironolactone 7448
Choice A is correct. Benzodiazepines should be avoided for a client with hepatic encephalopathy. These medications can worsen the sensorium of a client, therefore, making the client at high risk for falls and injury. Choices B, C, and D are incorrect. Rifaximin is an antibiotic and is indicated for hepatic encephalopathy. This oral medication is taken to decrease ammonia's gastrointestinal production, which is contributing to encephalopathy. Lactulose is the main staple in treating hepatic encephalopathy because it traps ammonia in the colon and increases its transit. Thereby decreasing serum ammonia levels. Spironolactone is the diuretic of choice for a client's ascites because it removes the fluid but holds on to the potassium. Hypokalemia should be avoided because it contributes to the production of ammonia. NCLEX Category: Pharmacological and Parenteral Therapies 40% correct
A 4-year-old boy is recovering from abdominal surgery at the pediatric unit. As the nurse caring for the child, which of the following activities do you recommend that he prioritize? A. Blowing bubbles B. Peek-a-boo C. Building blocks D. Playing with clay 2783
Choice A is correct. Letting the child blow bubbles will stimulate lung expansion, preventing respiratory problems arising from surgery. Following the abdominal surgery, respirations are not as efficient because anesthesia hampers it, and it hurts to breathe. Consequently, mucus builds up, and the lung may collapse fully or partially ( atelectasis). Pneumonia may follow. The collapsed lung may result in dyspnea and respiratory failure and complicate the post-operative recovery. Therefore, primary health care providers ( PHCP) order incentive spirometers to reduce the risk of respiratory problems after surgery. However, if the child is under the age of five or is unable to use the incentive spirometer for another reason, they should blow bubbles for two to three minutes every hour. Blowing bubbles will serve as an alternative to incentive spirometry in these children. Choices B, C, and D are incorrect. Peek-a-boo is appropriate for infants, not preschool children. Furthermore, peek-a-boo ( Choice B) does not promote lung expansion. While playing with building blocks ( Choice C) is suited for preschool children, this activity does not promote lung expansion. Clay ( Choice D) is suited for toddlers to play with but does not serve as an alternative to incentive spirometry.
The nurse in the surgical ward cares for a client who has just undergone a procedure for a Kock pouch as a treatment for his bladder cancer. The initial nursing interventions for this patient would include: A. Monitor urine output through the pouch; checking the ostomy pouch for leaks; taking note of the size, shape, and color of the stoma. B. Talking to the client's family and updating them about the client's status. C. Teaching the client about stoma care and skincare. D. Irrigating the ureteral catheters as needed 2887
Choice A is correct. Monitoring the urine output, checking for leaks, and taking note of the stoma's characteristics are the initial nursing interventions for a patient status-post urinary diversion procedure. The nurse should monitor the urine output and report if the volume is less than 0.5 ml/kg/hr or no output for more than 15 minutes. Checking for leaks makes sure that the skin under the pouch is not irritated. Noting the characteristics of the stoma gives baseline information regarding the stoma's appearance. Following the procedure, a stoma site is usually hyperemic (red or pink). Any changes in the stoma site's color from reddish/pink to cyanotic/dusky may indicate impairment of arterial blood supply (ischemia). If cyanosis is noted, the nurse must notify the physician immediately. A cyanotic stoma is a medical emergency and, if not addressed, can lead to necrosis. Choice B is incorrect. Updating the client's family regarding the patient's condition is typically the role of the doctor. Choice C is incorrect. Stoma care and skincare should be taught to the client at the time of discharge, not immediately after the surgery. Choice D is incorrect. Irrigation of ureteral catheters should not be done unless there are specific orders from the physician. Unnecessary irrigation increases the risk of ascending urinary tract infections. 89% correct Subject Adult Health Lesson Urinary/Renal/Fluid and Electrolytes Client Need Area Reduction of Risk Potential
what is sinus tachycardia
Choice A is correct. This rhythm represents a 3rd-degree heart block because there is no QRS complex after every other p wave. This is because the AV node has no conduction during a 3rd-degree heart block. Therefore, the p waves and QRS complexes are not interacting with each other. Choice B is incorrect. This rhythm represents a 1st-degree heart block. This rhythm occurs when the AV conduction is slowed, therefore creating a more extended time between the p wave and the QRS complex. Choice C is incorrect. This rhythm represents a 2nd-degree heart block or Mobitz type 2. This occurs when the AV node is taking longer to conduct. The PR interval may be regular or lengthened. This rhythm indicates problems in the Purkinje system. Choice D is incorrect. This rhythm is sinus tachycardia, which is a heart rate over 100 bpm. 34% correct, adult, cv, physiological adaptation
A client who is a native of the Middle East is now on her 24th-week gestation. As part of her culture, she usually wears a long robe that covers her arms and body, with a shawl that covers her head and neck. Which supplement will the nurse most likely expect to give her? A. Vitamin D B. Vitamin C C. Calcium D. Zinc 2746
Choice A is correct. Women from the Middle East are usually covered from head to foot. This causes them to receive little sun exposure. Unless the client's diet is rich in good sources of vitamin D, she needs to supplement it. Choices B, C, and D are incorrect. The situation has no data indicating the need for vitamin C, Calcium, or Zinc supplementation.
The nurse is educating the parents of a child who plans on riding their bicycle. Which statements, if made by the parents, indicate effective understanding? A. "I should tell my child should ride against the traffic pattern." B. "I should instruct my child to walk their bike through busy intersections." C. "Wearing a helmet is only necessary when my child is riding near a busy intersection." D. "My child can ride their bike barefoot as long as it's short distances." 9242
Choice B is correct. A child should walk their bike through busy intersections to reduce their risk of being hit by an automobile. Choices A, C, and D are incorrect. These statements require follow-up because they do not indicate effective teaching. When riding a bicycle, it should be directed with the traffic flow. Any individual riding a bicycle should always wear a helmet, no matter the distance they plan on riding. To avoid serious foot injuries, the child should always wear proper fitting shoes while bicycling.
The patient is experiencing post-operative tachycardia with low blood pressure. The nurse should be most concerned about which of the following surgical complications? A. The development of an infection B. Hemorrhage C. Wound dehiscence D. Hematoma 4021
Choice B is correct. A patient with low blood pressure and tachycardia after a surgical procedure may be experiencing an illness. Blood loss results in lowered blood pressure and the heart rate increases to compensate. Choice A is incorrect. The development of an infection after surgery usually presents with tachycardia and fever. Hypotension may or may not be present. Choice C is incorrect. Wound dehiscence occurs when the edges of a surgical site rupture. It is not categorized by tachycardia and low blood pressure. Wound dehiscence is a serious complication of surgery and needs immediate treatment. Choice D is incorrect. A hematoma, or a bruise, is a non-serious occurrence after surgery. It is caused by a collection of blood beneath the skin's surface.
The registered nurse is working together with the LPN in a psychiatric ward. In a busy day, the nurse understands that it is necessary to delegate tasks to LPNs. Which job would the RN delegate to the LPN? A. Escorting a client with a serum lithium level of 2.2 mEq/L to the ER. B. Accompanying a bulimic client for an hour after lunch. C. Conducting art therapy to a group of clients in the day room. D. Accompany the client who is talking to her mother on the phone.
Choice B is correct. Clients with bulimia need someone to prevent them from purging and letting the LPN sit with her for one hour after her lunch precludes the client from inducing vomiting. Choice A is incorrect. A client in this case has lithium toxicity. This client is unstable; thus, the RN must accompany this client to the ER. Choice C is incorrect. The LPN is not trained in this type of activity. The registered psychiatric nurse should be the one conducting this. Choice D is incorrect. The LPN should not be tasked to listen to the client's phone conversation. This is a violation of the client's right to privacy. 49% of peers got it right
Which of these would be the most appropriate way to document a patient's refusal of medication? A. The patient refused the heparin injection when I tried to administer it. She yelled at me, saying, "I do not want that injection right now!" and told me to leave the room. I explained the risks of not taking the medication. She seemed very annoyed that I tried to give it at that time. I will attempt again later in my shift. B. Subcutaneous heparin injection was attempted to be given to the patient per the physician's order. The patient refused, stating, "I do not want that injection." Potential risks for refusing the medication were reviewed with the patient and the patient verbalized understanding. C. Pt stated she did not want the SQ heparin at this time. Risks of not taking this med were reviewed with the pt and pt verbalized understanding. D. Heparin was refused during the shift. Risks reviewed. 4577
Choice B is correct. Documentation in healthcare should be objective, thorough, and direct. It should be articulate, with proper grammar and spelling. Legal experts will scrutinize the health record if a dispute about a client's care arises. In court, the health record is relevant evidence of the attention given to a client and is used to judge whether the interventions were timely and appropriate. Expert reviewers look for documentation of the client's baseline status, changes in condition, interpretation of the changes, interventions implemented, and the client's responses to those interventions. The patient has the right to refuse a medication regardless of her reasons and regardless of the consequences, except under certain circumstances (e.g. incompetency). It is up to the nurse to document thoroughly and accurately any patient's refusal. Choice A is incorrect. This answer choice is not direct, although thorough. Additionally, documenting "I will attempt later in my shift" is not the correct form for documentation. Only care/treatments that have been attempted or successfully provided should be documented. Choice C is incorrect. Correct grammar and spelling should be used. When documenting the refusal of care, abbreviations should be avoided. Choice D is incorrect. This option does not provide enough information.
