Archer Review - Baseline assessment

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

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

Pulmonary Tuberculosis- - Fever - SOB - Hemoptysis - Unintentional weight loss - Adventitious lung sounds Influenza- - Fever - SOB - Adventitious lung sounds Pneumothorax - - SOB

For each client finding, click to specify if the finding is consistent with pulmonary tuberculosis, pneumothorax, or influenza. Each client finding may support more than one (1) condition or disease process

Choice B is correct. Kurt Lewin's theory of leadership is the most similar to the styles of parenting. Lewin describes the leadership styles as the autocratic, participative, democratic, and laissez-faire styles of leadership, which are the same as the different parenting styles. All these styles of leadership and parenting styles have their distinct advantages and disadvantages.

Parenting styles are most similar to whose theory of leadership? A. Bass B. Lewin C. House D. Fiedler

Choice B is correct. Relaxin can lead to clumsiness because of increased flexibility and ligament relaxation. This clumsiness increases the risk of musculoskeletal injury. Relaxin may also cause round ligament pain, indigestion, and an increase in the frequency of urination.

Relaxin is a hormone that is released throughout a woman's pregnancy to help prepare her uterine ligaments for the growth of her fetus and uterus. A downside to relaxin is that it may: A. Cause high blood pressure in some women B. Lead to musculoskeletal injury due to loose ligaments C. Make urinating more difficult than normal D. Increase bowel motility

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

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

Activity- - Out of Bed to Chair Diet- - Clear Liquids Medications- - Multivitamin - Hydrocodone-Acetaminophen - Docusate Consultations - - Registered Dietician - Diabetic Educator Venous Thromboembolism (VTE) Prophylaxis - - Sequential Compression Stockings - Prophylactic Anticoagulant Therapy

Select the anticipated provider orders from each of the following categories. Each category must have at least one option selected, and each category may have more than one option selected. Categories Potential Orders Activity- - Strict Bed Rest - Head of Bed Restrictions - Out of Bed to Chair Diet- - Clear Liquids - Full Liquids - Nothing by Mouth (NPO) Medications- - Multivitamin - Hydrocodone-Acetaminophen - Docusate Consultations - - Registered Dietician - Diabetic Educator - Ostomy Venous Thromboembolism (VTE) Prophylaxis - - None - Sequential Compression Stockings - Prophylactic Anticoagulant Therapy

Choice C is correct. Bacterial meningitis is a medical emergency, and priority actions for the nurse are to assess the client's airway, breathing, and circulation; beyond the assessment of the ABCs and vital signs, the nurse should immediately establish a peripheral vascular access device and obtain blood cultures and laboratory work such as lactic acid and complete blood count. Lactic acid is a marker that may support the co-existing diagnosis of sepsis. The client will need an immediate lumbar puncture which will definitively exclude or confirm the diagnosis of bacterial meningitis. Considering this client has been diagnosed with bacterial meningitis, the nurse must collect blood cultures and then administer prescribed antibiotics that are aggressively dosed. Antibiotics commonly prescribed for bacterial meningitis include ceftriaxone and vancomycin.

The emergency department (ED) nurse is caring for a client with suspected bacterial meningitis. The nurse should take which priority action? A. Notify public health services B. Dim the lights in the assigned room C. Obtain blood cultures D. Explore the client's feelings regarding the diagnosis

Choice C is correct. The primary responsibility of the triage nurse is to perform an initial nursing assessment and determine which patient(s) require immediate care or isolation. The triage nurse should be able to identify patients who pose a potential risk to others by being familiar with commonly occurring illnesses/infections. Emergency department nurses and triage nurses must be adept at prioritization. Prioritizationrefers to the concept of deciding which duties/clients require immediate attention and which ones could be delayed until later. None of the clients in the options above show any signs of unstable vitals. Therefore, the safety of the client and other clients takes priority.

The emergency department (ED) triage nurse is assigned to see the following clients. Which of the following clients requires the most rapid action in the ED? A. A travel blogger who needs tuberculosis testing after exposure to a person with TB during his trip. B. An elderly woman who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) leg wound infection. C. A pregnant woman with a blister-like rash on the face who possibly has varicella. D. An infant with a runny nose and whose older brother has pertussis.

Choice A is correct. A yellow triage tag indicates the victim has injuries that are not immediately life-threatening and can wait up to an hour before receiving treatment. This patient is responsive, with adequate respiratory function (respirations below 30/minute) and perfusion intact (capillary refill under 2 seconds). This patient could wait until the most severe injuries are treated before receiving treatment.

The hospital's disaster plan is initiated due to a nearby factory fire. One of the victims is responsive but unable to walk, with a respiratory rate of 28 and capillary refill <2 seconds. What color tag would the ED triage nurse assign to this patient? A. Yellow B. Red C. Black D. Green

Choice B is correct. This image shows wound dehiscence (following an inguinal hernia repair). Wound dehiscence is a partial or total separation of previously approximated wound edges due to a failure of proper wound healing, sometimes described as "splitting open of the wound." The abdominal muscle layer is intact in wound dehiscence, preventing the internal organs from protruding out. Typically, this occurs five to eight days following surgery when healing is still in the early phases. The causes of wound dehiscence correlate with the causes of poor wound healing, including ischemia, infection, increased abdominal pressure, diabetes, malnutrition, smoking, and obesity. Additional studies have correlated increased findings of dehiscence occurring more often in clients with diabetes, obesity, immune deficiency, malnutrition, or those who utilize steroids.

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

Choice C is correct. The most effective way to evaluate your adult client's response to non-pharmacological comfort interventions is to compare pre- and post-intervention data using a numerical pain rating scale. Typically, the use of a traditional verbal pain scale from 0 to 10, with 0 being the absence of pain, 1 being the presence of minimal pain, and 10 being the greatest pain imaginable, is the most effective method of evaluating a client's response to non-pharmacological comfort interventions.

The most effective way to evaluate your adult client's response to non-pharmacological comfort interventions is to: A. Use the PQRST pain assessment method to measure comfort B. Ask the client if they feel better after the comfort intervention C. Compare pre- and post-intervention data using a numerical pain rating scale D. Compare pre- and post-intervention data using the NIPS pain rating scale

Choices A, B, and E are correct. Osmosis, diffusion, and ultrafiltration are essential principles upon which peritoneal dialysis functions. Osmosis is the passive movement of solvents, such as water, across a permeable membrane. The peritoneum is a permeable membrane (choice A). Diffusion is the passive movement of solutes across a membrane. Solutes diffuse from an area of higher concentration to an area of lower concentration across the peritoneum until there is an equal amount of each on both sides of the membrane (choice B). Ultrafiltration is the removal of excess fluid from the body. Ultrafiltration occurs as the dialysis fluid dwells in the peritoneal cavity, causing a shift of fluid from the bloodstream into the peritoneal cavity (choice E).

The new nurse is caring for a client scheduled for peritoneal dialysis. Which of the following functional principles does the new nurse understand about peritoneal dialysis? Select all that apply. - Osmosis - Diffusion - Oncotic pressure - Osmotic pressure - Ultrafiltration

Choice D is correct. The client is exhibiting symptoms and signs of left ventricular heart failure. Decreased cardiac output associated with acute systolic heart failure results in reduced blood pressure, weak pulses, and acute pulmonary edema (dyspnea, frothy pink sputum, and lung crackles). Diltiazem and other calcium channel blockers (CCBs) produce a negative inotropic effect (reduced myocardial contractility) and are contraindicated in acute systolic heart failure. CCBs may exacerbate systolic dysfunction and cause heart failure symptoms to worsen. The nurse should question this order to determine if there is a more appropriate medication to accomplish the intended therapeutic effect with a lower risk of complications.

The nurse attends to a client with shortness of breath, bilateral lung crackles, weak pulses, and frothy pink sputum. Which of the following orders should the nurse question for this client? A. Supplemental oxygen via nasal cannula or mask B. Losartan C. Fowler's position D. Diltiazem

First, determine how many mL/hr the client is receiving (dose ordered / dose on hand x volume) 1300 units / 25000 units x 500 mL = 26 mL Next, take the mL/hr the client is receiving and multiply it by 8 26 mL x 8 hours = 208 mL

The nurse cares for a client receiving 1300 units/hr of heparin. The bag is labeled 25,000 units in 500 mL of dextrose 5% in water. How many mL should the nurse record that the client received in eight hours? Fill in the blank.

Choice D is correct. Terbutaline may increase the client's blood glucose level. The nurse should monitor the client's blood sugar levels while on this medication. This glucose level is normal and indicates to the nurse that the infusion may continue.

The nurse cares for a client receiving terbutaline infusion to prevent preterm labor. Which clinical findings indicate that the nurse should continue the infusion? A. Blood pressure 91/58 mmHg B. Heart rate 132 beats/minute C. Serum potassium 3.3 mEq/L (3.3 mmol/L) D. Blood glucose 104 mg/dL (5.7 mmol/L) [70-110 mg/dL (4-6 mmol/L)]

Choice A is correct. Impaired gas exchange is the most appropriate nursing diagnosis for a client with iron deficiency anemia. Hemoglobin is the component in the blood responsible for transporting oxygen throughout the body. Iron is an essential substance for hemoglobin synthesis. In iron deficiency anemia, the hemoglobin is decreased, leading to impaired gas exchange.

The nurse caring for a client with iron deficiency anemia is preparing the client's plan of care. Which nursing diagnosis is the most appropriate for this client's care plan? A. Impaired gas exchange B. Ineffective airway clearance C. Deficient fluid volume D. Ineffective breathing pattern

Choice C is correct. Aplastic anemia (AA) can cause a critically low neutrophil count because of the pancytopenia it induces. The low neutrophil count puts the client at risk for a life-threatening infection. The client's remarkable fever warrants prompt follow-up so the nurse may initiate measures such as blood culture collection, administer prescribed antibiotics and antifungals, and provide supportive measures such as antipyretics.

The nurse has been made aware of the following client situations. The nurse should first follow up with the client A. receiving a chemotherapy infusion who reports nausea and vomiting. B. newly diagnosed with polycystic kidney disease reporting hematuria and flank pain. C. being treated for aplastic anemia and has a temperature of 101.1° F (38.4° C). D. being treated for pulmonary tuberculosis and ambulating in the hallway wearing a surgical mask.

Choice B is correct. The whooshing or blowing sound sometimes heard upon cardiac auscultation is known as a heart murmur and may indicate valve incompetency. "Stenosis" refers to a narrowing of the heart valve, whereas regurgitation indicates a "leaky" valve. An aortic stenosis murmur is best heard at the second intercostal space in the right upper sternal border (aortic area). A mitral stenosis murmur is best heard at the apex (mitral area).

