ATI QUESTIONS TO REVIEW BEFORE EXIT & NCLEX:

COMPLICATIONS OF HF:

- 1.) Cardiomyopathy: - Impaired cardiac fxn leading to HF. Blood circulation is impaired to the lungs or body when the cardiac pump is compromised - Of the 3 types (dilated, hypertrophic, and restrictive) dilated cardiomyopathy is the most common -2.) Cardiogenic shock: - A serious complicarition of pump failure that occurs commonly following an MI and injury to greater than 40% of the left ventricle - Sx's include: tachycardia, hypotension, inadequate urinary output, altered LOC, resp distress (crackles, tachypnea), cool, clammy skin, decreased peripheral pulses and chest pain -3.) Pericardial Tamponade: - This can result from fluid accumulation in the pericardial sac - Signs include: hypotension, jugular venous distention, muffled heart sounds, and paradoxical pulse (variance of 10 mmHg or more in systolic BP b/w expiration and inspiration -4.) Pulmonary edema: - A severe, life-threateinig accumulation of fluid in the alveolli and interstitial spaces of the lungs that can result from severe HF

MEDICATIONS USED IN THE TX OF HF:

- Diuretics: to decrease preload; loop diuretics ushc as Furosemide; thiazide diuretics such as hydrochlorothizide; potassium-sparing diuretics, such as spironolactone - Afterload-reducing agents help the heart pump more easily by altering the restistance to contraction: Angiotensin-converting enzyme (ACE) inhibitors, such as enalapril; angiotension receptor II blockers ushc as losartan - Inotropic agent, such as digoxin, dopamine, and dobutamine, to incrase contractility and improve CO - Nitroglycerine & isosorbide mononitrate to prevent coronary artery vasospasm and reduce preload and afterload, decreasing myocardial O2 demand - Human B-type natriuretic peptides (hBNP): meds such as nesiritide used to treat acute HF by causing natriuresis (loss of sodium and vasodilation)

MANIFESTATIONS OF LEFT-SIDED HF:

- Dyspnea, orthopnea, nocturnal dyspnea - Fatigue - Displaced apical pulse (hypertrophy) - S3 heart sound (gallop) - Pulmonary congestion (dyspena, cough, bibasilar crackles) - Frothy sputum (may be blood-tinged) - Altered mental status - Sx's of organ failure, such as oliguria

MANIFESTATIONS OF RIGHT-SIDED HF:

- Jugular vein distention - Ascending dependent edema (legs, ankles, sacrum) - Abdominal distention, ascites - Fatigue, weakness, - Nausea, anorexia - Polyuria at rest (nocturnal) - Liver enlargement (hepatomegaly) and tenderness - weight gain

CAUSES OF HYPONATREMIA:

- Loss of sodium - Renal losses thru excretion, diuretics, renal dx (salt-wasting nephropathy) - GI losses thru vomiting, diarrhea, suctioning, tap water enemas (TWE's) , GI surgery, bulimia Skin losses thru perspiration environment heat and humidity, burns, tissue destruction - Conditions that increase extracellular water - Hormone regulation of ADH and aldosterone, leading to fluid shifts and water gain - Disorders that add to increased volume, such as CHF, cirrhosis & nephrotic syndrome - COnditions such as psychiatirc disorders that involve compulsive water drinking - Disorders such as tumors, SIADH (syndrome of inappropriate antidiuretic hormone), and adrenal insufficiency that affect hormonal response, leading to increased secretion - Hyperglycemic states such as diabetic ketoacidosis (DKA) that cause cellular dehydration - Prolonged or excessive use of hypotonic fluid administration - Anorexia and other eating disorders

HYPOVOLEMIA (DEHYDRATION) Nursing Assessment

- Low urine volume: <1-2 mL/kg/hr in children; <30 mL/hr (240 mL/8 hours) OR 0.5 mL/kg/hr in Adults - Concentrated dark urine w/SG higher than 1.035 (?) (normal=1.010-1.030) - Low grade fever (higher fever can occur in severe dehydration)