The community health nurse is doing a home visit on a client that was admitted to the hospital two weeks ago for hypertension. The nurse notes that the client was prescribed amlodipine 5 mg daily and was advised to lose weight. The nurse should be concerned when the client notes which of the following during his visit? Correct A. The patient states that he has already enrolled himself in a gym and is getting dietary counseling from a nutritionist. B. The nurse notes the patient drinking grapefruit juice. C. The patient asks the nurse multiple questions regarding how he can follow his treatment regimen. D. The patient stated that he has had an episode of dizziness a day after he was discharged but has since been fine. 2875
Choice B is correct. Grapefruit juice and calcium channel blockers may combine to cause toxic effects. This should cause concern to the nurse and should necessitate further teaching regarding calcium channel blockers (ie, amlodipine). Choice A is incorrect. The patient stating that he is already starting to exercise and modify his diet is a positive sign that he is complying with his treatment. Choice C is incorrect. The patient asking various questions regarding his treatment signifies to the nurse that the patient is eager and willing to undergo therapy. The nurse should encourage the patient. Choice D is incorrect. The dizziness that the patient has stated is just a common side effect of his medication (calcium channel blocker).
A nurse is instructing a patient about a newly prescribed medication, phenytoin. Which statements, if made by the patient, indicate effective teaching? A. "If my gums get irritated and large, I can stop this medication." B. "I will need laboratory work to monitor the medication level." C. "It is okay for me to increase this medication if I have a seizure." D. "I should take this medication with low protein foods." 6477
Choice B is correct. Phenytoin is an anticonvulsant and is indicated for epilepsy. Therapeutic levels must be maintained to ensure the effectiveness of the drug. The therapeutic drug levels of phenytoin are 10-20 mcg/mL. Choices A, C, and D are incorrect. Phenytoin is an anticonvulsant medication that requires adherence to prevent seizure activity. The client should not stop the drug because of the side-effect of gingival hyperplasia; instead, the client should report this effect. The client's self-discontinuing the medication increases the risk of a seizure. The client should not increase the drug if they have a seizure. Phenytoin can be taken with or without food. This medication does not have any dietary restrictions.
The nurse is caring for a client who is receiving prescribed lamotrigine. Which of the following findings is highly concerning? A. Abnormal dreams B. Skin blistering C. Dyspepsia D. Xerostomia 6569
Choice B is correct. Skin blistering associated with lamotrigine therapy is a critical finding to report. This is a feature of Steven-Johnson syndrome (SJS). Lamotrigine has been implicated as causing this adverse finding. Choices A, C, and D are incorrect. Lamotrigine may cause alteration in the mood either intentionally or unintentionally. The indication for this medication is epilepsy or bipolar disorder. Abnormal dreams are a common effect associated with this medication but are not highly concerning compared to skin blistering, which is consistent with SJS. Dyspepsia (painful digestion) and xerostomia (dry mouth) are not priority effects that should be reported as they are not life-threatening.
A client is diagnosed with a spontaneous pneumothorax which results in the need to insert a chest tube. What is the best explanation for the nurse to provide this client? A. "The tube will prevent you from having chest pains." B. "The tube will remove excess air from your chest." C. "The tube controls the amount of air that enters your chest." D. "The tube will seal the hole in your lung." 4170
Choice B is correct. The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space. Choice A is incorrect. Chest tubes do not prevent chest pain. Many patients complain of pain and discomfort because of the tube. However, the necessity of removing air is paramount. Choice C is incorrect. The purpose of the chest tube is to remove air that has accumulated, not control the amount of air entering the lung. Choice D is incorrect. The chest tube does not seal a hole in the lung. 86% correct
You are caring for a 55-year-old male patient in the emergency department. He has a history of chronic obstructive pulmonary disease (COPD). He came to the ED with a complaint of shortness of breath. His respiratory rate is 28 per minute, and his breaths are shallow and somewhat difficult. You put him on supplemental oxygen at 2 L/minute. You draw ABGs. You receive results of the arterial blood gas that show: pH = 7.30 PaCO2 = 49 Bicarbonate = 25 You determine that this ABG shows: A. Metabolic alkalosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic acidosis 4502
Choice B is correct.This ABG shows a respiratory acidosis. The first clue in this patient is the diagnosis of COPD. In COPD, the patient suffers from severe hypoventilation. This hypoventilation results in the retention of carbon dioxide. The registered nurse must know the basics of ABG interpretation, including the normal ranges for each of the values. First, the nurse should look at the pH. The normal range is 7.35-7.45. A value below 7.35 indicates an acidosis; a value above 7.45 indicates an alkalosis. The normal partial pressure of carbon dioxide (PaCO2) is 35-45 mmHg. Standard bicarbonate for a man this age is 22-29 mmol/L. The pH in this patient shows that the condition is acidosis. The high PaCO2 indicates that it is a respiratory problem. These values would support the assumption based on the diagnosis of COPD. The pH and PaCO2 define respiratory disorders. Respiratory acidosis is defined as a pH below 7.35 and a PaCO2 above 45 mmHg. Respiratory alkalosis is defined as a pH above 7.45 and a PaCO2 below 35 mmHg. Metabolic disorders are defined by the pH and the bicarbonate (HCO3). Metabolic acidosis is defined as a pH below 7.35 and an HCO3 below 22 mmol/L. Metabolic alkalosis is defined as a pH above 7.45 and an HCO3 above 29 mmol/L. Choices A, C, and D are incorrect. NCSBN Client Need Topic: Physiological Adaptation, Sub-Topic: Fluid and Electrolyte Imbalances, Respiratory 90% correct
As you are bathing your client and providing nail care, you notice that the client's fingernails are clubbed (white at just the tips with normal perfusion through the rest of the fingers) What disorder or disease would you suspect? A. Diabetes B. Iron deficiency anemia C. Hypoxia D. A nail fungus 3055
Choice C is correct. The picture shows clubbing of the fingernails. Clubbing, which is also referred to as Hippocratic fingers, indicates that the client has a pulmonary or cardiac condition that causes significant hypoxia over time. Choice A is incorrect. You would not suspect diabetes. Diabetes does not lead to the abnormal appearance of the nails that are shown in the picture; however, lost nails may occur with diabetes as the result of impaired microcirculation, which is a complication of diabetes. Choice B is incorrect. You would not suspect iron deficiency anemia, although another nail abnormality called spooning is associated with this disorder. Choice D is incorrect. You would not suspect a nail fungus because a nail fungus is characterized by discoloration, thickening, and brittleness. 70% correct Subject Adult Health Lesson Integumentary Client Need Area Physiological Adaptation
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 4349
Choice C is correct. 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. Choice A is incorrect. Steatorrhea is caused by the presence of undigested, unabsorbed fat. Steatorrhea, infection, and diabetes are signs that pancreatic damage is worsening. Choice B is incorrect. The most common signs/symptoms of celiac disease are diarrhea, flatulence, abdominal distention, and malnutrition symptoms such as weight loss and steatorrhea. Choice D is incorrect. 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. 25% correct Subject Adult Health Lesson Gastrointestinal/Nutrition Client Need Area Basic Care and Comfort
The nurse is caring for a group of clients. It is a priority to follow up on which client situation? A. A client admitted with an asthma exacerbation that is wheezing while receiving albuterol via nebulizer. B. A client admitted with pulmonary emphysema who puts on their nasal cannula oxygen before eating. C. A client with pneumonia is ambulating around the nursing unit while wearing a surgical mask. D. A client receiving oxygen via nonrebreather and has an oxygen saturation of 92%. 6961
Choice D is correct. A client receiving oxygen via non-rebreather is receiving approximately 80%-95% Fio2. If the best oxygen saturation is 92%, this is concerning and may warrant more aggressive measures to improve oxygen saturation. Choices A, B, and C are incorrect. A client admitted with an asthma exacerbation would have manifestations such as tachypnea and wheezing. This is not a priority because the prescribed treatment is being administered. A concern would be if the wheezing does not improve or if the sudden cessation of wheezing should occur. A client with pulmonary emphysema should eat while using a nasal cannula as this increases the oxygen demand. A client with pneumonia should be encouraged to ambulate around the nursing unit. The appropriate PPE is applied to this client, which is a surgical mask. 49% correct
Which of the following lab values would be most significant in determining renal function in a client with a history of polycystic kidney disease? A. BUN 90 mg/dL B. Serum potassium 7.0 MEq/L C. Uric acid 7.5 D. Creatinine 8.7 mg/dL 4177
Choice D is correct. Creatinine is a specific indicator of renal function/failure. Polycystic kidney disease is a genetic disorder that causes fluid-filled cysts to grow inside the kidneys. Unlike simple kidney cysts that may develop later in life, PKD cysts can change the shape of organs and alter the functioning of organs. Several tests can evaluate renal functioning. Choice A is incorrect. Although BUN is a measure of kidney function, patients without kidney disease who are dehydrated can show an elevation in BUN. Choice B is incorrect. This elevated potassium does not correspond with polycystic kidney disease. Choice C is incorrect. This uric acid level does not correspond with polycystic kidney disease. 66% correct
The Registered Nurse is preparing a patient for a pneumonectomy. What teaching should the nurse discuss with the patient? A. Instruct patient to lie on the non-operative side following the procedure. B. Expect the remaining lung to return to normal function within 2-6 hours. C. Advise the patient to avoid coughing and make sure the nurse will use wall suction to clear secretions. D. Keep head of bed elevated at 30-45 degree angle post-procedure. 3776
Choice D is correct. Keeping the head of the bed between 30-45 degrees will minimize respiratory efforts and facilitate recovery post-pneumonectomy. This intervention will also prevent post-pneumonectomy pulmonary edema. The patient should lie on the operative side and should have the head of the bed raised to 45 degrees as soon as awake. These positions minimize the gravitational effect on capillary pressure in the remaining lung. Choice A is incorrect. Lying on the non-operative side will increase the risk of pulmonary edema and therefore, should be avoided. The patient would be instructed to lie on the back or operative side only to prevent leaking of fluid into the operative side (pulmonary edema) and to allow full expansion of the remaining lung. Choice B is incorrect. The remaining lung will require 2-4 days to adjust to increased blood flow. Choice C is incorrect. Deep breathing, coughing, and splinting are encouraged during the post-op period to promote the expansion of the lung. Wall suction is contraindicated after pneumonectomy.