The nurse has performed a cardiovascular assessment on a client, and while auscultating heart tones, the nurse auscultates a harsh blowing sound. The nurse should document this finding as a A. pericardial friction rub. B. heart murmur. C. normal lub-dub sounds. D. S3 heart sound.

Choice B is correct. Facial flushing is often a side effect of niacin, mainly when prescribed in high doses. The physician may instruct the client to take an aspirin to offset the flushing sensation.

The nurse has provided discharge instructions to a client who was prescribed niacin. Which of the following statements, if made by the client, would indicate effective teaching? A. "This medication may increase my blood pressure." B. "I may experience flushing while taking this medication." C. "This medication may raise my total cholesterol." D. "I may feel fatigued and tired after taking this medication."

A - This image demonstrates hypertrophic pyloric stenosis; hypertrophy of the circular muscles of the pylorus. This causes the narrowing of the pyloric canal and does not allow food to pass from the stomach to the duodenum. The symptoms that this infant presents with are a classic presentation of pyloric stenosis. This is what the nurse expects the surgeons to find when they operate.

The nurse in a busy pediatric ER is evaluating a 1-month-old infant who presents with the following symptoms: projectile vomiting after feeding, visible peristaltic waves across the epigastrium, and an olive-shaped mass in the epigastrium just right of the umbilicus. Choose the image that matches the anatomy expected in this case.

Choices D and E are correct. The nurse should always inform the client of the reason for being placed in the restraint and what behavior needs to be demonstrated to terminate the restraints. It is appropriate for the nurse to ensure two fingers can be placed under each restraint as this verifies that it will not cause damage to the client's skin.

The nurse is applying soft wrist restraints to a client who is violent towards the nursing staff. Which actions by the nurse are appropriate? Select all that apply. - Places a pair of scissors at the bedside for emergent discontinuation. - Positions the client supine after applying both wrist restraints. - Releases both restraints at the same time, every two hours. - Informs the client of the behavior necessary to demonstrate to end the restraints. - Ensures two fingers can be placed under each restraint.

Choices B, C, and D are correct. Alcoholism causes diuresis, which lowers serum magnesium levels. Additionally, chronic alcoholism impairs the absorption of magnesium. Anorexia nervosa is a psychiatric illness where the individual eats very few calories that causes electrolyte disturbances such as low potassium, magnesium, and sodium. All of which may be life-threatening. Diarrhea causes a depletion of all electrolytes, which would appropriately explain the low magnesium levels.

The nurse is assessing a client who was admitted four hours ago with hypomagnesemia. Which of the following findings should the nurse recognize as a common cause of hypomagnesemia? Select all that apply. Renal failure Alcoholism Anorexia nervosa Diarrhea Hypothyroidism

Choice B is correct. Individuals who binge eat are more likely to have depression (and/or anxiety) than those who do not. Therefore, following this client admitting to binge eating, the nurse should screen this client for depression and suicidal ideation. Depression associated with the binge-eating disorder could be linked to their body image; however, other causes may be evident.

The nurse is assessing a client with a binge eating disorder. The nurse understands which other comorbidity is commonly found with this disorder? A. Disorganized behavior B. Depression C. Fear of abandonment D. Perfectionism

Choices A, D, and E are correct. A client presenting with DKA will have signs and symptoms of dehydration that range from mild to severe. Tachycardia is a common finding in DKA because of the fluid volume deficit. This, in turn, causes a client to have a thready pulse. Orthostatic hypotension is also a common finding because of dehydration.

The nurse is assessing a client with diabetic ketoacidosis (DKA). Which of the following would be an expected finding? Select all that apply. Thready pulse Jugular venous distention (JVD) Coarse tremors Tachycardia Orthostatic hypotension

Choices A, C, and D are correct. Hepatitis A produces an array of symptoms that usually last for 28 days. The symptoms have an abrupt onset and include nausea, vomiting, abdominal pain, fever, anorexia, dark urine, scleral icterus, pale stools, jaundice, and pruritus.

The nurse is assessing a client with hepatitis A. Which of the following would be an expected finding? Select all that apply. Pruritus Bloody stools Abdominal pain Scleral icterus Periumbilical bruising

Choices A and E are correct. Diltiazem is a rate lowering calcium channel blocker used in the management of atrial fibrillation. This medication assists in maintaining rate control. While not always indicated, an anticoagulant such as warfarin or rivaroxaban is used in the management of atrial fibrillation as this arrhythmia puts the patient at high risk for a stroke.

The nurse is caring for a client diagnosed with atrial fibrillation. The nurse should anticipate a prescription for which of the following medications? Select all that apply. Diltiazem Nitroglycerin Clonidine Atorvastatin Warfarin

Choice B is correct. A client experiencing an adrenal crisis (Addisonian crisis) tends to have significant hypovolemia and hyponatremia. Because of the deficiency of steroid hormones, distributive shock may follow. Restoring the circulatory volume is essential in the management of this crisis. Isotonic solutions such as 0.9% saline or D5NS ( dextrose 5% in water combined with 0.9% saline) must be used. Isotonic saline can address both hypovolemia and hyponatremia in the adrenal crisis. If there is concomitant hypoglycemia, the D5NS solution is preferred to increase the glucose, sodium, and circulatory volume.

The nurse is caring for a client experiencing an adrenal crisis (Addisonian crisis). The nurse should be prepared to administer which intravenous fluid? A. Lactated Ringers (LR) B. 0.9% saline C. Dextrose 5% in water (D5W) D. Dextrose 5% in water and Lactated Ringers (D5LR)

Choice B is correct. In clients with COPD, there is a loss of elastic recoil in the lungs leading to hyperinflation of the lungs, as seen on chest x-ray. Prolonged hyperinflation of the lungs causes barrel chest in COPD clients.

The nurse is caring for a client hospitalized due to acute chronic obstructive pulmonary disease (COPD) exacerbation. What assessment finding would the nurse expect to find? A. ABG showing a carbon dioxide level of 31 mmHg. B. An overinflated chest on chest x-ray. C. Improving oxygen saturation upon exercise. D. A wide diaphragm on chest x-ray.

Choice B is correct. This strip indicates a late deceleration. Late decelerations are visually apparent and usually symmetric in shape, with a gradual decrease and return of the fetal heart rate (FHR) to baseline. Late decelerations are caused by decreased perfusion to the fetus. Maternal repositioning is an effective intervention for this nonreassuring pattern. Other interventions include oxygen administration and the administration of intravenous isotonic fluids.

The nurse is caring for a client in labor. The following tracing was on the fetal heart rate monitoring strip. The nurse recognizes that this tracing is a See the exhibit. View Exhibit A. variable deceleration. B. late deceleration. C. early deceleration. D. normal variability pattern.

Choice A is correct. Bupropion is an antidepressant medication that may be used for clients with major depressive disorder (MDD).

The nurse is caring for a client receiving bupropion. Which of the following findings would indicate a therapeutic response? A. A decrease in depressive symptoms B. A decrease in manic symptoms C. A decrease in delusions D. A decrease in alcohol cravings

Choice A is correct. Caring for a client who is Native American requires the nurse to be culturally competent and sensitive. One of the cultural norms is avoiding direct eye contact, as excessive eye contact may be seen as disrespectful.

The nurse is caring for a client who is a Native American. Which of the following actions would be necessary for the nurse to take? A. Avoid excessive direct eye contact B. Ensure that the nurse is of the same gender C. Refer healthcare decisions to the male D. Allow time for meditation to a shrine of Buddha

Choice D is correct. A client experiencing psychosis does not exhibit a rational thought process and may have impaired reality testing. If the client is paranoid, the nurse should attempt to understand the paranoia as the patient has likely misconstrued an action.

The nurse is caring for a client who is experiencing psychosis. The client states, "You all are trying to kill me!" Which of the following responses would be most appropriate for the nurse to make to the client? A. "What you are experiencing is not real." B. "Are you hearing voices?" C. "You are safe here, please be calm." D. "What makes you think we are trying to kill you?"

Choices B, C, are D are correct. Olanzapine is a second-generation antipsychotic (SGA). SGAs such as olanzapine and clozapine have a high risk of causing a client to develop metabolic syndrome. Metabolic syndrome includes hyperglycemia, overweight or obesity, abdominal obesity, hyperlipidemia, and hypertension. Olanzapine and clozapine are implicated in causing some of the worse metabolic effects.

The nurse is caring for a client who is receiving prescribed olanzapine. Which findings would indicate that the client has an adverse effect from this medication? Select all that apply. Weight loss Hyperglycemia Weight gain Hyperlipidemia Nystagmus

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.

The nurse is caring for a client with a sodium level of 130 mEq/L(135-145 mEq/L). Which of the following medications may cause this abnormality? Select all that apply. Spironolactone Hydrochlorothiazide Prednisone Sodium polystyrene Tolvaptan

Choices B, C, and D are correct. Sodium polystyrene is a medication that causes potassium to be excreted in the feces. This lowers the amount of potassium in circulation and is an appropriate treatment for hyperkalemia. Regular insulin is a standard and effective treatment for hyperkalemia. The standard dose is ten units given by intravenous push. Hemodialysis is an appropriate treatment for hyperkalemia. Hemodialysis can remove potassium from the blood.

The nurse is caring for a client with hyperkalemia. Which of the following treatments would the nurse recognize as appropriate options for treating this electrolyte imbalance? Select all that apply. - Spironolactone - Sodium polystyrene - Regular insulin - Hemodialysis - Magnesium sulfate

Choice D is correct. A client receiving oxygen via a non-rebreather is receiving approximately 80%-95% Fio2. This is concerning if the best oxygen saturation is 92% and may warrant more aggressive measures to improve oxygen saturation. The client receiving this type of supplemental oxygen device should have a much higher oxygen saturation.

The nurse is caring for a group of clients. It is a priority to follow up on which client situation? A client A. admitted with an asthma exacerbation that is wheezing while receiving albuterol via nebulizer. B. admitted with pulmonary emphysema who puts on their nasal cannula oxygen before eating. C. with pneumonia is ambulating around the nursing unit while wearing a surgical mask. D. receiving oxygen via nonrebreather and has an oxygen saturation of 92%.

Choice D is correct. A newborn is at risk of cold stress during the first few hours of post-intrauterine life. The nurse should dry the newborn thoroughly and place the newborn skin-to-skin with a parent.