NURSING CARE OF THE PT W/HF:

- Monitor daily weight & I & O - Monitor for SOB and dyspnea on exertion - Administer O2 as prescribed - Monitor VS and hemodynamic pressures - position the pt to maximize ventilation (high-fowlers) Check ABG's, electrolytes, (esp K+ if on diuretics) , SaO2, and chest x-ray results - Encourage bed rest until the pt is stable Encourage energy conservation by assiting w/care and ADLs Maintain dietary restrictions as prescribed (restricted fludi intake, restricted sodium intake)

MANIFESTATIONS OF PULMONARY EDEMA:

- anxiety - inability to sleep - persistent cough w/pink, frothy sputum (cardinal sign) - tachypnea, dyspnea, and orthopnea - Hypoxemia - Cyanosis (later stage) - crackles - tachycardia - Confusion, stupor - S3 heart sound (gallop)

CARE OF THE PT EXPERIENCING PULMONARY EDEMA:

- monitor VS and I&O - monitor hemodynamic status (pulmonary wedge pressures, CO) - monitor ABG's, electorlytes (esp K+ if on diuretcis), SaO2, and chest-xray results - Maintain a patent airway. Suction as needed - Position the pt in high-fowlers position w/feet & legs dependent or sitting on the sideo fo the bed to decease preload - Administer O2 using a high flow rebreather mask. BiPAP or intubation/ventilation can become necessary - Restrict fluid intake (slow or discont. infusing IV fluids - Administer meds to promtoe fluid excretion (diuretics), vasodilation (nitrates), decrease preload and afterload (vasodilators and antihypertensives), and improve cardiac output (inotropic agents)

HEART FAILURE:

- occurs when the heart muscle is unable to pump effectively, resulting in inadequate CO, myocardial hypertrophy, and pulmonary/systemic congestion - The result of an acute or chronic cardiopulmonary problem, such as systemic HPTN, MI, pulmonary HPTN, dysrhythmias, valvular heart dx, pericarditis, and cardiomyopathy

HF--DIAGNOSTIC PROCEDURES:

-Hemodynamic monitoring: HF generally results in increased CVP, increased right arterial pressure, increased pulmonary wedge pressure (PAWP), increased pulmonary artery pressure (PAP) and decreased CO - Ultrasound: An ultrasound (also called caridac US or echocardiogram), 2-D or 3-D is used to measure both systolic & diastolic fxn of the heart - Left Ventricular ejection Fraction (LVEF): The vollume of blood pumped frpm the left ventricle into the arteries upon each beat. Normal is 55-70% - Right Ventricular Ejection Fraction (RVEF): The volume of blood pumped from the right ventricle to the lungs upon each beat. Normal=45-60% - A chest x-ray cna reveal cardiomegaly and pleural effusions - Electrocardiogram (ECG), cardiac enzymes, electrolytes, and ABG's are used to assess factors contributing to HF &/or th eimpact of HF

NORMAL URINALYSIS LAB VALUES: A.) Urine specific gravity B) Protein C) Glucose D.) Ketones E) pH F)WBC's (males & females)

A) 1.005-1.025 B) 0.8 mg/dL C) <0.5 g/day D.) none E) 4.6-8 F) Males: 0-3/high-power field; Females: 0-5/high-power field

NORMAL ARTERIAL BLOOD GAS (ABG) VALUES: A) pH B) PaCO2 C) PaO2 D) HCO3

A) 7.35-7.45 B) 35-45 mmHg C) 80-100 mmHg D) 21-28 mEq/L

NORMAL BLOOD GLUCOSE LEVELS: A) Glucose (fasting) B) HbA1C

A) 70-105 mg/dL B) 4-6% (expected reference range); >8%=indicates poor diabetes mellitus control

NORMAL RENAL FXN TEST VALUES: A) Serum Creatinine (males & females) B.) BUN C.) Creatinine clearance test (males & females)