The charge RN is delegating assignments on the orthopedic unit. The client is a 90-year-old woman who is two days post-operative arthroplasty. Vital signs are stable, and the patient's post-op course has been uneventful. The most appropriate nursing assignment for this patient would be: A. The charge RN B. Another RN C. An LVN/LPN with 5 years of experience in orthopedics D. An LVN/LPN with 5 years of experience in geriatric care 4751
Choice D is correct. The charge RN knows that this patient has been stable following her surgery. The client will require routine post-op care rather than specific orthopedic care. The responsibility for this patient can be handled by an LPN/LVN after the initial evaluation. However, given the client's advanced age, there are additional needs specific to the geriatric age group. Therefore, the most appropriate assignment is the LVN/LPN with five years of experience in geriatric care. Choices A, B, and C are incorrect. Effective use of resources is crucial in healthcare settings. A charge RN ( Choice A) assumes a leadership role and oversees a specific department or unit. Charge nurses are responsible for delegating nursing duties and assignments to other nurses and hence, have more complex duties to attend. An RN ( Choice B) can probably be used more effectively with another patient that requires additional teaching or advanced assessment. Assigning the elderly client to an LVN/LPN ( Choice C) experienced in orthopedic care alone will not address the other needs specific to this geriatric client. 32% correct
The nurse is discharging the client that has been admitted due to subarachnoid hemorrhage. The client still has some speech and balance deficits. Which referral should the nurse make? A. Refer the client to hospice care. B. Refer the client to speech therapy. C. Refer the client to physical therapy. D. Refer the client to a home health agency. 3501
Choice D is correct. The client is going home, thus the client needs to be referred to a home health agency so that there is continuity of care even at home. Choice A is incorrect. Hospice care is for clients that are terminally ill. This client is not terminally ill. Choice B is incorrect. Speech therapy aids clients in regaining speech and swallowing abilities. Speech therapy should have been initiated and ongoing while the client was in the hospital. Choice C is incorrect. Physical therapy aids clients in regaining muscle strength and balance. Physical therapy should have been initiated and ongoing while the client was in the hospital. 25% correct
The nurse is caring for a client with a sodium level of 130 mEq/L. Which of the following medications may cause this abnormality? Select all that apply. A. Spironolactone B. Hydrochlorothiazide C. Prednisone D. Sodium polystyrene E. Tolvaptan 6517
Choices A and B are correct. Spironolactone is a diuretic that retains potassium but causes the loss of water and sodium. Hydrochlorothiazide is a thiazide diuretic that may contribute to hyponatremia because while it does raise serum calcium levels, it depletes every other electrolyte. Choices C, D, and E are incorrect. Prednisone is a corticosteroid used for inflammatory conditions. This drug causes an increase in aldosterone, which increases sodium and water retention. Sodium polystyrene is used for individuals with hyperkalemia, and its use will not only lower potassium but may also raise sodium. Tolvaptan is a medication used to treat syndrome of inappropriate antidiuretic hormone (SIADH). It depletes the water but not the sodium.
The nurse is planning a staff development conference about hospice services. Which of the following information should the nurse include? A. Hospice services are useful for symptom management of acute diseases. B. Treatment is limited to pain management and symptom control. C. The goal is to implement curative therapies and treatments. D. Services may be offered in settings such as the home and inpatient. 2408
D Services may be offered in settings such as the home and inpatient.
If a female patient weighed 7 lbs at birth, the nurse would expect her weight at her 2-year-old well-child visit to be: A. 35 lbs B. 40 lbs C. 21 lbs D. 28 lbs 4848
D. 28 lbs Choice D is correct. A healthy child is expected to quadruple their weight by the age of 2. Choices A and B are incorrect. Both of these answer choices reflect a child that is over the expected 2-year weight if he/she was 7 lbs at birth. Choice C is incorrect. A healthy child should triple his/her birth weight by one year of age.
The nurse is on her shift in the nursery. Which of the following newborns would warrant further investigation and intervention from the nurse? A. A 1-hour old newborn with lanugo B. A 6-hour old newborn with a respiratory rate of 50 C. A crying 12-hour old newborn that is turning red D. A 1-day old newborn that has not yet passed meconium
D. A 1-day old newborn that has not yet passed meconium
The nurse has received an assignment of four patients on the Medical-Surgical floor. Which patient should she/he check on first? A. A 61-year-old male patient who is one day post-op from hernia repair with complaints of pain at the incision site. B. A 68-year-old female patient with type II diabetes who is complaining of stomach discomfort. C. A 72-year-old male patient with emphysema and a history of uncontrolled hypertension who is complaining of a headache. D. A 70-year-old female patient who is two days post-op from ankle surgery who complains of feeling some shortness of breath. 4581
D. A 70-year-old female patient who is two days post-op from ankle surgery who complains of feeling some shortness of breath. Choice D is correct. The ABCs identify the patient's airway, breathing, and cardiovascular status as the highest of all priorities in that sequential order. Maslow's Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the requirements for self-esteem and esteem by others, and the self-actualization needs in that order of priority. Examples of each of these needs, according to Abraham Maslow's Hierarchy of Needs, include: Physical and Biological Needs: Some physical needs include the need for the ABCs of the airway, breathing and cardiovascular function, nutrition, sleep, fluids, hygiene, and elimination. Safety and Psychological Needs: Psychological or emotional, safety and security needs include needs like low-level stress and anxiety, emotional support, comfort, environmental and medical protection, and emotional and physical security. Love and Belonging: The love and belonging needs reflect the person's innate need for love, belonging and the acceptance of others. Self-Esteem and Esteem by Others: All people need to be recognized and respected as valued people by themselves and by others. People need self-worth, self-esteem, and the esteem of others. Self Actualization: Self-actualization needs to motivate the person to reach their highest level of ability and potential. In addition to prioritizing and reprioritizing, the nurse should also have a plan of action to manage their time effectively; they should avoid unnecessary interruptions, time-wasters, and helping others when this could potentially jeopardize their priorities of care. Choice A is incorrect. Incision site pain is not uncommon, especially one-day post-op. Choice B is incorrect. Stomach discomfort is not an immediate cause of concern and is not a priority among the available answer choices. Choice C is incorrect. This client's complaint is not the most urgent. An expected symptom of uncontrolled hypertension is a headache.
You are assigned to administer hydromorphone to a patient with post-operative pain. You should be aware of which of the following legal mandates in terms of controlled substances? Select all that apply. A. The signatures of 2 registered nurses but not from practical nurses when a narcotic is wasted. B. Prohibitions against the use of a placebo for pain management. C. The signatures of 3 registered nurses or practical nurses when a narcotic is wasted. D. The verification of the narcotic count at the beginning and the end of the shift. E. Check the controlled substance at least 3 times prior to its administration. F. The secure locking of controlled substances to prevent diversion and theft.