The nurse is caring for a newborn immediately after delivery. Which of the following actions would be appropriate? A. Perform APGAR assessment at five and ten minutes B. Suctions the nose then the mouth C. Administer RhoGAM intramuscularly D. Place the infant skin to skin with a parent

Choice B is correct. The subjective symptoms reported by the client may indicate impaired circulation, deep vein thrombosis (DVT), thrombophlebitis, or another surgical or post-surgical complication. The client's verbalized complaint and post-surgical status align with the symptoms and risk factors for a DVT. Although there is no evidence that early activity increases the risk of clot dislodgement and pulmonary embolism and may help to reduce the risk of postphlebitic (post-thrombotic) syndrome, ambulation should not be encouraged in this client until the cause of the client's symptoms has been confirmed by the PHCP, as no diagnostic testing or imaging has been performed at this time. The next action for the nurse is to instruct the client to remain in bed (to ensure the client is safely situated) before contacting the PHCP to alert them of the assessment findings.

The nurse is caring for a post-operative client two days following abdominal surgery. Upon assessment, the client reports a dull ache in their right calf with a "funny feeling" in the toes. What should the nurse do next? A. Elevate the client's legs by placing a pillow underneath the ankles and tell them to drink more water. B. Tell the client to stay in bed and contact the primary health care provider (PHCP) to report the assessment findings. C. Instruct the client to rub or massage their legs to stimulate blood flow. D. Encourage the client to ambulate and educate them on the dangers of prolonged bed rest.

Choice A is correct. For a preschooler experiencing pain resulting from a tonsillectomy, give the child a "magic" blanket to take the pain away. Preschoolers are magical and mystical thinkers, so this "magic" blanket may be an effective pain management technique for children of this age.

The nurse is caring for a preschooler following a tonsillectomy. Which intervention would be appropriate for the nurse to implement? A. Place a "magical" blanket on the client to take the pain away. B. Offer hot soup in the toddler's favorite cup C. Provide the client with privacy so they are not embarrassed about crying. D. Assist the client in developing better coping skills for their pain.

Choices A, B, and D are correct. Risk factors for testicular cancer include cryptorchidism, human immunodeficiency virus (HIV), and family history. Cryptorchidism (Choice A) refers to undescended testicle where the testicle fails to descend to its normal position in the scrotum. Undescended testicles are associated with decreased fertility, testicular torsion, inguinal hernias, and an increased risk of testicular germ cell tumors. HIV-positive ( Choice B) men are more likely to develop testicular cancer. Family history (Choice D) of testicular cancer is another risk factor, with 8-10 times increased risk if the man has a sibling with testicular cancer.

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing testicular cancer? Select all that apply. Cryptorchidism Human immunodeficiency virus (HIV) Vasectomy Family history Herpes simplex virus (HSV)

Choices B, C, and D are correct. Naltrexone, Methadone, and Buprenorphine are three agents approved for the management of opioid use disorder. These medications have various mechanisms of action. Naltrexone is an opioid receptor antagonist and may be administered as a single dose injection. Buprenorphine is a partial agonist and is available in preparations such as sublingual tablets or film. Methadone is a full agonist that may be used daily. It is dispensed in a supervised setting.

The nurse is counseling a client with opioid use disorder. Which of the following medications may be used to treat this disorder? Select all that apply. Selegiline Naltrexone Methadone Buprenorphine Bupropion

Choice C is correct. Anticholinergic medications (atropine, scopolamine) can increase intraocular pressure (IOP) and worsen the condition of clients with glaucoma. Anticholinergic agents also have the potential to produce central side effects in adults, such as confusion, an unsteady gait, or drowsiness. Other classes of medications, such as tricyclic antidepressants and antihistamines, also have anticholinergic side effects and should be avoided in glaucoma.

The nurse is educating a client with glaucoma. Which of the following classifications of medications should the nurse instruct the client to avoid? A. Osmotic diuretics B. Beta-adrenergic blockers C. Anticholinergics D. Alpha-2 adrenergic blockers

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

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

Choice B is correct. For a client experiencing suicidal ideations, safety is essential. The nurse should make ensure that the environment is safe by locking any cabinet doors because by locking the cabinet doors, the client will not be able to access client care equipment that could potentially be used to harm themselves. The nurse should also inspect their belongings to make sure nothing harmful is present.

The nurse is establishing a care plan for a client with suicidal ideations. The priority for the nurse when caring for the client is to A. maintain a therapeutic rapport. B. ensure that the room is secure by locking cabinet doors. C. obtain a prescription for an antidepressant. D. planning appropriate group therapy sessions.

Choice A is correct. This is an accurate statement by the client. The client should be taught how to attach the pouch properly onto the stoma. The pouch should allow only 1/16 to 1/8 of an inch of room around the stoma. The client needs to understand that if the bag does not fit well, it can cause skin breakdown from contact with feces while allowing for passage of effluent through the stoma.

The nurse is explaining the different aspects of ostomy care to a client with a newly created ileostomy. Which statement from the client indicates an understanding of the nurse's teaching? A. "I need to cut the pouch to fit the stoma, allowing one-sixteenth of an inch of room around it." B. "I must avoid eating spinach, parsley, and yogurt." C. "I need to drink at least 800 mL of water daily." D. "I can eat a large meal during dinner."

Choice D is correct. Evidence shows that adequate folate intake before conception and in the first trimester of pregnancy reduces the incidence of neural tube defects. Folic acid (vitamin B9) works with vitamins B12 and C to help the body break down, use, and make new proteins. The vitamin helps form red and white blood cells. It also helps produce DNA, the building block of the human body, which carries genetic information. Groups of people considered at-risk for folate deficiency include women who are pregnant, women who wish to become pregnant, alcoholics, liver disease and dialysis patients, as well as breastfeeding mothers.

The nurse is participating in a community health fair. Which client has the greatest risk for folate deficiency? A. An 80-year-old man living in a nursing home B. A 4-year-old boy who is developmentally delayed C. A 16-year-old girl who just started her menstrual cycle D. A 25-year-old woman who is attempting to get pregnant

Choice C is correct. The infection control measure that must be initiated is airborne transmission precautions because the mode of transmission for rubeola, or measles, is airborne. This type of transfer occurs when the pathogen is carried in dust or droplets and remains in place for enough time to infect a person exposed to this air. Airborne precautions require the client to be placed in a room with negative airflow. Healthcare staff should don a respirator or N95 mask prior to entering the client's room. The door should remain closed. Do not confuse rubeola with rubella. Rubeola (measles) requires airborne precautions, whereas rubella requires droplet precautions.

The nurse is planning care for a child admitted with Rubeola. Which infection control precautions should the nurse implement? A. contact transmission precautions B. droplet transmission precautions C. airborne transmission precautions D. no isolation precautions

Choice C is correct. Establishing a therapeutic environment that involves privacy is essential to ensuring the client feels comfortable discussing their current health status. The nurse has an obligation to protect client confidentiality by having the necessary safeguards in place.

The nurse is planning to interview a client interested in establishing care with a primary healthcare provider (PHCP). The nurse should initially A. obtain the client's vital signs. B. identify the client's chief complaint. C. provide a private area for the interview. D. inquire about the client's allergies.

Choice B is correct. Although the side effect of a brief headache is a self-limiting manifestation that usually resolves without any specific treatment, a headache lasting several days is cause for concern. A headache lasting for "several days" is not an anticipated side effect following the administration of contrast media, and the nurse would not educate the client that this is anticipated. More specifically, the duration of the headache is the primary concern in this instance.

The nurse is preparing a client for angiography using contrast media. Which of the following side effects should the nurse educate the client is not an expected side effect? A. Sudden nausea B. A headache lasting several days C. A feeling of facial flushing D. Sudden urge to urinate

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

The nurse is preparing a client for the insertion of a subclavian central vascular access device. To reduce the client's risk for an air embolism, the nurse places the client in which position? See the images below.

Choices A, B, and C are correct. Assault is a threat or an attempt to do bodily harm. This may include verbal or gestures intended to cause intimidation. Battery is intentionally touching another's body without the other's consent. An example of battery is threatening to give a client an injection without the client's consent, if the nurse gives the injection, this would be battery. Unintentional torts, including negligence or malpractice.

The nurse is reviewing leadership and management concepts with a student nurse. The student nurse demonstrates understanding if they made which of the following statements? Select all that apply. - "Battery is an intentional touching of another's body without the other's consent." - "Assault is when the nurse makes a verbal or physical threat." - "Unintentional torts include negligence and malpractice." - "Defamation is presenting false credentials for employment." - "Occurrence reports reduce the liability for a negligent tort."

Choices A, B, & C are correct. These statements are incorrect regarding changes in the older adult and, therefore, require follow-up by the supervising nurse. Older adults commonly experience a loss of acuity for high-pitchedfrequencies (presbycusis) due to changes in the inner ear, such as sclerosis (Choice A). Glare sensitivity is increased, not decreased. As adults age, changes in the eye, such as smaller pupils and reduced light accommodation, can result in increased sensitivity to glare (Choice B). Age-related changes in the ear also include thickening the tympanic membrane rather than increased flexibility (Choice C).

The nurse is supervising a new nurse caring for an elderly client. Which of the following statements regarding sensory changes in an older adult, if made by the new nurse, would require follow-up? Select all that apply. - "Older adults have an increased acuity for high-pitched tones." - "Older adults have a decreased sensitivity to glare." - "Older adults have an increased tympanic membrane flexibility." - "Older adults have a diminished sound discrimination." - "Older adults have a decreased taste sensation."

Choice A is correct. The nurse would believe that the NG tube is correctly placed if the aspirate shows a pH below 5.5. Stomach contents should be acidic ( a pH less than 5.5). 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. 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.

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

Choice B is correct. Increasing one's exercise would decrease insulin requirements in a client with type I diabetes, as exercise causes the client's blood glucose to decrease. While exercising, muscles require more glucose, and any circulating insulin present becomes more efficient in lowering glucose. Exercise has a variable effect on blood glucose, depending on the timing of exercise in relation to meals and the duration, intensity, and type of exercise. In clients with type 1 diabetes, exercise can lead to hypoglycemia. Therefore, the client's blood glucose should be monitored immediately before and after exercise. The target range for blood glucose prior to exercise should be between 90 mg/dL and 250 mg/dL (5 mmol/L to 14 mmol/L). Clients who experience hypoglycemic symptoms during exercise should be advised to test their blood glucose and ingest carbohydrates or reduce their insulin dose as needed to get their glucose slightly above normal just before exercise.