A) Males=0.6-1.2 mg/dL; Females=0.5-1.1 mg/dL [Range=0.5-1.2 mg/dL] B.) 10-20 mg/dL C.) Males=90-139 mL/min; Females: 80-125 mL/min; [Range=80-139 mL/min]; This test is the best indicator of GFR and overall renal fxn

NORMAL ANTICOAGULANT THERAPY COAGULATION TIMES: A.) PT (normal & therapeutic) B.) Partial thromboplastin time (aPTT) C)INR (normal & therapeutic) D.) Platelets

A.) 11-12.5 seconds; Therapeutic range for anticoagulant therapy= 1.5-2x the normal or control value B) 30-40 seconds C.) Normal INR=0.7-1.8; Therapeutic INR= 2.0-3.0 D.) 150,000-400,000 mm^3

NORMAL SERUM ELECTROLYTE LEVELS: A.) Sodium (Na+) B.) Potassium (K+) C.) Calcium total (Ca++) D) Magnesium (Mg++) E) Phosphorus (PO4) F.) Chloride (Cl)

A.) 136-145 mEq/L B) 3.5-5 mEq/L C) 9.0-10.5 mg/dL D) 1.3-2.1 mEq/L E.) 3.0-4.5 mg/dL F) 98-106 mEq/L

NORMAL LIVER FUNCTION TEST VALUES: A) Albumin B) Ammonia C) Total bilirubin D) Total protein

A.) 3.5-5 g/dL B) 15-45 mcg/dL C) 0.1-1.0 mg/dL D) 6-8 g/dL

NORMAL BLOOD LIPID LEVELS: A) Total Serum Cholesterol B)LDL C) HDL D) Triglycerides

A.) Desirable= <200 mg/dL; Risk for cardiac stroke events: >150 mg/dL=range for therapy (shown to reduce cerebrovascular incidents) B.) Desirbale <130 mg/dL C.) Males= 35-65 mg/dL; Females: 35-80 mg/dL D.) desirable <150 mg/dL; Males: 40-160 mg/dL; Females: 35-135 mg/dL

NORMAL CBC LAB VALUES: A.) RBC's: males & females B) Hgb: (males females) C) Hct: (males females) D.) WBC's E) Erythrocyte sedimentation rate (ESR)

A.) Males: 4.7-6.1 mill/uL; Females: 4.2-5.4 mil/uL (Range=4.2-6.1 mill/uL) B.) Males: 14-18 g/dL; Females: 12-16 g/dL (Range=12-18 g/dL) C.) Males: 42-52%; Females: 37-47%; (Range=37-52%) D.) 5,000-10,000 mm^3 E.) Less than <20 mm/hr

A charge nurse is delegating a task. The nurse understands which of the following represents effective delegation? Select all that apply. Select one or more: a. Delegating a task that should be assigned to a manager. b. Referring to the ANA Code of Ethics for effective delegation practices. c. Asking the nurse if they are capable of completing the delegated task. d. Delineating the desired outcomes of the delegation. e. Monitoring how the delegated task is being accomplished

ANSWER(S)--> C, D, E RATIONALE: A.) Delegating a task that should be assigned to a manager is not effective delegation. Improper delegation includes delegating tasks and responsibilities that are beyond the capability of the person to whom they are being delegated or that should be done by the manager. D.) Effective delegation means planning ahead when identifying tasks to be accomplished. Assess the situation, and clearly delineate the desired outcomes. E.) Monitoring how the task is being accomplished is considered effective delegating.