D. The verification of the narcotic count at the beginning and the end of the shift. F. The secure locking of controlled substances to prevent diversion and theft. Choices D and F are correct. The verification of the narcotic count at the beginning and the end of the shift (Choice D) and the secure locking of controlled substances to prevent diversion and theft (Choice F) are legal mandates in terms of narcotics and controlled substances. Nurses are responsible for ensuring that there is adequate documentation in the medical record to support the administration and the wasting of controlled substances. It's legally mandated that controlled substances are securely locked to prevent diversion. Examples of storage systems for controlled substances include locked medication carts, locked cabinets, and automated dispensing systems. When controlled substances are removed from secure storage in quantities more than what needs to be administered, the nurse is responsible for wasting the excess/unused portion in the presence of a witness. The best practices for the spending of controlled substances include: Waste at the time of removal from the storage. Witnessing nurses must watch the administering nurse as the correct dose is drawn. Witnessing nurses must observe as the unneeded portion is wasted in the approved manner. Document the waste electronically or in writing. Witness the wasting of controlled substances then verify product label, the number of wastes matches what is documented, and that the medication is wasted in an irretrievable location. Two nurses, both the administering nurse and the witness, are responsible for documenting the wastage. Either a Registered Nurse or a Licensed Practical Nurse can witness and sign. A nurse should never document seeing controlled substance wastage that was not observed. Choice A is incorrect. Although the signatures of two nurses are legally mandated when a narcotic is wasted, licensed practical nurses can also sign when an opiate is wasted. Choice A claims practical nurses cannot endorse, which is an incorrect statement. Choice B is incorrect. Although there is a prohibition against the use of a placebo for pain management, this is an ethical and not a legal mandate. Choice C is incorrect. Although the signatures of more than one nurse are legally mandated when a narcotic is wasted, the names of 3 registered nurses or practical nurses are not legally required when an opiate is wasted. Two signatures of RNs or LPNs will suffice. Choice E is incorrect. Although checking the controlled substance and all other medications, at least three times before its administration is appropriate, this is a standard of practice and not a legal mandate.
After receiving client reports on the medical-surgical floor. Which of the following clients should the nurse see first? A. A client with a respiratory rate of 24 and an oxygen saturation of 92%. B. A client who is scheduled for gastric surgery related to peptic ulcer disease in two hours. C. A client who is six hours post-op from a hysterectomy and is complaining of nausea. D. A client who had a cast applied two hours ago and now has complaints of her arm feeling like it is "sleeping". 4115
D. A client who had a cast applied two hours ago and now has complaints of her arm feeling like it is "sleeping". Choice D is correct. The patient with a cast who describes her arm as feeling like it's asleep is likely experiencing impaired circulation. This patient should be assessed first and the physician should be notified. Prioritizing patient care related to the status of each patient in the nurse's care is a critical skill. While all patients are important and must be monitored, the ability to recognize a potential complication before it gets out of hand and causes more damage is crucial. Choice A is incorrect. Although the increased respiratory rate and lower O2 saturation may cause concern, there is nothing in this scenario that suggests the patient is in distress. Choice B is incorrect. This patient has no complaints and can be evaluated after the patient that is experiencing compromised circulation. Choice C is incorrect. Complaining of nausea after a hysterectomy is a potential problem that is often expected. It is not, however, of immediate concern. 72% correct
The nurse is going over the list of assigned clients for the shift. The nurse knows which client is most at risk for experiencing a fluid volume deficit? A. A client with cirrhosis B. A client with an ileostomy and normal amount of output C. A client with a BUN of 32 and creatinine of 2.7 D. A client with diabetes insipidus and an NG tube set to low intermittent wall suction 6046
D. A client with diabetes insipidus and an NG tube set to low intermittent wall suction Choice D is correct. A client with diabetes insipidus and an NG tube set to low intermittent wall suction is at very high risk for a fluid volume deficit. They have 2 risk factors and are therefore the client at the most risk. In diabetes insipidus, the body puts out huge amounts of dilute urine, depleting the body of fluid. Having an NG tube to suction also removes fluid from the client, by way of their GI secretions, making it another risk factor for fluid volume deficit. Choice A is incorrect. The client with cirrhosis is not at risk for a fluid volume deficit. Clients with liver failure are more likely to experience a fluid volume excess due to portal hypertension. This can be observed in edematous legs and ascites. Choice B is incorrect. A client with an ileostomy can be at risk for fluid volume deficit if there are large volumes of fluid dumping out of their ostomy. Since the question stem indicates that there was a normal amount of output from the ileostomy, this is not the client most at risk for fluid volume deficit out of the choices provided. Look for the client with the highest number of risk factors. Choice C is incorrect. A client with a BUN of 32 and Cr 2.7 is suffering from kidney damage. Decreased kidney function puts clients at risk for fluid volume excess due to their inability to concentrate urine and results in a subsequent build-up of fluid in the body. Subject Adult Health Lesson Urinary/Renal/Fluid and Electrolytes Client Need Area Basic Care and Comfort
Which of the following nursing diagnoses is appropriate for a client who has serum albumin of 2.8 g/dL and serum prealbumin of 17? A. At risk for renal calculi related to the albumin and prealbumin levels. B. At risk for hyperalbuminemia related to the albumin and prealbumin levels. C. At risk for hypoalbuminemia related to the albumin and prealbumin levels. D. At risk for the loss of muscle mass related to the albumin and prealbumin levels. 2998
D. At risk for the loss of muscle mass related to the albumin and prealbumin levels. Choice D is correct. The nursing diagnosis that is appropriate for a client with serum albumin of 2.8 g/dL and serum prealbumin of 17 is "at risk for the loss of muscle mass related to the albumin and prealbumin levels." These levels indicate that the client is affected by low albumin levels (hypoalbuminemia). Hypoalbuminemia can lead to the loss of muscle mass, poor wound healing, and other complications. Choice A is incorrect. "At risk for renal calculi related to the albumin and prealbumin levels" is not an appropriate nursing diagnosis for a client with serum albumin of 2.8 g/dL and serum prealbumin of 17. There is no relationship between albumin and prealbumin levels and the formation of renal calculi. Choice B is incorrect. "At risk for hyperalbuminemia related to the albumin and prealbumin levels" is not an appropriate nursing diagnosis for a client with serum albumin of 2.8 g/dL and serum prealbumin of 17 because these levels do not indicate high albumin. Choice C is incorrect. "At risk for hypoalbuminemia related to the albumin and prealbumin levels" is not an appropriate nursing diagnosis for a client with serum albumin of 2.8 g/dL and serum prealbumin of 17 because these levels indicate the need for an actual nursing diagnosis, rather than a potential "at-risk" nursing diagnosis.
The nurse in the ICU notes bleeding from the client's transparent dressing over her peripheral intravenous site, gum bleeding, and frank blood in the urine. The client was originally admitted for sepsis. What should be the nurse's immediate next action? A. Assess the client's hemoglobin and hematocrit level. B. Check the client's oxygen saturation. C. Apply pressure to the intravenous site. D. Call the physician. 3508
D. Call the physician. Choice D is correct. The client is manifesting signs of disseminated intravascular coagulation (DIC). This is a critical complication that often happens in the intensive care unit and usually is secondary to other serious etiologies such as sepsis. In this condition, the clotting system is activated significantly and leads to the consumption of platelets and clotting factors. DIC can manifest with either bleeding or clotting complications. Thrombocytopenia (low platelet count), coagulopathy (increased prothrombin time, increased partial thromboplastin time, decreased fibrinogen), and hemolysis are hallmarks of DIC. In the absence of any significant bleeding, transfusing platelets or clotting factors may fuel the thrombotic process in DIC. Therefore, platelets, cryoprecipitate, and fresh frozen plasma are not routinely injected in DIC unless there is significant bleeding. The client is bleeding from multiple sites. The nurse must call the physician first to initiate medical interventions, which may include ordering labs to confirm DIC, transfusing platelets, or infusing clotting factors. Choice A is incorrect. DIC is a consumption coagulopathy and also causes intravascular hemolysis. Intravascular small clots (microthrombi) form due to activation of the coagulation pathway in DIC. Red blood cells may rub against these thrombi leading to hemolysis. Fragmented red blood cells (schistocytes) can be seen in DIC due to this hemolysis. Hemolysis causes a drop in hemoglobin and hematocrit (resulting in anemia). The nurse should undoubtedly check the client's hemoglobin and hematocrit levels; however, the nurse needs to notify the physician right away since the client is showing bleeding signs of DIC. Choice B is incorrect. Assessing the client's oxygen saturation may also be performed later. The client is not in apparent respiratory distress based on the information presented. Hypoxia is not the cause of his bleeding complications. DIC should be suspected in this bleeding, septic patient and the nurse must notify the physician immediately since urgent intervention is needed Choice C is incorrect. The client is bleeding from multiple sites. The application of pressure to the intravenous site alone will not help stop the bleeding from other sites. DIC is a consumption coagulopathy. All the clotting factors and platelets are being used up in the clotting process. Therefore, the bleeding complications of DIC would necessitate platelets and clotting factor infusion.