The nurse is teaching a client about diabetes mellitus type I and exercise. Which statement, if made by the nurse, would be appropriate? A. Increasing exercise would increase insulin requirements B. Increasing exercise would decrease insulin requirements C. Insulin needs do not change with exercise D. Decreasing exercise would decrease insulin requirements

Choices A and B. Hypercalcemia can occur in various conditions such as primary hyperparathyroidism, malignancies, milk-alkali syndrome, medications, vitamin D toxicity, and sarcoidosis. Symptomatic hypercalcemia can lead to constipation, psychosis, polyuria, and dehydration. Clients with hypercalcemia should take some dietary precautions to reduce calcium intake. Broccoli is rich in calcium and should therefore be avoided in clients with hypercalcemia. Milk is rich in calcium and should therefore, be avoided in clients with hypercalcemia. Choice E. Vitamin D is one substance that, along with parathyroid hormones, regulates a person's calcium levels. Several kinds of seafood are rich in Vitamin D and should be avoided if hypercalcemia is a concern.

The nurse is teaching a client with hypercalcemia appropriate dietary measures. Which food selections by the client would require follow-up by the nurse? Select all that apply. broccoli 2% milk whole wheat pasta bananas seafood

Choice B is correct. Continuous quality improvement continually assesses and evaluates the effectiveness of client care.

The nurse manager regularly performs chart audits and room inspections in the unit. She tells the staff to address the unit's deficiencies during a meeting. Which concept of management is the nurse manager displaying? A. Benchmarking B. Continuous Quality Improvement C. Performance Improvement D. Quality Management

Choices A and D are correct. Food items that are soft, not hot, non-acidic, and do not have jagged edges are permitted to consume following a tonsillectomy. Items such as ice chips and applesauce are permitted.

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

Choice A is correct. Increased epinephrine levels are secreted during a major burn to reduce bleeding and fluid loss. Choice B is correct. Antidiuretic hormone is released in high levels to reduce bleeding and fluid loss. Choice C is correct. Aldosterone, released by the adrenal cortex, is released at high levels to reduce fluid loss. Aldosterone causes sodium retention (which in turn causes water retention) and potassium elimination. Choice E is correct. The adrenal glands release norepinephrine in response to a major burn, which causes vasoconstriction, thereby increasing fluid and blood volume.

The nurse reviews the pathophysiology of burns with students. It would be correct to state which hormone alterations occur during a major burn. Select all that apply. - Increased secretion of epinephrine - Increased secretion of antidiuretic hormone (ADH) - Increased secretion of aldosterone - Decreased levels of glucose - Increased secretion of norepinephrine

Choice C is correct. An incident (sometimes termed an event or occurrence) report is completed for situations such as a client fall, medication error, visitor fall, assault from a visitor (or client), accidental discarding of client property, and a delay in care. The report is the facility's property and should not be directly mentioned in the client's medical record or nursing notes. If the record went to court, the incident/event report would be discoverable if directly referenced in the client's medical record.

The nurse supervising a graduate nurse completes an incident report regarding a client who fell. Which of the following actions by the graduate nurse requires follow-up? A. Documents an objective description of what happened B. Indicates that a 2-inch laceration was present on the client's scalp C. Documents in the nursing note that an incident report was completed D. Notes the follow-up actions taken

Choice B is correct. Autonomic dysreflexia is a severe, life-threatening condition that can occur secondary to a spinal cord injury. In response to noxious stimuli such as full bladder, line insertion, or fecal impaction, the body mounts an exaggerated sympathetic response that causes bradycardia, hypertension, facial flushing, and headache. If left untreated, autonomic dysreflexia can cause cerebral hemorrhage, pulmonary edema, and seizures. Treatment is focused on removing the underlying noxious stimuli.

The nurse suspects a patient on the neurological floor is experiencing autonomic dysreflexia. What action should the nurse perform first? A. Administer sublingual nitroglycerin. B. Elevate the head of the bed. C. Obtain a residual volume reading with a bladder scan. D. Perform a digital examination to assess for the presence of stool.

Choice B is correct. Ensuring that the client meets the admission criteria of the external healthcare setting or service is crucial to facilitate a smooth transition of care. Admission criteria may vary among facilities or services, and the client's eligibility should be assessed to prevent delays or complications in the referral process.

The nurse, when referring a client to a healthcare setting or service extterm-127ernal to their current healthcare setting, must prioritize what specific aspect of the transition of care 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.

Isoniazid

The physician diagnoses the client with pulmonary tuberculosis. Which prescription should the nurse anticipate? Isoniazid Acyclovir Amphotericin B Metronidazole

Choice C is correct. Family members can become frustrated when clients with Alzheimer's disease lose short-term memory. The nurse should explain to the family member that it's the "short-term memory" that is declining and encourage the client to talk about things that he/she can remember

The son of a client with early Alzheimer's disease states, "I'm so tired of hearing Dad talk about the past all the time." What is the nurse's best resterm-48ponse? A. "You should be more patient with your father and accepting of his disease." B. "He is quite anxious at this stage. Reliving the past helps him become calm again." C. "He has lost his short-term memory but can still remember events from long ago." D. "Just remind him when he repeats himself and that will reinforce better behavior."

Choice A is correct. After informing the client's wife that she " . . . should not warm up the car in the garage because it is hazardous," you would explain how a buildup of carbon monoxide would occur and why it be deadly. Based on her statement, the client's spouse demonstrated a knowledge deficit by telling you that she warms up the car in the garage. In response, you must address her knowledge deficit with client (or caregiver) education.

The spouse of your elderly male client tells you that her husband becomes so cold when he is outdoors that she warms up his car in the garage before helping him get into his car. How should you respond to her statement? A. "You should not warm up the car in the garage because it is hazardous." B. "That is a good idea, as your husband frequently complains about being cold." C. "You can also dress him in warmer clothing than needed so he is not cold." D. "That is the most foolish thing I have heard in a long time. You have to stop that."

Vital signs: the pulse is high (normal 110-160/minute; may go to 180/minute when crying). The temperature of 95.7°F (35.3°C) is low (normal 36.5°-37°C [97.7°-98°F]). The infant has tachypnea (normal respiratory rate 40-60/minute). These findings strongly suggest cold stress. Neuromuscular: floppy, poor head control; hypotonic movement in all extremities is abnormal. The expected finding would be the extremities in some degree flexion with good muscle tone. The infant should be able to turn their head from side to side when prone. Hypotonia may suggest hypoglycemia which could be potentially caused by cold stress. Eyes: the eyes should have a positive pupillary and corneal reflex. It is normal for the lids to be edematous for 2 days after birth. The red reflex should be positive. The red reflex is the reflection of light on the vascular retina. The absence of the red reflex may indicate glaucoma, retinal abnormality, retinoblastoma, or cataracts. Skin: generalized cyanosis is a concerning finding for cold stress. The expected integument finding is bright red, puffy, smooth, and some facial edema. The presence of vernix caseosa (a white, oily substance that coats the term infant's body

Vital signs Pulse 184/minute; Temperature of 95.7°F; Respiratory rate 65/minute Head 33 cm head circumference; flat and soft fontanels; symmetrical in shape Eyes Positive corneal and pupillary reflex; negative red reflex Cardiovascular S1 and S2 heart tones present; regular rhythm; femoral pulses palpable Lungs Abdominal respirations; clear lung sounds bilaterally; absent cough reflex Neuromuscular Floppy, poor head control, hypotonic movements in all extremities Abdomen Cylindric in shape; no meconium stool; normoactive bowel sounds Skin Generalized cyanosis; vernix caseosa present in skin folds; lanugo present on back Cry Weak, jittery cry

Choice C is correct. The priority nursing intervention for a newly admitted client with the possible nursing diagnosis of "self-care deficit: bathing and hygiene" is thoroughly assessing the client's self-care strengths and weaknesses. Once the client's self-care strengths and weaknesses are known, a thorough assessment of the client's bathing and hygiene preferences may occur. Following these assessments, bathing and hygiene needs may be met by the nurse directly helping the client, use of unlicensed assistive personnel (UAP), or asking a friend or family member to assist the client with the bathing or hygiene needs.

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

Pulmonary tuberculosis

Which problem is the client most likely experiencing? Influenza Pulmonary tuberculosis Pneumothorax Pleurisy

- Five-day history of severe diarrhea - End-stage renal disease (ESRD) - Diabetic ketoacidosis (DKA)

X

Choice A is correct. This client with chronic pancreatitis and gastroparesis is complaining of a migraine headache. Butorphanol is available in the oral form, transnasal form, transdermal, and parenteral form. The doctor has ordered butorphanol orally as needed for pain, but you would call the doctor and suggest transnasal butorphanol because the client has gastroparesis.

Your client, who has chronic pancreatitis and gastroparesis, is complaining of a migraine headache. The doctor has ordered butorphanol orally as needed for pain. What would you do? A. Call the doctor and suggest transnasal butorphanol because the client has gastroparesis. B. Call the doctor and suggest rectal butorphanol because the client has pancreatitis. C. Administer the butorphanol orally as ordered. D. Administer the butorphanol transdermally for pain.

"Let's discuss some options for notifying your sexual partners."

x

52-year-old Native American high blood pressure high cholesterol He has a body mass index of 28

52-year-old Native American male presents to the clinic to establish primary healthcare. The client has a medical history of testicular cancer that was treated when he was 24. He also was told he had high blood pressure and high cholesterol two years ago but never followed up with treatment. He has a body mass index of 28 He drinks one glass of red wine three times a week and stopped smoking cigarettes one year ago.

Choice D is correct. This response by the nurse encourages verbalization of the client's feelings and is an example of therapeutic communication. This communication technique prioritizes the client's physical, mental, and emotional well-being. Therefore, this is the most therapeutic and appropriate response the nurse should make to this client.

A client is upset because they just found out that they have syphilis. The client tells the nurse, "This is so upsetting! Does everyone need to know?" Which of the following responses, if made by the nurse, is the most therapeutic? A. "We need to report this diagnosis to the local public health department, and they will contact your past partners." B. "According to the Health Insurance Portability and Accountability Act (HIPAA), I can't tell anyone without your permission." C. "You really should contact your sexual partners so they can be treated too." D. "I understand you're upset. I'll stay here with you so that you can talk about it."

Choice B is correct. The Nurse Practice Act describes the scope of nursing practice. It directs the philosophy and standards of nursing. The formulation of policies and procedures should be based on this document. Each NPA varies from state to state. Each state legislature sets the NPA.