Order of removal of PPE

Gloves-->Eye protection-->Gown-->Mask-->wash hands

Proper donning of PPE:

Gown-->Mask-->Eye protection-->Gloves

RISK FACTORS FOR LEFT-SIDED HF:

HPTN Coronary artery dx, angina, MI Valvular dx (mitral and aortic) Right-sided HF

FLUID VOLUME IMABALANCES: QUICK SUMMARY OF ASSESSMENT FINDINGS:

HYPOVOLEMIA (DEHYDRATION: - thirst (unreliable in older adults, children who cannot express needs) - Low urine output; concentrated, dark urine - Acute weight loss - Dry mucous membranes, tongue - Dry skin and decrsaed turgor; skin "tenting" - Decreased tearing and dry conjunctiva; sunken eyeballs - Sunken or depressed fontanels in infants - Flat neck veins (low CVP); poor peripheral vein filling - Hypotension (late sign); postural or frank - Tachycardia (earlier sign); weak, thready pulse - Delayed capillary refill - Tachypnea (usually w/out dyspnea) - Weakness, dizziness, lightheadedness, syncope - Mental status changes (irritability, restlessness, lethargy, confusion, drowsiness, seizures or coma) HYPERVOLEMIA (FLUID OVERLOAD): - Peripheral edema - Increased urine output that is dilute (if normal kidney fxn) - Acute, rapid weight gain - Tense or bulging fontanels (before age 18 mos) - Distended neck veins (high CVP); delayed peripheral vein emptying - S3 heart sounds in adults - possible hepatomegaly and splenomegaly from venous congestion - Tachypnea; dyspena; lung crackles; and other signs of pulmonary edema - Fullor bounding peripheral pulses; warm extremities; brisk capillary refill - Mental status changes (HA, confusion, lethargy, seizures possible)

LEFT-SIDED HEART FAILURE:

Results in inadequate left ventricle (cardiac) output and consequently in inadequate tissue perfusion - Types include: -->Systolic heart (ventricular) failure (ejection fraction below 40%, pulmonary and systemic congestion) -->Diastolic heart (ventricular) failure (inadequate relaxation or "stiffening" prevents ventricular filling)

RIGHT-SIDED HEART FAILURE:

Results in inadequate right ventricle output & systemic venous congestion (peripheral edema) - Risk factors: -->Left-sided heart (ventricular) failure -->Right ventricular MI -->Pulmonary problems (COPD, ARDS)

GRADING OF HEART FAILURE:

The severity of heart faillure is graded on the NY Heart Assoc. Functional classification scale indicating how little or how much activity it takes to make the pt symptomatic (chest pain or SOB - Class I: Pt exhibits no sx's w/activity - Class II: Pt has sx's w/ordinary exertion - ClassIII: Pt displays sx's w/minimal exertion Class IV: Pt has sx's at rest

A nurse is educating a client about implementation of bowel training program. Which of the following interventions should be included in the plan of care? Select all that apply. A.) Choose a regular toileting time based on the pts pattern B.) Take stool softeners daily C.) Advise the pt to lean forward at the hips while sitting on the toilet D.) Drink hot milk before defecation time E.) Avoid the use of time limits for defecation

ANSWER(S)-->A, B, C RATIONALE: Giving stool softeners orally every day or a cathartic suppository at least half an hour before the selected defecation time can assist with bowel training. Choosing a time in the client's pattern to initiate defecation control measures is appropriate. Clients can be encouraged to sit on the toilet about 30 minutes after a meal, whether or not they feel the urge to defecate. Instructing the client to lean forward at the hips while sitting on the toilet, to apply manual pressure with the hands over the abdomen, and to bear down but not strain can assist with stimulating colon emptying.

A client is undergoing cystoscopy. Which of the following interventions should the nurse include in the client's plan of care? A.) Provide education on home urinary catheter care B.) Monitor for infection for 48-72 hours following procedure C.) Increase oral fluid intake to flush contrast dye from system D) Educate pt on the need for anticoagulant therapy

ANSWER--->B) Monitor for infection for 48-72 hours following procedure RATIONALE: Cystoscopy does not require administration of contrast dye

A client is having an exercise electrocardiography (stress test) performed. The nurse recognizes the need to stop the test if which of the following occurs? a. The client begins to breathe harder b. The client experiences an increase in heart rate. c. An ST segment depression or T wave inversion on the EKG. d. QRS complexes begin to occur more frequently.