The community health nurse is evaluating an individual's risks of developing Hepatitis A. The nurse knows which age group is at the highest risk of acquiring Hepatitis A? A. Newborns B. The elderly, ages 60 to 90 C. Teenagers older than age 15 D. Children older than 1 year but younger than 15 years 4008
D. Children older than 1 year but younger than 15 years Choice D is correct. Children who are preschool and elementary school age and those younger than 15-years-old are at the highest risk of developing Hepatitis A virus (HAV). Hepatitis A is usually contracted by ingesting stool containing the virus. Since it's transmitted through the fecal-oral route, children are more prone as they may not practice proper hand hygiene. Often, children contract the infection by eating/drinking food/water (fruits, vegetables, ice, water) contaminated by stools containing HAV, being carried by the infected person that does not wash their hands after using the restroom or traveling to a developing country without being vaccinated for hepatitis A. Outbreaks may occur in child care centers. The CDC recommends Hepatitis A vaccine to the following groups: All children aged 12-23 months Unvaccinated children and adolescents aged 2-18 years International travelers Homeless people Men who have sex with men Those engaged in recreational drug use Those with HIV Those with chronic liver disease Those at risk for exposure during their work. Pregnant women at risk for Hepatitis A Hepatitis A vaccine is administered in a two-dose schedule. It is recommended to all children at one year of age (i.e. 12 to 23 months) and as a catch-up vaccine for all unvaccinated children and adolescents 2 to 18 years. Choice A is incorrect. Newborns are not the group most likely to develop Hepatitis A. Newborns and those less than age 12 months tend to harbor passively acquired maternal antibodies (passively transferred via the placenta). Routine Hepatitis A vaccination is not recommended to children younger than 12 months because their immune systems are not mature. Vaccines before 12 months of age might result in a suboptimal immune response. However, those children at 6-11 months who travel internationally should be given the vaccine. Choice B is incorrect. These elderly age groups do not have more occurrences of Hepatitis A than children under 15-years-old. However, the elderly tend to have more severe symptoms if they do develop Hepatitis A. Choice C is incorrect. Teenagers older than 15 years of age are not at the highest risk of developing Hepatitis A. Preschool to elementary school-aged, and those younger than 15-years-old are at the highest risk.
Minimizing and challenging the client's report of pain and pain intensity is: A. Often necessary if the client has a history of substance abuse. B. Often necessary if the client has a history of drug seeking behavior. C. Contrary to and in violation of the Nightingale oath. D. Contrary to and in violation of the American Nurses Association's standard of care. 3679
D. Contrary to and in violation of the American Nurses Association's standard of care. Choice D is correct. Minimizing and challenging the client's report of pain/pain intensity is in violation of the American Nurses Association's standards of care about pain/pain management. Specifically, the American Nurses Association's Standards of Professional Performance for Pain Management Nursing. For example, nurses are mandated to document pain as expressed by the client regardless of what the nurse believes to be true and accurate. Choice A is incorrect. Minimizing and challenging the client's report of pain/pain intensity is not often necessary if the client has a history of substance abuse; this expression and reporting of pain must be considered valid and accurate. Nurses are mandated to document pain as expressed by the client regardless of what the nurse believes to be accurate. Choice B is incorrect. Minimizing and challenging the client's report of pain/pain intensity is not often necessary if the client has a history of drug-seeking behavior; this expression and reporting of pain must be considered valid and accurate. Nurses are mandated to document pain as expressed by the client regardless of what the nurse believes to be accurate. Choice C is incorrect. Minimizing and challenging the client's report of pain/pain intensity is not in violation of the Nightingale oath. There is no mention of pain management in the Nightingale oath. 69% correct
The nurse is caring for a client who experienced a myocardial infarction (MI) 24 hours ago. It would be necessary for the nurse to immediately notify the primary health care provider (PHCP) if the client has which of the following? A. An elevated troponin level B. A white blood cell (WBC) count of 13,000 mm3 C. Apprehension about attending cardiac rehabilitation D. Crackles auscultated to the midline of the lung fields 6492
D. Crackles auscultated to the midline of the lung fields Choice D is correct. Following a myocardial infarction (MI), the client is at risk for developing pulmonary edema. This is caused by the heart's inability to eject blood, consequently caused by an insult to the myocardium. When caring for a client with an MI, the nurse should monitor for life-threatening ventricular arrhythmias as well as pulmonary edema. If a client is experiencing this complication, they will develop crackles in the lung fields, tachypnea, and hypoxia. Choices A, B, and C are incorrect. The client experienced an MI 24-hours ago, and it would be expected that the client's troponin would be elevated. This elevation may last up to up to two weeks. Leukocytosis (an elevated white count) is an expected finding following an MI caused by the inflammation of the myocardium. A client experiencing apprehension regarding cardiac rehabilitation is an expected finding as this tertiary form of prevention often requires a lifelong commitment to lifestyle change.
A health care provider (HCP) orders the immediate use of a piece of electrical care equipment for a client. When you go to use the piece of equipment, you immediately suspect it may be faulty. Your initial action should be which of the following? A. Try the piece of electrical care equipment and see if it becomes hazardous. B. Call the health care provider and report your suspicion. C. Ask the client if they want you to try the piece of electrical care equipment. D. Immediately remove the piece of electrical care equipment from service.
D. Immediately remove the piece of electrical care equipment from service. Choice D is correct. If you suspect that a piece of electrical care equipment may be faulty and you have a health care provider's (HCP) order for the immediate use of this equipment for the client, you should immediately remove it from service. You must not use this piece of equipment under any circumstances. Choice A is incorrect. If you suspect that a piece of electrical care equipment may be faulty and you have a health care provider's (HCP) order for the immediate use of this equipment for the client, you would not "[t]ry the piece of electrical care equipment and see if it becomes hazardous" because the practice would be considered dangerous, reckless, and against the standard of care. Choice B is incorrect. If you suspect that a piece of electrical care equipment may be faulty and you have a health care provider's (HCP) order for the immediate use of this equipment for the client, your initial action would not be to call the HCP. Choice C is incorrect. If you suspect that a piece of electrical care equipment may be faulty and you have a health care provider's (HCP) order for the immediate use of this equipment for the client, you would not ask the client if they want you "to try the piece of electrical care equipment," because the practice would be considered dangerous, reckless, and against the standard of care.
The nurse is caring for a client with heart failure. The patient is ordered a nitroglycerin patch to be attached. Which of the following nursing actions regarding the administration of a nitroglycerin patch is most relevant? A. Use a bare hand when putting the patch on the patient. B. Place the patch on the same spot every day. C. Place the client in the supine position with his feet elevated on a pillow. D. Instruct the client to rise slowly. 3282
D. Instruct the client to rise slowly. Choice D is correct. Patients under nitroglycerin therapy are at risk for postural hypotension. The client should rise slowly to avoid a sudden drop in blood pressure when standing up. Choice A is incorrect. The nurse should wear gloves when administering a nitroglycerin patch to avoid skin contact with the medication. Choice B is incorrect. The patch should be rotated to ensure optimum absorption through the skin. Choice C is incorrect. The purpose of nitroglycerin in heart failure is to dilate the venous circulation and trap the blood in the veins, decreasing the preload. Placing the client in the supine position and elevating his feet increases venous return, thus increasing preload. This defeats the purpose of nitroglycerin. Subject Adult Health Lesson Cardiovascular Client Need Area Pharmacological and Parenteral Therapies
A pregnant client is brought into an emergency department by her husband. The client reports she is currently at 37 weeks gestation and began experiencing severe abdominal pain and bright red vaginal bleeding which "runs down my legs" thirty minutes prior to arrival. She currently rates her abdominal pain 10/10. Based on this information, which assessment method should the emergency room nurse refrain from performing? A. External fetal heart rate monitoring B. Abdominal palpation C. Measurement of vital signs D. Internal vaginal examination 2501
D. Internal vaginal examination Choice D is correct. In the presence of vaginal bleeding, an internal vaginal examination is contraindicated unless performed inside an environment prepared to perform an emergent vaginal delivery or cesarean section (i.e., such as a labor and delivery unit). Additionally, this emergency room nurse is likely not permitted under hospital or emergency department policy to perform an internal vaginal examination on a full-term pregnant woman with vaginal bleeding and severe abdominal pain. Additionally, this emergency department nurse is likely not trained to perform an internal vaginal examination on a full-term pregnant woman, as this skill is not routinely performed or practiced in an emergency department. Choice A is incorrect. External fetal heart rate monitoring should be performed to determine the current status of the fetus. Continued fetal monitoring should continue to observe for any signs and symptoms to allow for early intervention. Choice B is incorrect. Abdominal palpation should be performed, as this can provide the nurse with valuable information regarding uterine contractions and abdominal tenderness, potentially assisting in determining the cause of the vaginal bleeding. Choice C is incorrect. The nurse should assess a complete set of vital signs on the client to ascertain the current physiological functioning of the client. 79% correct
The nurse is caring for a patient with post-gastrectomy dumping syndrome. What teaching should the nurse provide for this patient? A. Take small sips of water during meals to soften the food for easier digestion. B. Symptoms will resolve in about 4-6 weeks as the stomach adjusts post-surgery. C. Plan rest periods of 10-15 minutes after every meal. D. Meals should consist of dry foods with low carbohydrates, moderate fat, and protein content. 4335
D. Meals should consist of dry foods with low carbohydrates, moderate fat, and protein content. Choice D is correct. The patient should be instructed to eat small portions of dry foods to aid digestion. A low carbohydrate, moderate fat, and moderate protein content will promote tissue healing and help to meet the body's increased energy demands. Choice A is incorrect. Patients experiencing dumping syndrome should be instructed to avoid drinking during meals to prevent fullness and distention. Patients should drink in between meals at least 30-45 minutes before or after eating. Choice B is incorrect. Symptoms of dumping syndrome generally resolve in several months to a year after gastrectomy surgery. Choice C is incorrect. Post-meal rest periods should be at least 30 minutes to allow enough time for the digestion process to begin. 45% correct Subject Adult Health Lesson Gastrointestinal/Nutrition Client Need Area Basic Care and Comfort
The nurse is caring for a client with the following clinical data. Which prescription would the nurse request from the primary healthcare provider (PHCP) based on the clinical data? HPI: the client was found disoriented upon arrival in acute respiratory distress. the client's caregiver noted that the prescribed medications had not been taken for several days. Medical history include htn, diabetes, chf & arthritis. Assessment: bounding pulses, normotensive, crackles in the lung, tachypnea, jvd & abdominal distention Select all that apply. See the exhibits. A. Albuterol B. Hydrocortisone C. Diltiazem D. Nitroglycerin E. Furosemide
D. Nitroglycerin E. Furosemide Choices D and E are correct. Pulmonary edema secondary to acute decompensated heart failure (ADHF) is a medical emergency and requires rapid treatment. Vasodilators such as nitroglycerin help decrease preload and afterload, reducing the heart's workload. This medication is often combined with a loop diuretic such as furosemide or bumetanide to decrease volume. If vasodilators or loop diuretics are prescribed, close blood pressure monitoring is essential.