A mental health clinic is being constructed in a local community. A nurse manager is hired to facilitate the unit's nursing policies. Which of the following is the best resource for these policies? A. Code of Ethics B. Nurse Practice Act C. Patient's Bill of Rights D. Rights for the Mentally Ill

Choice D is correct. The nurse should place the client in Semi-Fowler's position with his extremities relaxed and straightened, as clients in a sickle cell crisis should be positioned to optimize circulation and oxygenation.

A middle-aged client is being treated in the emergency department (ED) for an acute sickle cell crisis. Which of the following should the nurse use when positioning the client to facilitate oxygenation and adequate circulation? A. Side-lying with flexed knees B. Fetal position C. Semi-Fowler's position with knees and hips bent D. Semi-Fowler's with legs extended on the bed

Choice C is correct. This statement is false and requires follow-up. A vegan diet may be continued during pregnancy if the woman is methodical in her food choices. The concern with vegan diets is the consumption of complete proteins. However, evidence has indicated that plant proteins can meet pregnancy needs.

A nurse is conducting a prenatal class. Which statement, if made by a client, would require follow-up? A. "Since my body mass index is normal, I should be gaining 25-35 pounds." B. "It will be okay for me to continue using sugar substitutes, such as sucralose." C. "Since I am pregnant, I will have to abandon my vegan diet." D. "I will need to keep my caffeine intake less than 200 mg/day."

Choice A is correct. The client's use of over-the-counter antacids such as Alka-Seltzer places the client at risk of developing metabolic alkalosis due to the high amount of sodium bicarbonate present in this medication. If the client uses the medication too frequently, the client's HCO3 level can increase, resulting in metabolic alkalosis.

A nurse is taking the health history of an 87-year-old client and asks for a list of current medications. The client lists lisinopril, digoxin, Tums, and Alka-Seltzer. Which of the following acid-base imbalances is this client at the highest risk of? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Respiratory alkalosis

Choice C is correct. A central concept of patient advocacy is ensuring that the patient's decisions are based on sufficient information and understanding while supporting the patient's right to exercise autonomy.

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

Choice B is correct. The patient is not allowed to put lotion or powder inside the cast or very close to it as it may be sticky and cause skin irritation. This statement requires follow-up and further instructions by the nurse (therefore, this is the correct answer to the question).

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

- Increased susceptibility to infection - Weight gain - Insomnia - Blood glucose elevation

A nurse at a community clinic is taking care of a 34-year-old patient who has been prescribed oral prednisone to treat respiratory issues. What education should the nurse include concerning the possible side effects of this medication? Select all that apply. - Increased susceptibility to infection - Weight gain - Insomnia - Blood glucose elevation - Increased urine output

Choice B is correct. Serotonin syndrome is a potentially life-threatening condition resulting from increased central nervous system serotonergic activity. Serotonin syndrome is often characterized by muscle rigidity, hyperthermia, autonomic hyperactivity, and altered mental status. Upon noticing these symptoms, the nurse must report these symptoms to the health care provider (HCP) immediately to initiate medical intervention.

A nurse in the psychiatric unit is administering fluoxetine together with tranylcypromine. Following the co-administration of these two medications, the nurse should monitor the client for which symptoms potentially signifying an adverse reaction from administering the combination of these two medications? A. Low blood pressure and urinary retention B. Muscle rigidity and hyperthermia C. Shortness of breath and pink, frothy sputum D. Weakness and diaphoresis

Choice B is correct. Metformin is an oral anti-diabetic indicated for type 2 diabetes mellitus. Metformin may cause renal impairment and a decrease in glomerular filtration rate (GFR) would be such evidence. During Metformin therapy, the client's renal function will be periodically monitored.

A nurse is caring for a client receiving metformin. Which of the following laboratory data should be reported to the provider? A. Decreased blood urea nitrogen (BUN) level B. Decreased glomerular filtration rate (GFR) C. Decreased fasting plasma glucose D. Decreased hemoglobin A1C

Choice A is correct. The nurse should replace the IV tubing as the existing tubing has now been contaminated and places the client at increased risk for systemic infection due to direct infusion into the bloodstream.

A nurse is preparing a client's intravenous (IV) infusion. As the nurse was preparing to attach the distal end of the IV tubing to the client's needleless access device, the exposed tubing slipped and hit the top of the client's bedside table. Which of the following is the most appropriate action by the nurse? A. Replace the IV tubing with new tubing B. Discard the client's current needleless access device and replace it with a new one C. Wipe the distal end of the tubing with povidone-iodine to render it sterile D. Clean the needleless access device with an alcohol swab

Choice B is correct. Digoxin and furosemide increase renal perfusion when taken together, leading to potassium loss. The client should be educated and instructed to monitor serum electrolyte levels (most notably the serum potassium) at designated intervals.

A nurse is preparing for the discharge of a client with heart failure. Upon review, the nurse notes that the client has been prescribed digoxin and furosemide. Which of the following laboratory tests must the client have monitored due to this combination of prescribed medications? A. Fecal occult blood B. Serum electrolytes C. Urinalysis D. Glycosylated hemoglobin

Choice D is correct. When administering magnesium sulfate, the nurse should monitor the client for respiratory depression. Magnesium toxicity can lead to respiratory paralysis, central nervous system depression, and cardiac arrest. If respiratory depression or another sign of magnesium toxicity is noted, the antidote is calcium gluconate, one gram, infused intravenously over two minutes.

A preeclamptic client, currently in the 38th week of pregnancy, was admitted and given magnesium sulfate to prevent seizures. The nurse understands that this client should be monitored for: A. Blurring of vision B. Tachypnea C. Pain in the epigastric region D. Respiratory depression

Choice A is correct. The submersion in water led to the client's respiratory impairment, resulting in an inability to oxygenate the client's tissues and organs. Anticipated findings for this client include hypoxia (decreased oxygen levels in the blood), hypercarbia (increased carbon dioxide levels in the blood due to hypoventilation), and acidosis due to the body's prolonged inability to oxygenate tissues and organs. Aspirated fluid can lead to surfactant washout and dysfunction, increased alveolar-capillary membrane permeability, decreased lung compliance, and ventilation/perfusion ratio mismatching, all of which contribute to the nurse's anticipated assessment findings in this client.

An emergency department (ED) nurse is caring for a client who suffered from a non-fatal drowning at a local beach. Which of the following assessment findings would the nurse anticipate? A. Hypoxia, hypercarbia, and acidosis B. Coma, hyperthermia, and alkalosis C. Hypothermia, hypocapnia, and alkalosis D. Hyperthermia, hypoxia, and acidosis

Choice D is correct. Children between birth and three years of age have the highest incidence of victimization. The current rate is approximately 16 in 1,000 children. Also, the impact is higher in girls than in boys. Child abuse crosses all cultures, ages, economic levels, races, and religions, but is most prevalent in families living in poverty and those families composed of adolescent parents with young children. Nurses should never make assumptions about certain groups being at higher risk for child abuse but rather should be aware that social, economic, and personal stressors can contribute to the incidence of child abuse. Acts of commission in child abuse are situations in which the responsible person, often the parent, intentionally harms the child via physical, emotional, or sexual abuse. Acts of omission in child abuse are situations in which a parent or caregiver, to their best of abilities and often inadvertently, cannot provide adequate nutrition, shelter, warmth, appropriate seasonal clothing (e.g. winter coats), safety, and education for his or her child. Both are considered significant categories of child abuse, and situations identified in both groups must be reported. Th

In which age group is child abuse most likely to occur? A. Ten-years-old or older B. 6-10 years old C. 4-6 years old D. Birth-3 years old

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.

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."

Choice C is correct. A plaster cast should be kept clean and dry. The client stated that he could shower with the cast, which requires follow-up. The only way a client should shower with this particular cast would be with a waterproof bag affixed over the cast. If that is not available, and the client has a fractured arm, they should take a bath and keep the affected extremity outside the tub.

The nurse educates a client about the application of a plaster cast to a fractured radius. Which of the following statements by the client would require follow-up? A. "If my arm feels itchy, I can use a hair dryer on the cool setting for relief." B. "I can reduce my arm's swelling by elevating it with a pillow." C. "I should be okay to shower with my cast." D. "It will be normal for me to feel heat after the cast is applied."

Choice A is correct. This is an incorrect nursing intervention and, therefore, the correct answer to this question. For clients with deep partial-thickness and/or full-thickness burns, opioids (e.g., morphine sulfate) are the class of medication used to control pain. Opioid pain medication should be administered intravenously to the client at least 30 minutes before any dressing change.

The nurse in the burn unit is preparing to perform a dressing change on a client with deep partial-thickness and full-thickness burns. The nurse understands that minimizing the client's pain during the dressing change is the top priority. All the following are appropriate nursing interventions, except: A. Administer a COX-2 inhibitor orally 30 minutes before the dressing change. B. Provide a clear explanation to the client about the procedure and how it will be performed. C. Changing the client's dressing carefully and handling burned areas gently. D. Let the client watch their favorite television show while dressing change is being performed.

Choice A is correct. This nurse has demonstrated an authoritative leadership approach by retaining authority and assigning roles to other staff nurses. This approach is useful in emergencies or crises as it minimizes confusion and improves clarity for the team. This leadership style may be viewed unfavorably if it is used frequently because it may erode the autonomy of members of the teams.

The nurse in the emergency department (ED) assembles a team of nurses to care for a client in cardiac arrest. The nurse is assigning various roles to each nurse and is demonstrating which management style? A. Authoritative B. Situational C. Democratic D. Laissez-faire

Choice C is correct. Fever, mydriasis, agitation, paranoia, hypertension, and tachycardia are all manifestations of amphetamine intoxication. Substances producing this type of intoxication include amphetamines, methamphetamines, and cocaine, a central nervous stimulant. When a client experiences amphetamine withdrawal, they are likely to experience hypersomnia, fatigue, increased appetite, and dysphoria.

The nurse in the emergency department (ED) is caring for a client experiencing agitation, anxiety, and hypertension. On assessment, the client has mydriasis and diaphoresis. The nurse suspects that this client may be intoxicated with which substance? A. Opioids B. Barbiturates C. Amphetamines D. Cannabis

Choice D is correct. Pain associated with pressure ulcers should be appropriately addressed, specifically with dressing changes. The nurse must provide adequate pain medications to the client before the dressing changes. Pressure ulcers (pressure injuries/ decubitus ulcers/ bed sores) are caused by prolonged pressure on an area of skin that leads to ischemia (reduced blood supply), skin breakdown, and underlying tissue injury. Usually, these occur over bony prominences. Depending upon the clinical appearance and the degree of damage, pressure-induced skin, and soft tissue injuries are staged from stage 1 to stage 4 and unstageable pressure injuries. Stage 3 and stage 4 ulcers are ulcers with full-thickness tissue loss. Management of these deeper injuries involves debridement and covering with appropriate dressings. Generally, pressure ulcers are very painful, and optimal pain medications (using the WHO analgesic ladder) should be administered to control pain. There is significant tissue damage in stage 3 and 4 ulcers; therefore, only a little or no pain may be experienced at the baseline. However, the pain may be worse than the baseline during dressing changes, even with stage 3 ulcers.