ANSWER--->C) An ST segment depression or T wave insertion on the EKG RATIONALE: QRS complexes are a normal part of the cardiac cycle and an increase in QRS complexes represents an increase in heart rate - a normal finding with exercise.

A nurse is caring for a client with severe peripheral arterial disease of the right lower extremity. Which intervention is appropriate? A.) Apply cold compresses to the affected extremity B.) Apply warm compresses to the affected extremity C.) Keep the affected extremity above the level of the heart D.) Keep the affected extremity below the level of the heart

ANSWER--->D.) Keep the affected extremity below the level of the heart RATIONALE: The nurse should NEVER apply direct heat to the limb. Sensitivity is decreased in the affected limb & burns may result

A nurse is providing education to a client with coronary artery disease. Which of the following cholesterol values should the nurse identify as a goal for this client? a. HDL-C level 60 mg/dL b. HDL-C level 20 mg/dL c. LDL-C level 98 mg/dL d. LDL-C level 120 mg/dL

ANSWER-->A) HDL-C level 60 mg/dL RATIONALE: While a value of <130 mg/dL is an accepted normal value, this client has coronary artery disease and a value below 70 mg/dL is desirable for clients diagnosed with CVD or who are diabetic.

A nurse is caring for a client with a new onset bowel obstruction. What assessment finding would be anticipated when completing an abdominal assessment? a. Hyperactive bowel sounds. b. Hypoactive bowel sounds. c. Normal bowel sounds. d. Absent bowel sounds.

ANSWER-->A) Hyperactive bowel sounds RATIONALE: Hypoactive bowel sounds may be found in later stages of obstruction, but hyperactive bowel sounds are typical in early stages of obstruction.

A nurse is caring for a client with heart failure. Which of the following interventions should the nurse take if the client is experiencing dyspnea? a. Place client in high Fowler's position. b. Place client in the reverse trendelenberg position c. Perform coughing and deep breathing exercises every 8 hours. d. Obtain serial ABGs every 8 hours.

ANSWER-->A) Place pt in high fowler's position RATIONALE: Placing the client in reverse trendelenberg would not promote lung expansion and improve oxygenation as well as high Fowler's position.

A nurse is caring for a client who is being treated with internal radiation. Which nursing interventions are appropriate for this client? Select all that apply. Select one or more: a. Encourage visitors to stay at least 6 feet from the client. b. Always face the radiation source. c. Assign the client to a private room with a private bath d. Discard bed linens daily e. Limit visitors to 30 minutes twice daily

ANSWER=A, B, C RATIONALE: The nurse should wear a lead shielding apron and should always face the radiation source. The nurse should never turn his/her back toward the radiation source. The client should be assigned to a private room with a private bath. Visitors should be advised to stay at least 6 feet from the radiation source at all times All dressings and bed linens should be saved until after the radioactive source is removed. After the source is removed, the dressings and linens can be disposed of in the usual manner. Other equipment can be removed from the room at any time. Each visitor should be limited to one 30 minute visit per day.

A nurse is caring for an infant prescribed digoxin. The client's apical heart rate is 88 beats per minute. Which of the following interventions should the nurse take? Select all that apply. Select one or more: a. Notify the physician. b. Obtain a rhythm strip to assess for heart block c. Call an emergency code for the arrest team d. Administer the medication as ordered e. W/hold the medication

ANSWER=A, B, E RATIONALE: A heart rate less than 90 bpm is a sign of digoxin toxicity in an infant. Digoxin slows the heart rate by slowing conduction through the AV node. The infant's cardiac rhythm should be assessed for heart block. The infant is exhibiting a sign of digoxin toxicity, administering the medication may result in further toxicity.