During a client's bronchoscopy, the nurse notices the client necessitates the use of a rigid scope. During the insertion of the scope by the health care provider (HCP), the nurse notes the client is experiencing a vasovagal response when noticing which of the following? A. Dilated pupils B. Bronchodilation C. Decrease in gastric secretions D. Noticeable drop in heart rate 2644
D. Noticeable drop in heart rate Choice D is correct. The nurse would notate a vasovagal response upon seeing a sudden, noticeable drop in the client's heart rate. Here, during the bronchoscopy, the involvement of a foreign object (i.e., the HCP's scope) in the client's pharynx likely caused vagus nerve stimulation. This stimulation resulted in a vasovagal response by the client, manifested by a sudden decrease in the client's heart rate. Choice A is incorrect. Stimulation of the vagus nerve does not cause dilation of the pupils. Choice B is incorrect. Stimulation of the vagus nerve does not cause bronchodilation. Choice C is incorrect. During vagus nerve stimulation, an increase, not decrease, in gastric secretions is typically noted. This response occurs as a result of increased parasympathetic activity. 75% correct
The nurse is caring for a client that was newly prescribed clozapine. It would be essential to teach the client to do which of the following? A. Maintain a healthy diet because of weight gain B. Exercise regularly and maintain hydration C. Expect excessive secretions in the mouth D. Obtain follow-up laboratory work
D. Obtain follow-up laboratory work Choice D is correct. Follow-up laboratory work is essential for a client taking clozapine. The medication may adversely cause neutropenia. The client will be instructed to obtain this necessary laboratory work to ensure they are not experiencing agranulocytosis, which may make the client susceptible to infection. Choices A, B, and C are incorrect. Clozapine may cause significant weight gain and hypersalivation. The client should be instructed to watch their calorie intake and exercise with appropriate hydration.
The nurse is caring for a newly admitted client. Which task can the nurse delegate to the unlicensed assistive personnel (UAP)? A. Apply nasal cannula oxygen B. Remove a vascular access device that is not patent C. Perform venipuncture for laboratory work D. Obtain vital signs every four hours 4499
D. Obtain vital signs every four hours Choice D is correct. The collection of vital signs may be delegated to a UAP. This includes pulse, blood pressure, temperature, and oxygen saturation. Choices A, C, and D are incorrect. Oxygen is regarded as medication, and any adjustment or application of oxygen is not within the scope of a UAP. Venipuncture is not within the scope of a UAP, and it would be inappropriate for this task to be delegated. Removing a vascular access device may be delegated to an LPN - not a UAP. 91% correct
A nursing assistant tells the nurse that her patient with COPD reports he did not get his annual flu shot this year and has not had a pneumonia vaccination. The nurse should instruct the CNA that which of the following is the priority? A. Blood pressure 150/80 mmHg B. Respiratory rate 26 breaths/min C. Heart rate 92 beats/min D. Oral temperature of 101.4 degrees F 5015
D. Oral temperature of 101.4 degrees F Choice D is correct. An elevated temperature indicates some form of infection which may be respiratory in origin. A patient who did not receive pneumonia or influenza vaccines is at increased risk of developing pneumonia and influenza. Monitoring for signs/symptoms of infection is a crucial nursing intervention. Choices A, B, and C are incorrect. Although all of the vital signs in these answer options are slightly elevated, they do not represent a cause for immediate concern.
The nurse is performing health education to a 21-year-old male who just had a fiberglass cast fitted on his right forearm for an ulnar fracture. They are talking about the early signs of compartment syndrome. The nurse notes that the patient has a full understanding of the topic when he states which of the following signs and symptoms: A. Pallor and pulselessness B. Inability to move his fingers and swelling at the site C. Fever and erythema D. Pain with passive motion and loss of sensation
D. Pain with passive motion and loss of sensation
A client is currently experiencing bradycardia, low blood pressure, and dizziness. Which of the following does the nurse expect to be ordered? A. Defibrillation B. Digoxin C. Monitor the client closely D. Prepare patient for transcutaneous pacing 4067
D. Prepare patient for transcutaneous pacing Choice D is correct. The normal heart rate in an average adult is between 60 to 100 beats per minute. A heart rate less than 60 beats per minute is referred to as bradycardia. Bradycardia can be symptomatic or asymptomatic. Some healthy adults and athletes may have a heart rate between 40 and 60 beats per minute and do not experience any symptoms. When symptomatic, bradycardia can lead to shortness of breath, dizziness, and low blood pressure (hypotension, shock). A patient experiencing symptomatic bradycardia will likely need transcutaneous pacing. In addition, an EKG must be performed to confirm the rhythm. The etiology of bradycardia may vary and include reversible (medications) and irreversible causes (heart blocks). Therefore, one should explore causes, but the priority intervention in a patient experiencing symptoms from bradycardia is to restore the heart rate quickly with transcutaneous pacing and maintain circulation. Choice A is incorrect. Defibrillation is recommended when the patient is experiencing pulseless ventricular tachycardia or ventricular fibrillation. Choice B is incorrect. Digoxin is a cardiac glycoside that has negative chronotropic action on the sinus node. Therefore, digoxin decreases the heart rate and would be dangerous in this patient with symptomatic bradycardia. Choice C is incorrect. While this patient should be monitored closely, priority action (transcutaneous pacing) should quickly restore the heart rate.
The nurse is caring for a client at the first prenatal visit. The primary healthcare provider (PHCP) has prescribed testing for syphilis. The nurse anticipates which laboratory testing? A. Brain Natriuretic Peptide (BNP) B. Comprehensive Metabolic Panel (CMP) C. Complete Blood Count (CBC) D. Rapid Plasma Reagin (RPR) 7462
D. Rapid Plasma Reagin (RPR) Choice D is correct. An RPR is a common screening test for syphilis infections. This test is often confirmed with a fluorescent treponemal antibody absorption (FTA-ABS) test. Choices A, B, and C are incorrect. A BNP test is utilized to assist in the diagnosis of heart failure. A CMP is testing that may detect problems with the liver or any other electrolyte abnormalities. A CBC is testing that may reveal disorders associated with blood dyscrasias. 53% correct Subject Adult Health Lesson Infectious Disease Client Need Area Reduction of Risk Potential
A nurse is caring for a client who has missed their last appointment with the primary healthcare provider (PHCP). The client states, "I missed my appointment because I overslept, but I knew it would be pointless anyway." The client is demonstrating which of the following? A. . Projection B. Reaction formation C. Denial D. Rationalization 6956
D. Rationalization Choice D is correct. Rationalization is a higher-level defense mechanism that involves an individual justifying behavior that is often offensive or abnormal through statements that they believe provide validation. However, the rationalization of the behavior is done to avoid authentic feelings such as guilt if they have done something wrong. The client missing their appointment because they overslept is rationalizing this choice because they perceived the appointment as pointless. Choices A, B, and C are incorrect. The client is not demonstrating projection because they are not attributing their unacceptable feelings and thoughts to someone else. Reaction formation is when an individual acts in an opposite way of their true feelings or actions. Denial is not exhibited because the client is acknowledging the missed appointment. Denial is when the individual blocks a situation because they refuse to embrace the situation and associated emotions.