The nurse is about to change a dressing on an older man with a stage 3 pressure ulcer. What should be the nurse's first action? A. Gather all the necessary equipment. B. Use non-sterile gloves to remove the old dressing. C. Explain the procedure to the client immediately before dressing change. D. Check the medication record to see if pain medications were administered.

Choice D is correct. Peripheral neuropathy puts the client at increased risk for traumatic injury and tissue breakdown since the client may not notice early skin damage due to altered sensation. Of the options provided, educating the client on proper footwear is the only action that aims to prevent injury related to the client's altered sensation in the feet.

The nurse is assessing a client who reports intermittent tingling and numbness in bilateral lower extremities. Which intervention by the nurse would be most important to prevent injury for this client? A. Perform Semmes-Weinstein monofilament test B. Refer the client for a diabetic diet consult C. Obtain an order for Gabapentin D. Teach the client about appropriate footwear

Choice A is correct. Pain medication orders may be titrated based on the client's pain level. However, the nurse cannot adjust the physician's order based on the client's pain level. If the nurse wants to adjust the dosage, the nurse will need the physician to adjust the prescription.

The nurse is assisting a student nurse in developing a care plan for a client receiving morphine sulfate for chronic pain. Which of the following aspects in the plan of care require revision? A. Adjust the physician's order based on the client's pain level B. Ensure naloxone is always available C. Check the client's blood pressure before administering morphine sulfate D. Provide a high-fiber diet

Choice C is correct. Administering acetaminophen is the priority nursing action in this scenario. The question states that the patient has been febrile for 24 hours. It is the priority of the nurse to address this concern; the nurse can do so through the administration of the antipyretic acetaminophen.

The nurse is caring for a 1 year old client diagnosed with acute otitis media. The client is experiencing otalgia, has been febrile for 24 hours, and is pulling at his left ear. Which intervention is the priority nursing action? A. Position the child on his left side B. Administer antibiotic ear drops C. Administer acetaminophen as prescribed D. Apply a heat pack to the left ear

- Validate that the parents are competent to provide consent for the client - Witness the signature on the informed consent Choices C and D are correct. Since the client is 14, they are a minor, and their parents will be responsible for signing informed consent. The nurse is accountable for validating that the parents are competent to provide consent for the client (Choice C). The nurse will serve as the witness for the informed consent. This is one of the primary responsibilities of the nurse when a client is getting a procedure and signing a consent. The other primary responsibility will be to serve as the client's advocate and ensure that the parents have received sufficient information to make an informed decision. If they have not, the nurse must call the surgeon to return and speak further with the parents (Choice D).

The nurse is caring for a 14-year-old scheduled for an appendectomy. What is the nurse's role in obtaining informed consent before surgery? Select all that apply. - Informing the parents that only the surgeon may withdraw the surgical consent - Review the risks and benefits of the surgery with the parents - Validate that the parents are competent to provide consent for the client - Witness the signature on the informed consent - Make sure that the consent is witnessed by two healthcare professionals

Choices A, C, D, and E are correct. Albuterol is a short-acting bronchodilator indicated in treating asthma and other chronic respiratory illnesses. Side effects associated with this medication include hyperglycemia, tremors, hypokalemia, and nervousness. Albuterol can stimulate the beta-2 receptors in the salivary glands, which can cause a decrease in the production of saliva.

The nurse is caring for a client receiving albuterol via metered dose inhaler (MDI). Which of the following adverse/side effects of this medication would be expected? Select all that apply. - Tachycardia - Hypotension - Tremors - Dry mouth - Hyperglycemia - Bradycardia

Choice B is correct. If pneumonia is suspected, cultures may be taken via tracheal suctioning or bronchoscopy to establish the diagnosis and identify the causative organism. However, this strategy helps diagnose pneumonia and tailor the treatment against the specific causative organism but has no role in prevention.

The nurse is caring for a client receiving mechanical ventilation. Which of the following actions would not reduce the client's risk of ventilator-acquired pneumonia (VAP)? A. Performing oral care a minimum of every 2 hours. B. Obtain a specimen for culture via tracheal suctioning C. Elevate the head of the bed to 45 degrees D. Performing hand hygiene before and after suctioning

Choices A, C and F are correct. Dexamethasone is a corticosteroid indicated in treating asthma exacerbations, rheumatoid arthritis, or pulmonary emphysema. Like all corticosteroids, prolonged exposure and higher doses increase the risk for adverse effects such as immunosuppression, fluid retention (peripheral edema), hypertension, irritability, and insomnia.

The nurse is caring for a client receiving prescribed dexamethasone. Which of the following adverse reactions may occur? Select all that apply. - Infection - Hypotension - Peripheral edema - Hypoglycemia - Weight loss - Insomnia

Choices A, C, and D are correct. Sertraline is a Selective Serotonin Reuptake Inhibitor (SSRI). This medication is efficacious in depression, anxiety, and obsessive-compulsive disorders.

The nurse is caring for a client who has been prescribed sertraline. The nurse understands that this medication is prescribed for which of the following conditions? Select all that apply. - Major Depressive Disorder - Attention Deficit Hyperactivity Disorder - Obsessive-Compulsive Disorder - Generalized Anxiety Disorder - Bipolar Disorder

Choice B is correct. Denial is a coping mechanism used to protect a client from a traumatic experience. A client in denial will behave as though the trauma never occurred. Based on the available information this client is likely experiencing denial.

The nurse is caring for a client who has recently arrived at the emergency department after experiencing a very traumatic event. The client appears calm and in control. The nurse assesses this behavior as which of the following defense mechanisms? A. Projection B. Denial C. Rationalization D. Regression

Choice C is correct. The initial action is to assess the client for postpartum hemorrhage. The normal pad count after birth is one pad every two hours. If the client should exceed this, then the client should be assessed for postpartum hemorrhage.

The nurse is caring for a client who is six hours post-partum. The client informs the nurse that they have changed their peri-pad four times in the last six hours. The nurse should take which action? A. Document the finding as expected B. Massage the client's fundus C. Assess the client for hemorrhage D. Ambulate the client to the bathroom

Choices A, B, D, and E are correct. Increased urinary output, tachycardia, and orthostatic hypotension are expected findings with hyperglycemia. Blurred vision: hyperglycemia causes alteration of the eye lens, which explains the blurred vision. Polyuria: Increased urine output due to glycosuria. Glycosuria causes osmotic diuresis - glucose in the urine pulls excessive water with it, resulting in significant water losses and subsequent dehydration. Tachycardia: increased heart rate from the diuresis leading to dehydration. Orthostatic hypotension: Postural (orthostatic) hypotension is defined as a drop in systolic blood pressure of at least 20 mm Hg or more and diastolic blood pressure of at least 10 mm Hg or more within two to five minutes of quiet standing after five minutes of supine rest. Symptoms of hyperglycemia include increased thirst (polydipsia), polyuria, polyphagia, weight loss, blurry vision, and slow wound healing. Long-standing hyperglycemia can lead to nerve damage resulting in neuropathy (tingling, numbness, neuropathic pain). Hyperglycemia leads to osmotic diuresis when glucose levels are so high that glucose is excreted in the urine. Water follows the glucose concentrat

The nurse is caring for a client who presents with hyperglycemia. Which of the following findings are expected? Select all that apply. Blurred vision Increased urinary output Cool and clammy skin Tachycardia Orthostatic hypotension

Choice B is correct. Edentulous is a medical term referring to the complete loss of all teeth (i.e., dentition). Edentulous clients lack teeth; therefore, a mechanical soft diet would be the diet most likely to be ordered for this client, as this diet would facilitate mastication. Providing meals to the client in this manner would facilitate the client's chewing or gnawing of their food with their gums. The other diet choices do not offer safe eating options for an edentulous client.

The nurse is caring for a client with edentulous. It would be appropriate for the nurse to obtain an order for a A. low sodium diet. B. mechanical soft diet. C. renal diet. D. high-fiber diet.

Choices B, C, and D are correct. A client experiencing status epilepticus will require aggressive treatment as this is a persistent seizure that continues to recur despite treatment or a seizure that has lasted more than five minutes. The RRT should be notified as this is a medical emergency and requires evaluation by the RRT team. Obtaining a prescription for a parenteral benzodiazepine such as lorazepam is appropriate and should be completed by the nurse. Benzodiazepines are key in terminating a seizure. Central to caring for a client with a seizure is, placing them on their side and loosening any restrictive clothing.

The nurse is caring for a patient who is experiencing status epilepticus. Which of the following actions should be prioritized by the nurse? Select all that apply. - administer prescribed carbamazepine - notify the rapid response team (RRT) - obtain a prescription for lorazepam - loosen any restrictive clothing - review the client's most recent phenytoin level

Choice C is correct. According to the current American Society for Parenteral and Enteral Nutrition ( ASPEN) guidelines for nutrition support, enteral nutrition should not be stopped for a gastric residual volume (GRV) of less than 500 mL unless there are other signs of feeding intolerance. Signs/symptoms of feeding intolerance include nausea, vomiting, abdominal distention, constipation, and abdominal pain. If no bowel sounds are present, the nurse should assess the client's abdomen for changes from the baseline, such as tenderness or distension. If there are no changes from the baseline, the feeding bolus may be administered as ordered

The nurse is caring for a patient with a percutaneous endoscopic gastrostomy tube. Prior to administering the next tube feeding, the nurse aspirates 80 mL of gastric residual. The nurse should then A. notify the physician. B. hold the tube feeding and recheck residual volume in one hour. C. administer the prescribed feeding. D. reposition the patient in semi-Fowler's position.

Choice D is correct. The nurse should use all the data gathered to analyze the situation. The client had abdominal surgery and has hypoactive bowel sounds. The nurse needs to perform further assessments (i.e., evaluation of last bowel movement, questions regarding dietary intake, abdominal distention, etc.) to determine if there are any impending gastrointestinal problems for the client and if any treatments need to be initiated.