A nurse is caring for a terminally ill client of the Muslim faith and observes the client to be unconscious and having Cheyne-Stokes respirations. The family has repositioned the bed so that the client is on the right side facing toward the wall. The nurse does not question this action because of which of the following? Select one: a. This positioning has religious significance for the client and family. b. The religious practice of concealing the face of the dying client should be supported. c. The nurse should support the family in their efforts to make the client comfortable. d. This positioning is preferred for a client with respiratory distress.

ANSWER=A RATIONALE= There is no requirement to conceal the face of the dying person in the Muslim faith. If possible, it is preferable for a female pt to be allowed to wear the muslim hijab (body covering) w/the hospital gown. Once death has occurred, the entire body should be covered

A nurse is planning care for a client newly admitted to an inpatient mental health unit for treatment of a gambling addiction. The client is having difficulty concentrating and is worried about the future. Which initial intervention will maximize the client's success for recovery? Select one: a. Arrange for the client to attend Gamblers Anonymous. b. Suggest the client replace work out on the treadmill. c. Recommend the client participate in group discussion. d. Administer an anti-anxiety medication to the client

ANSWER=A (said D but rationale hints that A is right) RATIONALE: Pts w/non-substance abuse often have few meaningful personal relationships. Group discussion may provide for human interaction but most likely will not lead to long term relationships. Therefore, personalized self-help programs work most effectively for pts w/gambling addictions

A nurse is caring for a neonate diagnosed with a congenital heart defect. Which of the following signs and symptoms would the nurse note if the client was experiencing heart failure? Select all that apply. Select one or more: a. Mottling b. Hyperglycemia c. Feeding difficulties d. Tachypnea e. Bounding pulses

ANSWER=A, C, D RATIONALE: Feeding difficulties would be as ign of heart failure. Dyspnea and activity intolerance make it difficult for the neonate to consume adequate calorie. Mottling may occur with heart failure. Tissue hypoxia and vessels are compensating for heart failure creating a mottled splotchy appearance. Tachypnea is a sign of heart failure. It is a compensatory mechanism to increase available oxygen to the tissues.

A nurse is part of an interprofessional team. What qualities will the nurse use to implement effective collaboration. Select all that apply. Select one or more: a. Assertive communication b. Coercive behavior c. Agressive reasoning d. Critical Thinking e. Structured decision-making

ANSWER=A, D, E RATIONALES: Assertiveness is an effective quality to implement collaboration. Critical Thinking is an effective quality to implement collaboration. Using structure to make new decisions is a good trait for collaborative work.

A nurse is admitting a client diagnosed with schizophrenia. In order to establish a therapeutic nurse-client relationship with the client, the nurse's initial actions should include which of the following? Select one: a. Provide confidentiality b. Establish trust c. Develop a contract d. Maintain consistency

ANSWER=B RATIONALE: Once the relationship has been established the pt has a right to know that shared info will be kept confidential unless something is shared that is harmful to the pt, pt threatens self-harm, or the pt does not intend to follow thru w/the tx plan

A nurse has completed medication teaching regarding methylphenidate with a client. Which of the following client statements indicates an understanding of the nurse's teaching? Select one: a. "Weight gain is common if I take methylphenidate long term." b. "Avoiding afternoon doses of methylphenidate will help me sleep better." c. "Methylphenidate is a safe drug with very few side effects." d. "If I don't like how I feel on methylphenidate, I may stop it at any time."

ANSWER=B RATIONALE: Prolonged therapy w/methylphenidate is assoc. w/weight loss b/c of appetite suppression

Principles of surgical asepsis

All objects used in a sterile filed must be sterile - Sterile objects become unsterile when touched by unsterile objects - Sterile items that are out of sight or below the waist or table level are considered unsterile Sterile objects can become unsterile by prolonged exposure to airborne-microorganisms - Fluids flow in the direction of gravity Moisture that passes thru a sterile object draws microorganisms from unsterile surfaces above or below to the sterile surface by capillary action - The edge of a sterile field are considered unsterile - The skin cannot be sterilized and is unsterile - Conscientiousness, alertness, and honesty are essential qualities in maintaining surgical asepsis