The nurse is developing the care plan for an 86-year-old patient with a diagnosis of cor pulmonale. Which nursing intervention would be most important to include in regards to monitoring this patient's peripheral edema? A. Assess for skin tenting over the sternum B. Weigh patient at same time daily C. Obtain baseline BNP level D. Record calf circumference daily 6408
D. Record calf circumference daily Choice D is correct. Cor pulmonale describes right ventricular enlargement due to pulmonary hypertension. The accumulation of fluid in the interstitial spaces results in dependent edema, jugular vein distension, shortness of breath, and weight gain. Measuring and recording the circumference of the extremity at the same location daily is the best way to monitor for changes in the patient's peripheral edema. Choice A is incorrect. Checking for tenting is a technique to assess skin turgor for dehydration, not to monitor peripheral/dependent edema. Additionally, assessing for the turgor does not provide an accurate measure of dehydration in older patients due to loss of skin elasticity with age. Choice B is incorrect. Weighing the patient daily would be an appropriate method of monitoring for alternations in overall fluid status, but does not specifically address peripheral edema. Choice C is incorrect. BNP (B-type natriuretic peptide) reflects left ventricular presence/severity of heart failure. This value may be abnormal due to cor pulmonale, but would not specifically reflect the patient's level of edema.
The nurse is teaching a group of students about tertiary prevention. Which of the following would be a form of tertiary prevention? Select all that apply. A. Yearly fecal occult blood testing B. Testicular self exams C. Digital rectal exams D. Rehabilitation programs E. Support groups for chronic illness
D. Rehabilitation programs E. Support groups for chronic illness
The nurse is taking care of a 9-year-old boy undergoing testing for acute myeloid leukemia (AML). She is assisting with the client's positioning for a lumbar puncture. Which of the following positions is appropriate? A. Prone B. Trendelenburg C. Supine D. Side lying
D. Side lying
The nurse is paired with an LPN in the pediatric unit. A four-month-old infant with a temporary colostomy is being discharged today. What is the most appropriate action of the nurse and the LPN? A. The LPN completes the discharge instructions to the mother. B. The LPN demonstrates to the mother how to irrigate the child's colostomy. C. The LPN gives the mother the child's medications, instructions on how to administer them, and explains the purpose of the medications. D. The LPN is tasked by the nurse to remove the child's IV catheter. 3622
D. The LPN is tasked by the nurse to remove the child's IV catheter. Choice D is correct. The LPN can remove the child's IV catheter and perform other routine tasks. Choice A is incorrect. The LPN cannot provide discharge instructions. It is not within their scope of practice. Choice B is incorrect. Demonstrating how to irrigate a colostomy to the mother constitutes discharge teaching. The LPN cannot provide discharge instructions and education. It is not within their scope of practice. Choice C is incorrect. Providing medication education and instruction to the mother constitutes discharge teaching. The LPN cannot provide discharge instructions and teaching. It is not within their scope of practice.
A newly registered nurse is caring for a school-aged child with cerebral palsy under the supervision of a senior nurse. Which action by the new RN would warrant the senior nurse to intervene? A. The new RN initiates gentle range-of-motion exercises to the client. B. The new RN lowers the bed to its lowest position. C. The new RN wheels the client to the playroom via wheelchair. D. The new RN feeds the child with the bed elevated at 30 degrees. 2780
D. The new RN feeds the child with the bed elevated at 30 degrees. Choice D is correct. The nurse should position the client with the head of the bed elevated at 60 - 90 degrees to prevent aspiration. Choice A is incorrect. ROM exercises prevent contractures in the child with cerebral palsy. Choice B is incorrect. Lowering the bed in its lowest position decreases the risk of injury during a fall. Choice C is incorrect. Taking the client to the playroom gives the client a chance to play. This action of the nurse represents patient advocacy.
Today, you are the charge nurse for the nursing care unit overseeing RNs, LPNs, and unlicensed assistive personnel (UAPs). As you prepare the staff assignments prior to the shift, which of the following legal documents must you consider as you are making staff assignments and delegating tasks for the day? A. Competency checklists for all the team members scheduled for the shift B. Job descriptions of all team members on the unit for today's shift C. The scope of practice for both RNs and LPNs as established by the American Nurses Association D. The state's scope of practice documents for RNs, LPNs, and any applicable unlicensed assistive personnel (UAP) 2448
D. The state's scope of practice documents for RNs, LPNs, and any applicable unlicensed assistive personnel (UAP) Choice D is correct. The state's scope of practice documents for RNs, LPNs, and applicable unlicensed assistive personnel are the legal documents that must be considered when creating assignments or delegating tasks for the day. These legal documents abide by specific state regulations differentiating what healthcare team members may or may not do under the licensure they possess (or, in the case of an UAP, the lack of licensure). Therefore, Choice D is correct. Choice A is incorrect. Although competency checklists for each team member should be considered when making daily assignments and/or delegating tasks, competency checklists are not legal documents. Therefore, Choice A is incorrect. Choice B is incorrect. Although the job descriptions for each team member should be considered when making daily assignments and/or delegating tasks, job descriptions are not legal documents. Therefore, Choice B is incorrect. Choice C is incorrect. Each state specifies the role of RNs and LPN/LVNs via legislation as defined in the Nursing Practice Act. The American Nurses Association does not produce legal documents or create the Nursing Practice Act. Therefore, Choice C is incorrect. 67% correct
A nurse is educating a client who just had a skin test for hypersensitivity reactions. The nurse should teach the client which of the following? A. To ensure that the skin tested areas are kept moist with a mild lotion. B. To keep out of direct sunlight until the tests are read. C. To wash the sites every day with a mild soap. D. To make sure that he comes back on the correct date for reading. 2725
D. To make sure that he comes back on the correct date for reading. Choice D is correct. An important aspect of skin tests is reading the results at the proper time. Specific hypersensitivity changes such as erythema, wheals, and induration are measured. The provider can analyze immediate hypersensitivity reactions soon after the test; however, delayed hypersensitivity reactions should be measured 48 -72 hours later. A reading done too early or too late would give inaccurate and unreliable results. Therefore, the nurse should make sure the client has a return appointment and emphasize the importance of getting the skin test site. Choices A, B, and C are incorrect. The site should be kept dry, and it is not necessary to wash the areas with soap. Direct sunlight will not affect the results; therefore, it's inappropriate to educate the client to keep the skin test site out of direct sunlight specifically.