The nurse is caring for a post-abdominal surgery client four days after surgery. The nurse notes a temperature of 37°C, no complaints of pain at the incision site or elsewhere, a dry and intact wound dressing, and hypoactive bowel sounds in all four quadrants. Based on all the assessment data, what conclusion can the nurse make? A. The client's wound is becoming infected. B. Pain relief measures should be implemented. C. There are no current concerns for the client. D. Additional gastrointestinal assessments should be performed.

Choice B is correct. For the client taking warfarin reporting black, tarry stool, this is an immediate concern for internal bleeding. The nurse needs to follow up with this client and contact the physician to order an occult blood test for the stool. This, coupled with an order for an international normalized ratio (INR) level, should be a priority.

The nurse is caring for assigned clients. The nurse should immediately follow up on the client with A. chronic obstructive pulmonary disease (COPD) and has respiratory acidosis on the most recent arterial blood gas (ABG). B. atrial fibrillation taking prescribed warfarin and reports black, tarry stools. C. diabetes mellitus who refuses to eat following the administration of glargine insulin. D. acute pancreatitis and reports nausea with epigastric pain rated as a 3 on the Numerical Rating Scale.

Choice B is correct. This client shows signs of heparin-induced thrombocytopenia (HIT): a 50% decrease in platelets 5-10 days after initiating heparin therapy. This is a thrombotic emergency, and the nurse should assess the client, notify the physician, discontinue the heparin drip, and obtain a prescription for a non-heparin-based anticoagulant.

The nurse is caring for assigned clients. The nurse should initially follow-up on the client who A. has a blood glucose of 250 mg/dL while being treated with prednisone for pneumonia. B. is receiving a continuous infusion of heparin and has a 50% reduction in platelets over the past five days. C. has diabetes mellitus (type two) and reports burning and tingling in both feet. D. is being treated for acute post-streptococcal glomerulonephritis and has an hourly urinary output of 20 ml/hr.

Choice D is correct. A client requesting diphenhydramine following the initiation of an antibiotic requires immediate follow-up because the client could be experiencing an allergic reaction ranging from mild to severe. Thus, the nurse should quickly assess the client.

The nurse is caring for the following assigned clients. Which client should the nurse see first? The client A. going for an echocardiogram and is allergic to contrast dye. B. refusing to eat their meal following an injection of glargine insulin. C. scheduled for discharge in three hours and needs transportation. D. requesting diphenhydramine after starting an intravenous antibiotic.

Choice D is correct. Normal albumin levels are 3.5-5.0 g/dL. Collaboration with a registered dietitian (RD) is recommended for numerous reasons. First, the registered dietician can perform a nutritional assessment. Second, following the nutritional assessment, the registered dietician can focus on increasing the protein intake necessary for healing. Third, the registered dietician can make recommendations regarding appropriate foods that may be integrated into the client's diet based on the client's personal preferences. Fourth, the registered dietician can perform client education and educate the client regarding the nutritional needs of the client and food sources of protein. Therefore, collaborating with a registered dietician will significantly benefit this client experiencing hypoalbuminemia and should be included in the client's care plan.

The nurse is helping develop a care plan for a client with a low serum albumin level. The nurse should take which action? A. Obtain a capillary blood glucose B. Implement seizure precautions C. Implement strict bed rest D. Collaborate with a registered dietician

Choices B, E, and F are correct. These actions by the student are incorrect and require the nurse to intervene. The accuracy of blood pressure measurement may be skewed if the cuff is placed over clothes because it may impede blood pressure cuff fit and distort auscultatory sounds. The cuff should be snug over the client's skin. Further, BP results can be inaccurate if the client's extremity is not supported or at the level of their heart. If the arm is unsupported, it may cause a false-high reading. Further, if the arm is above the client's heart, it may cause a false-low reading. Pulse oximeter probes should be applied on an extremity that is non-edematous, has good peripheral blood flow, and is not obstructed by a blood pressure cuff (the cuff should be on the opposite side of the extremity where the pulse oximetry is being measured).

The nurse is observing a student collect vital signs on a client. Which action by the student requires the nurse to intervene? Select all that apply. The student - obtains the blood pressure with a cuff bladder width of at least 40% of arm circumference. - places the BP cuff over the client's clothing garment. - requests the client remove their hearing aid before obtaining a tympanic temperature. - assesses the client's respirations after obtaining the pulse rate. - obtains blood pressure by placing the client's upper extremity below their heart. - places the pulse oximeter probe on the client's finger that has edema.

Choice A is correct. This is the correct assessment technique for stereognosis. The concept of stereognosis is for the individual to recognize (or perceive) an object without using vision. For example, having a client close their eyes and placing a toothbrush in their hand can accurately state that it is a toothbrush.

The nurse is observing a student perform a physical assessment. It will demonstrate appropriate technique if the student assesses for stereognosis by instructing the client to A. close their eyes, place an object in their hand, and ask them to identify it. B. close their eyes with feet together, arms at the sides, and observe for loss of balance. C. walk on their heels and then on their tiptoes for at least ten feet. D. touch the tip of their nose with the index finger and return the arm to an extended position.

Choices A, B, C, and E are correct. These findings require follow-up because they are not correct. Contact precautions do not require the client's door to be kept closed. This is required if a client was placed on airborne precautions. Gloves should not be worn while passing or collecting meal trays. This would be an ineffective use of resources. Gloves are only worn when contact with blood or bodily fluids is likely. Disposable dishes are not used for clients on any isolation precautions. Alcohol-based sanitizers should not be used for pathogens such as C. diff because they are ineffective in killing the spore.

The nurse is observing infection control practices on the nursing unit. Which of the following findings requires follow-up? Select all that apply. - Doors kept closed for clients with contact precautions - Gloves being worn by staff to pass meal trays - Disposable dishes being used for clients on isolation precautions - Bedside fan being removed from a room with negative pressure - Alcohol-based hand sanitizers for a client with C. diff

Choice B is correct. It would be appropriate for the nurse to delegate to the LPN/VN to administer prescribed medications. Administering medications by mouth, topically, intramuscular, otic, subcutaneous, intranasal, and intravenous piggyback is within the scope of the LPN/VN.

The nurse is planning client assignments in the mental health unit. Which task should the nurse delegate to the licensed practical/vocational nurse (LPN/VN)? A. conduct a suicide assessment on a newly admitted client B. administering prescribed lithium to a client with bipolar disorder C. leading a group therapy session for clients with depressive disorders D. monitoring a client who is talking on the phone to a family member

Choice D is correct. The client should lay on the right side with a pillow against the biopsy site at the right costal margin. Following the liver biopsy, the right lateral decubitus position reduces the risk of post-biopsy bleeding by putting pressure on the liver biopsy site.

The nurse is positioning a client following a liver biopsy. Which position is best suited for this client? A. On the left side with a pillow under the ribs. B. Supine with a pillow under the client's knees. C. Face down with a pillow under the hips. D. On the right side with a pillow under the biopsy site.

Choice A is correct. Epidural analgesia has a common adverse reaction of hypotension. It is routine for clients being prepared for epidural analgesia to receive a liter of isotonic fluids to preempt this adverse reaction.

The nurse is preparing a client who is prescribed continuous epidural analgesia. Which of the following pre-procedure prescriptions should the nurse be prepared to administer? A. Lactated Ringers B. Ondansetron C. Ketorolac D. Haloperidol

Choices A, B, and D are correct. These are all risk factors for sensorineural hearing loss. Presbycusis is progressive and irreversible hearing loss that is often associated with aging. Ototoxic substances (gentamycin, vancomycin) may also induce sensorineural hearing loss. Exposure to loud noise is a pointed risk factor because this causes damage to the hair cells of the cochlea.

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. - Presbycusis - Ototoxic substance - Foreign body - Exposure to loud noise - Edema

Choices D and E are correct. When administering platelets to a client, the nurse should ensure that a completed blood product consent is obtained before transfusion. Further, the nurse (or UAP) will obtain pre-transfusion vital signs and infuse platelets over 15-30 minutes. The blood product that requires transfusion over 2 to 4 hours is a unit of packed red blood cells - not platelets.

The nurse is preparing to transfuse platelets to a client. Which of the following actions would be appropriate for the nurse to take? Select all that apply. - Obtain the client's weight - Ensure ABO type compatibility - Infuse the platelets over 2 to 4 hours - Verify completed consent for platelet transfusion - Obtain pre-transfusion vital signs

Choice A is correct. An essential aspect of advocacy is speaking on behalf of the patient, to help meet the patient's needs, such as when calling the physician to discuss the need for more effective pain management - since it is the patient's fundamental right to be free from pain.

The nurse is providing care for a patient recently transferred from the post-anesthesia care unit [PACU]. The chart indicates that the patient was medicated for pain 1 hour ago, yet the patient reports that he is experiencing extreme pain. He is not due for further medication until another 2 hours. How might the nurse intervene as a patient advocate? A. Contact the physician regarding the need for more effective pain management. B. Assist the patient to use non-pharmacological pain management strategies. C. Explain to the patient that giving the pain medication too soon can be dangerous. D. Provide a quiet environment to help the patient rest and cope with his pain level.

Choice B is correct. Trichomoniasis clients would yield a malodorous, thin, yellow discharge. Trichomoniasis is caused by a protozoon, Trichomonas vaginalis.

The nurse is working at a women's health clinic. A client comes in suspected of having trichomoniasis. Upon physical examination of the perineal region, the nurse should expect which type of sign? A. White, "cheesy" discharge B. Malodorous, thin, yellow discharge C. Grayish-white, malodorous discharge D. No vaginal discharge

Choice C is correct. A neonate is expected to be pinkish in appearance. Saliva should be minimal and the normal temperature for a newborn is from 36.5 °C to 37 °C. These symptoms could indicate potential respiratory distress or other health issues that require immediate assessment and intervention.

The nurse is working in the NICU for the morning shift. While assessing four neonates less than 6-hours old, which neonate warrants additional attention from the nurse? A. A neonate with a molded head and overriding sutures. B. A neonate with cyanotic hands and feet that has not passed meconium. C. A neonate that is spitting up excessive mucus, with a temperature of 36.1 °C (97°F), and is dusky in appearance. D. A neonate with abdominal respirations and intermittent tremors of the extremities.