When suctioning a client with a tracheostomy tube, a nurse would perform the following steps: (Place in order of priority: may use each answer more than once) 1)Check the suction source and adjust pressure dial to 80-120 mm HG. 2) Assess breath sounds. 3) Wash hands. 4) Hyperoxygenate with 100% oxygen. 5) Set up sterile field. 6) Quickly insert catheter until resistance is met. 7) Document procedure and client's response. 8) Explain procedure to the client. 9) Withdraw catheter using intermittent suction. Select one: a. 9, 2, 4, 6, 7, 8, 3, 2, 5, 1, 2 b. 3, 2, 8, 1, 5, 4, 6, 9, 4, 2, 3, 7 c. 5, 2, 1, 7, 2, 9, 3, 6, 3, 4, 8 d. 5, 4, 2, 1, 9, 6, 2, 3, 7, 8, 2

ANSWER-->B RATIONALE: Correct Sequence: 3. Wash hands (hand washing is completed upon entering the room and before any intervention) 2. Assess breath sounds (suctioning is needed when audible or noisy secretions, or crackles are heard on auscultation) 8. Explain procedure to the client (Client may have sensations such as shortness of breath and coughing are expected but any discomfort will be very brief) 1. Check the suction source and adjust pressure dial to 80-120 mm (to prevent trauma to the mucosa) 5. Set up sterile field (Sterile technique should be utilized to decrease risk of nosocomial pneumonia by introducing bacteria into the trachea) 4. Hyperoxygenate with 100% oxygen (to prevent hypoxemia) 6. Quickly insert catheter until resistance is met (do not apply suction during insertion) 9. Withdraw catheter using intermittent suction (to prevent trauma to mucosa suctioning only 10-15 sections using a twirling motion) 4. Hyperoxygenate with 100% oxygen (until client's baseline heart rate and oxygen saturation are within normal limits.) 2. Assess breath sounds (reassess breath sounds to assess for need for further suction. May repeat as needed for up to three total suction passes) 3. Wash hands (hand washing is completed upon completion of any intervention) 7. Document procedure and client's response (documentation is completed after every procedure)

A client experiencing intermittent chest pain has been admitted to the hospital. Which of the following laboratory values should the nurse report to the health care provider immediately? a. Total myoglobin 60 mcg/L b. Cardiac troponin T 1.2 ng/mL c. C-reactive protein (CRP) 0.2 mg/dL d. Creatine kinase (CK) 90 units/

ANSWER-->B) Cardiac troponin T 1.2 ng/mL RATIONALE: Normal creatine kinase for females is 30-135 units/L and 55-170 units/L for males.

A nurse is caring for a client post aortofemoral bypass surgery. Which of the following interventions would be contraindicated? a. Monitoring client for changes in blood pressure. b. Encouraging client to sit in high Fowler's position. c. Maintaining NPO status until first postoperative day. d. Coughing and deep breathing every 1 to 2 hours.

ANSWER-->B) Encouraging pt to sit in high-fowlers position RATIONALE: Coughing and deep breathing should be encouraged to promote gas exchange and prevent atelectasis.

A nurse is caring for a client at risk for atelectasis. Which of the following should the nurse monitor for manifestations of atelectasis? a. Intake and output b. Pulse oximetry c. Lung sounds d. Daily weight

ANSWER-->B) pulse oximetry RATIONALE: Lung sounds should be monitored in the client at risk for atelectasis but this is not the best method to monitor for the manifestations of atelectasis.