The nurse is giving discharge instructions to a client recently diagnosed with vaginitis. Which of the following instructions should the nurse include? A. Use oral contraceptives during sexual intercourse. B. Practice regular douching. C. Abstain from eating yogurt. D. Wear loose-fitting clothing and cotton underwear. 3306
D. Wear loose-fitting clothing and cotton underwear. Choice D is correct. Clients are encouraged to wear loose-fitting clothing, cotton underwear, avoid tight pants and thongs, as well as avoid using tampons to facilitate ventilation and improve circulation. Choice A is incorrect. The client should use a condom during sexual intercourse to prevent her partner from acquiring the infection. Oral contraceptives do not provide a barrier that prevents disease. Choice B is incorrect. Clients are advised not to practice regular douching unless prescribed by the healthcare provider. Choice C is incorrect. Clients are advised to include yogurt or supplements containing Lactobacillus acidophilus in their diet to maintain vaginal flora. 91% correct, adult health, reproductive, physiological adaptation
The nurse is teaching a group of nursing students about the five rights of delegation. The nurse is correct to include that this involves the right A. intention. B. alternative. C. assessment. D. task. 2367
D. task. Choice D is correct. The right task is within the five rights. When a nurse is delegating, the task must be within the individual's scope of practice and competency. For example, a right task would be delegating a practical/vocational nurse to administer an intramuscular (IM) injection of vitamin B12. Choices A, B, and C are incorrect. These statements are not included within the five rights of delegation The "right" task The "right" circumstances The "right" person The "right" directions and communication The "right" supervision and evaluation 79% correct
what is the nightingale oath
I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug
how does diabetes insipidus cause hypernatremia
It causes a "free water" loss which increases the serum NA concentration. Hypernatremia is most often due to unreplaced water that is lost from the urine that is constantly on the way out in diabetes insipidus
Sodium polystyrene sulfonate
Kayexalate -Treatment option for hyperkalemia; works in the colon to bind to potassium to aid in excretion. Causes diarrhea! - reduces total potassium in the body (should be in the cells, it's ok to excrete the potassium in the body)
what are the 5 types of diuretics
Loop Osmotic Thiazide Potassium sparing Carbonic anhydrase inhibitor
what foods are in a low sodium diet
NON PROCESSED FOODS Fresh or frozen fish or shellfish. Chicken or turkey breast without skin or marinade. Lean cuts of beef or pork. Unsalted nuts and seeds. Dried beans, peas, and lentils — like black beans and garbanzo beans (chickpeas)
The nurse is caring for an elderly patient who is status-post total hip replacement surgery. The nurse notices that the patient's left leg is externally rotated. Which of the following should the nurse do next? A. Place a trochanter roll on the outer aspect of the thigh B. Perform a range of motion exercises on the left leg C. Internally rotate the left leg D. Tell the client to keep his leg in a neutral position 3617
Place a trochanter roll on the outer aspect of the thigh Choice A is correct. A trochanter roll placed on the outer aspect of the thigh holds the hip in a neutral position and keeps the leg in normal alignment. A trochanter roll refers to a towel/blanket rolled up into a cylindrical prop and placed around the lateral/hip thigh area extending from above the hip to above the knee. When the patient is supine, this trochanteric roll prevents external rotation and decreases the chance of further tissue damage or hip dislocation. The soft tissues and muscles around the hip are weak following surgery so, patients are instructed to follow "standard hip precautions" to decrease the chance of hip dislocation following total hip arthroplasty (THA). Choice B is incorrect. Range of motion exercises would not prevent or address the external rotation of the leg. Choice C is incorrect. Internal rotation of the leg is not beneficial to the client and may cause more injury. Normal alignment is required, and the pin must be in a neutral position. Choice D is incorrect. Telling the client to stay in a hip-neutral position may not help. The leg will come back to the external rotation once the client becomes unaware of the situation. The pin needs to be propped up in proper alignment with a trochanter roll. 71% correct- know this
Before administering a nasogastric feeding to a preterm infant, the nurse prepares to aspirate the residual fluid from the stomach. Please place the following nursing actions in sequential order. Press and hold an option to rearrange Aspirate gastric contents Position the patient with the head slightly elevated Return the aspirate and subtract the amount of the aspirate from the feeding Begin the prescribed nasogastric feeding Measure the aspirate 4127
Position the patient with the head slightly elevated Aspirate gastric contents Measure the aspirate Return the aspirate and subtract the amount of the aspirate from the feeding Begin the prescribed nasogastric feeding The correct sequence is: Position the infant with his or her head slightly elevated to reduce the risk of aspiration. This should be done before the feeding is resumed. If the infant is on "continuous" feeding, it is assumed that the head end is already kept elevated all the time. About 40% of clients on enteral feeding aspirate have associated complications/ morbidity. Elevating the head of the bed to 30-45 degrees helps prevent or reduce the risk of aspiration. Aspirate the gastric contents. Measure the aspirate: Aspirate should first be measured, so the nurse knows how much to subtract from the feeding. Return the aspirate and subtract the amount of the aspirate from the feeding. This is done to maintain the gastric enzymes and acid-base balance. Begin the prescribed nasogastric feeding. 59% correct
what is the vasovagal response
Relaxation of the muscles in the walls of the blood vessels, slowing of the heart rate (This decrease in heart rate can be profound, with asystole lasting as long as several seconds), hypotension, and sometimes fainting & other dysrhythmias
what are the symptoms of hypernatremia
Restless ● Agitated ● Lethargic ● Drowsy ● Stupor ● Coma Twitching ● Cramps ● Weakness ● Fever ● (Hypervolemic: Edema, Hypertension & Bounding pulses) (Hypovolemic: Hypotension, Weak pulses) Flushed skin ● Decreased UOP ● Dry mouth
Chovstek's sign
Sign of hypocalcemia or hypomagnesemia; abnormal functioning of the facial nerve causes a twitch on the same side of the face
unresolved autonomic dysreflexia can result in
Stroke Retinal hemorrhage Cardiac arrest Pulmonary edema
what is total clearance
Sum of ALL elimination routes of a drug from the body, including renal, hepatic and respiratory
causes of siadh acronym
Surgery Intracranial (CVA, head injury, infection) Alveolar (cancer & puss) Drugs (opiates, antiepileptics, cytotoxics, antipsychotics) Hormonal (hypothyroidism, low corticosteroids)
what is hypovolemic hyponatremia
Water and sodium are both lost, but unequally, with the sodium loss being greater.
A slit lamp is a tool used by an advanced provider that may determine
abnormality in the cornea, lens, or anterior vitreous humor.
how is potassium important for acid base balance
acidosis increases k_
Symptoms of a severe anaphylactic reaction include
airway compromise due to laryngeal edema or angioedema (stridor) bronchoconstriction (wheezing, cough, and dyspnea) and/or circulatory collapse (shock).
how fast should we give platelets, max ____ units an hr
as fast as possible, up to 4 units an hr
how fast do you give plasma
as quickly as possible because about 2 ml/min for the first 15 mins, then the rest over 1-2 hours (150-250 ml/hr) no more than 4 hours
what is the priority symptom the nurse should observe for in a post-punch biopsy client.
bleeding
Bowel sounds less than 5 per minute may indicate
blockage
what does diuretics do to sodium levels
causes hypovolemic hypernatremia
what does hyponatremia do to bp
causes orthostatic hypotension
we correct hypernatremia balances slowly because of risk for what
cerebral edema we're going to give fluids to correct but we don't want to give them edema
symptoms of syphilis
chancre in the primary stage, a diffuse rash in the secondary stage, and systemic cardiovascular abnormalities in the tertiary stage
actions that increase intraocular pressure
coughing, sneezing, muscle exertion, bending at the waist or vomiting
what does it mean when someone with acute appendicitis has a sudden relief in pain after several hours?
could signify a rupture of the appendix
tpn contains what
dextrose (glucose), amino acids, electrolytes
what should you avoid when taking lithium
dehydration and hyponatremia Lithium is a salt, and when the client has decreased fluid volume, the drug will accumulate and raise the lithium level. HCTZ is a thiazide diuretic and is contraindicated for a client taking lithium because of its ability to decrease fluid and sodium levels.
medications that act on the kidney to increase production of urine & increase elimination of h2o, metabolic wastes & electrolytes from the body
diuretics
what medication should you avoid when taking lithium
diuretics, especially hctz it decreases fluid volume and sodium levels
The process of absorbing drugs before elimination after they have been excreted into bile and delivered to the intestines is called
enterohepatic cycling
which do you give first for anaphylaxis: epi or benadryl
epi Epinephrine is the priority treatment over diphenhydramine in anaphylaxis because of its ability to relieve upper airway obstruction or hypotension.
causes of autonomic dysreflexia
full/distended bladder, impaction, constipation, pressure on skin, cool draft, painful stimuli
prolongation/widened of the PR and QRS intervals tall peaked t waves -P wave amplitude is diminished in the early stage - T wave amplitude increases. if we see this on an ekg, what are we suspicious of
hyperkalemia
Diuretics causes what type of sodium imbalance
hypovolemic hyponatremia
Weak pulse, Tachycardia, Hypotension, Dizziness cv symptoms of hyper or hypovolemic hyponatremia?
hypovolemic hyponatremia
burns causes what type of sodium imbalance
hypovolemic hyponatremia
What is redman syndrome?
inflammation of the veins caused from fast infusion of Vancomycin & other Antibiotics such as ciprofloxacin, amphotericinB, rifampcin and teicoplanin
where is potassium mostly
inside the cells to control nerve impulse conduction, where as sodium lives outside the cells to control fluid balance
adrenal insufficiency does what to potassium and sodium
low sodium, high potassium, low cortisol
is hypoactive bowel sounds a red flag after an appendectomy
no, it is expected in the immediate postop period
intervention for early decelerations
none
what produces adh
pituitary gland
Late decelerations are due to
placental insufficiency
contraindications to taking ephedrine
raynauds & pvd Clients with Raynaud's disease or any other peripheral vascular disease are contraindicated to receive ephedrine or any other adrenergic agonist as these diseases could be exacerbated by systemic vasoconstriction. The nurse should question the physician regarding this prescription.
how to treat hypovolemic hyponatremia
restore volume & sodium with saline of some sort for mild: normal saline 0.9% for severe: 3%
lithium is a
salt
what is phenytoin for
seizure disorders
what are variable decelerations
sharp and profound drops in the fetal heart rate unrelated to the time of contraction
what is mcburney's sign & what is it a sign of
significant pain upon palpitation of the point 2/3 of the way in between the belly button & the r hip appendicitis
what electrolyte do we think of when we hear neuro
sodium
what precautions is AIDS
standard
what precautions is hiv
standard
Classic manifestations of cardiac tamponade include
tachycardia, tachypnea, jugular venous distention, and hypotension with a narrowed pulse pressure. ex: HR: 128 bpm; RR: 26; BP: 88/71 mmHg
Sodium polystyrene treats what
treats constipation or hyperkalemia is used for individuals with hyperkalemia, and its use will not only lower potassium but may also raise sodium
what are causes of euvolemic hyponatremia
● SIADH ● Adrenal insufficiency ● Addison's disease ● Polydipsia ● Excessive hypotonic IVF ● Low dietary intake of sodium