Choice B is correct. Post-maturity refers to any baby born at or beyond 42 weeks gestation (42 0/7 weeks) or at or beyond 294 days from the first day of the mother's last menstrual period (LMP). Post-maturity is also referred to as prolonged pregnancy, post-term, and post-dates pregnancy. At about 40-42 weeks, placental insufficiency ensues due to the aging placenta. Therefore, the infants rely on their subcutaneous fat reserves to sustain them after 40 to 42 weeks since the aging placenta is unable to provide the necessary nutrition. Due to these depleted subcutaneous fat reserves, the post-term infant is at risk for hypoglycemiaand hypothermia. In at-risk infants, the incidence of neonatal hypoglycemia is highest in the first few hours after birth. In this case (Choice B), a 4-hour old infant delivered at 42 weeks is at-risk. Additionally, the risk of meconium aspiration is high in the post-term fetuses and can cause respiratory distress when the baby is born. The nurse should prioritize and assess this post-term infant first.

The nurse just finished receiving the shift report from the night nurse. Which of the following newborns should the nurse assess first? A. A 3-hour old newborn weighing 6 pounds B. A 4-hour old newborn delivered at 42 weeks C. A 6-hour old newborn that is 21 inches long D. An 8-hour old newborn delivered at 40 weeks

Choice A is correct. The recommendation of a handheld showerhead is appropriate because the client can use this device to bathe without having to move and pivot in the shower, thus, reducing the risk of falling while in the bathtub. The handheld showerhead also allows easier cleaning because of its ability to clean the lower extremities easier.

The nurse performs a home safety assessment for an older adult with rheumatoid arthritis. The nurse should make which recommendation to promote safety in the bathroom? A. Recommend using a handheld (adjustable) shower head B. Advise the client to lower the toilet seat to its lowest level C. Instruct the client to reduce bathroom lighting D. Recommend the use of towel racks for grab bars

- Chlamydia - Cystitis - Gonorrhea

The nurse reviews the client's laboratory results The nurse understands that the client is most likely experiencing which condition? Select all that apply Pyelonephritis Chlamydia Cystitis Gonorrhea Pre-eclampsia

- Sodium rich - maintain a daily fluid intake of 2 to 3 liters - a fine hand tremor - thyroid panel

The nurse reviews the physician's orders and educates the client on the prescribed lithium Complete the sentences below by choosing from the list of options

Choice C is correct. Dizziness is not expected with a C. diff infection. This could be regarded as a complication because the dizziness is likely associated with severe dehydration caused by diarrhea. The nurse needs to follow up with this client because of the potential for further clinical deterioration.

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

Choices B, C, and E are correct. B is correct. Since the client has agoraphobia, they fear leaving places where they feel safe and comfortable. Desensitization to this fear should occur gradually, starting with small steps outside their comfort zone. Taking a short walk in the hallway outside their room, where they feel safe, is an appropriate choice for desensitization therapy. Choice C is correct. Building rapport and trust with the client is crucial during desensitization therapy. Trust enables the client to feel comfortable and supported, allowing for successful progress as they are guided to face their fears gradually. Choice E is correct. Agoraphobia is classified as an anxiety disorder. Teaching and encouraging relaxation techniques, such as deep breathing exercises, progressive muscle relaxation, and mindfulness techniques, would be appropriate to help the client manage anxiety symptoms.

The nurse works in a long-term psychiatric rehabilitation center and is assigned to a patient with debilitating agoraphobia. The patient is going through desensitization therapy. Which of the following interventions is an appropriate part of this treatment? Select all that apply. - Speak frequently of what causes the fear to start for him. - Take a short walk in the hallway outside of his room. - Build rapport with the client - Encourage him to face his fear outside where he is least comfortable. - Teach anxiety management techniques

Choice B is correct. Dorsiflexion is the position where the foot is flexed upward, with the toes pointing toward the ceiling. This position helps maintain the ankle joint in a neutral position and prevents the foot from dropping into plantar flexion, which can lead to foot drop. Foot drop is a condition where the client is unable to dorsiflex their foot, resulting in a permanent or temporary loss of the ability to lift the front part of the foot, leading to a dragging gait. It is essential to maintain dorsiflexion to preserve the client's range of motion and prevent contractures while on bed rest, ultimately reducing the risk of foot drop.

The nurse, in caring for a client on bed rest following a spinal injury, should consider which position the most appropriate to prevent foot drop? A. Supination B. Dorsiflexion C. Hyperextension D. Abduction

Choice B is correct. Cyanosis is the bluish discoloration of the skin and mucous membranes that results in the presence of poorly oxygenated blood. Cyanosis, a bluish coloring of the skin, is caused by decreased peripheral circulation or reduced oxygenation of the blood. It may be related to cardiac, pulmonary, or peripheral vascular problems (e.g. arteriosclerosis). In dark-skinned clients, you can best see cyanosis by examining the conjunctiva, tongue, buccal mucosa, and palms and soles for a dull dark color.

When a nursing student asks a nurse on her assigned floor what cyanosis means, what is the nurse's best response? A. Cyanosis means the client has been exposed to cyanide poisoning. B. Cyanosis is the blue coloring of the skin and mucous membranes in the presence of poorly oxygenated blood. C. Cyanosis is the primary indication that the client has pneumonia. D. Cyanosis is the blue coloring of skin and mucous membranes in the presence of highly oxygenated blood.

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.

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 medication

Choice C is correct. Placebo use is unethical unless it is used in research, the subject of the study had full disclosure, and they consented to be a subject in the research study. The American Nurses Association, American Society for Pain Management Nurses, American Pain Society, and Oncology Nursing Society's codes of ethics prohibit the use of placebos without client consent.

Which statement about the placebo is the most accurate? A. Placebos are often used to determine if the client's reports of pain are valid. B. Placebos are not used in research because the client has not given consent. C. Placebo use is unethical unless they are used in research with the subject's consent. D. Placebo use is illegal according to all states and the federal government.

Choices A, B, C, and D are correct. A is correct. EMR systems enable nurses to store and access patient information conveniently and organized, improving documentation efficiency. B is correct. EMR systems enable healthcare professionals to exchange patient information, easily promoting effective communication and collaboration. C is correct. EMR systems provide accurate and up-to-date patient information, which helps prevent medication errors and ensures proper treatment planning. D is correct. EMR systems often include features that allow nurses to access relevant medical research and clinical guidelines, promoting evidence-based decision-making.

Which statements about an electronic medical record (EMR) system are true for the nurse working in a hospital? Select all that apply. - Allows for efficient and centralized documentation of patient information. - Enhances communication among healthcare providers by facilitating the sharing of patient data. - Improves patient safety by reducing the risk of errors in medication administration and treatment plans. - Supports evidence-based practice by providing access to medical research and clinical guidelines. - Eliminates the need for physical storage of paper records, reducing clutter and saving space.

- Fever - Hemoptysis - Night sweats

Which three (3) findings in the history and physical requires follow-up? Fever Hemoptysis Osteoarthritis Daily aspirin use Night sweats Hyperlipidemia Irregular pulse

Burning with urination Vaginal discharge

Which two (2) client findings in the history and physical require further investigation? Select all that apply Nausea Breast tenderness Fatigue Burning with urination Vaginal discharge Amenorrhea

Pregnancy - - Increased urinary frequency - Breast tenderness - Amenorrhea Gonorrhea- - Malodorous vaginal discharge - Increased urinary frequency - Burning with urination Cystitis - - Increased urinary frequency - Burning with urination

X

X

X

Choice A is correct. This is a normal ABG. 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. Since this patient's values are all within the normal range, this is a normal ABG. 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.

You are assessing a 35-year-old male patient in the clinic. He had a cough and intermittent abdominal pain for a few days. You receive results of an arterial blood gas that show: pH = 7.41 PaCO2 = 40 Bicarbonate = 25 You determine that this ABG shows: A. Normal ABG B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic acidosis

Choice C is correct. Topical nitroglycerin is used to help prevent/ treat anginal symptoms in coronary artery disease. To apply nitroglycerin correctly, be sure to rotate the application sites with each application to avoid irritation from the medication. The medication comes with a supply of paper applicators with a small ruler on the paper for proper measurement of the drug. Apply the appropriate amount of ointment on the paper and apply the cream to an area of the skin.

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

Choice B is correct. Sickle cell anemia is an autosomal recessive disease. The normal chromosome is represented as S, and the sickle cell gene-containing chromosome is expressed as s. Therefore, ss characterizes sickle cell anemia, Ss defines the carrier, and SS is the normal phenotype. The baby has a 50% chance of having sickle cell anemia (ss). From the information presented in the question, the father is ss because he has the disease, and the mother is Ss since she is a carrier. The disease is referred to as sickle cell anemia or sickle cell disease, whereas the carrier state is referred to as sickle cell trait.

You are reinforcing counseling for two parents who are preparing for the birth of their first child. The father has sickle cell anemia, and the mother is a carrier. You tell them that their baby has what chance of having sickle cell anemia? A. 25% B. 50% C. 75% D. 100%

Choice B is correct. Following the recent diagnosis of a chronic and incurable genetic condition such as cystic fibrosis, this family will require significant emotional support. Throughout the shift, the parents will likely have numerous questions regarding the need to follow up on genetic counseling, treatment options, prognosis, and/or resources, making Choice B the priority.

You receive the change-of-shift report for an infant whose family has just been informed of the infant's cystic fibrosis diagnosis. As the nurse caring for this pediatric client and the family, which of the following should you prioritize? A. Arrange and schedule a follow-up appointment with a pediatric pulmonologist B. Provide emotional support for the family C. Arrange for financial assistance D. Arrange for parental genetic testing, as the pareterm-44nts mention they want another child soon

"It would be best for me not to have sexual intercourse during my pregnancy."

x

Appendicitis - - N/V - Periumbilical abdominal pain - Fever - Anorexia Pregnancy - - N/V Cholecystitis - - N/V - Fever - Anorexia

x

Appropriate - - Obtain an order to screen for additional sexually transmitted infections - Obtain an order for a transvaginal ultrasound - Review the client's current medications, including any over-the-counter supplements or vitamins Not appropriate - -Obtain a prescription for antivirals

x

Indicated - - Obtain peripheral vascular access - Administer broad spectrum antibiotics - Obtain blood cultures - Place the client on nothing-by-mouth (NPO) status Not indicated - - Prepare the client for a barium enema

x

Isoniazid - "Do not consume any alcohol while taking this medication." -"Take a B-complex vitamin to prevent neuropathy." -"Notify your doctor if you notice the darkening of your urine." Rifampin - "Do not consume any alcohol while taking this medication." -"Notify your doctor if you notice the darkening of your urine." -"This medication may cause orange-reddish staining of the skin and urine."

x

sputum culture airborne keeping the door to the room closed

x

x

x