A nurse is providing care for a client with a Jackson-Pratt drain. Which of the following nursing interventions has the highest priority? A.) Securing the tube and drainage bulb to the pt B.) Keeping the drainage bulb depressed to manual suction C.) "Milking" the tubing before emptying the drain D.) Cleansing the insertion site of the tube w/betadine

ANSWER-->B.) Keeping the drainage bulb depressed to manual suction RATIONALE: Securing the tubing helps to keep tension from being placed on the tubing & bulb. While this is helpful, maintaining the bulb to suction is the highest priority nursing intervention

A client is recovering from acute respiratory distress syndrome (ARDS). Which clinical manifestation requires immediate attention by the nurse? a. Increase in pulse rate b. A decrease in temperature c. A decrease in blood pressure d. Increased oxygen saturation

ANSWER-->C) A decrease in BP RATIONALE:An increase in a client's pulse rate is a finding that needs additional data collection because it may be indicative of an autonomic response to pain, anxiety, and other

A nurse is caring for a post-operative client who underwent thoracic surgery 7 hours prior, and now has in place a chest tube for drainage. What finding would require the nurse to contact the provider immediately? A.) Chest tube & tubing become disconnected during pt transfer B) Pt complains of left-sided chest pain of 7 on pain scale when performing incentive spirometry C) Chest tube drainage measures 80 mLs/hr of red blood D) Diminished breath sounds auscultated in left lower lobe

ANSWER-->C) Chest tube drainage measures 80mL/hr of red blood RATIONALE: If the tubing separates the RN will ask the pt to exhale as much air as they can to remove air from the pleural space & the nurse would cleanse the tips & reconnect the tubing

A client is admitted to the hospital with a diagnosis of Grave's disease. Which of the following findings should be reported to the provider immediately? a. Hyperactive deep tendon reflexes b. Increase in white blood cell count from 6,000 mm3 to 8,000 mm3 c. Increase in temperature from 99.5 F to 100.5 F d. Increased number of stools

ANSWER-->C) increase in temp from 99.5 to 100.5 F RATIONALE: Hyperactive deep tendon reflexes are a common manifestation of Grave's disease.

A nurse is obtaining a sterile specimen from an indwelling urinary catheter. Place the following steps in the order the nurse should use to obtain this specimen: A. Remover clamp to resume drainage. B. Drain the cathether's tubing of urine. C. Place urine sample in sterile container. D. Clamp the catheter's tubing below port for 20 minutes. E. Clean the injection port cap of the catheter drainage tubing with antiseptic. F. Attach a sterile syringe to the port and aspirate quantity of urine required. Select one: a. A, C, E, D, B, F b. D, A, C, F, E, B c. B, D, E, F, C, A d. B, E, F, C, A, D

ANSWER-->C.) B, D E, F, C, A RATIONALE: Draining urine from the tubing and then clamping allows urine to collect in the tubing so a fresh specimen is obtained. Aseptic technique should be maintained during procedure and cleansing port with an appropriate antiseptic solution will remove surface contaminates. Use of a sterile syringe and container is necessary to prevent contamination of specimen. Removing clamp after the procedure allows for continued urine drainage.

A nurse is caring for a client with a tracheostomy. In which order should the following interventions be performed when providing tracheostomy care? A. Document the type and amount of secretions. B. Suction the tracheostomy. C. Clean the inner cannula with hydrogen peroxide followed by sterile saline. D. Apply an oxygen source loosely to prevent desaturation. E. Change tracheostomy ties if soiled. F. Apply a split 4X4 dressing around the tracheostomy. Select one: a. A, B, D, E, F, C b. B, C, D, F, A, E c. B, D, C, F, E, A d. C, B, D, A, F, E

ANSWER-->C.) B, D, C, F, E, A RATIONALE: B. Suction the tracheostomy tube, if necessary, using sterile suctioning supplies. D. Apply the oxygen source loosely if the client's SaO2 decreases during the procedure. Use surgical asepsis to remove and clean the inner cannula with ½ strength hydrogen peroxide and rinse it with a sterile saline solution. C. Clean the stoma site and the tracheostomy plate with ½ strength hydrogen peroxide followed by sterile saline. F. Place a split 4X4 dressing around the tracheostomy. E. Change ties if they are soiled. A. Document the type and amount of secretions, the general condition of the stoma and surrounding skin, the client's response to the procedure, and any teaching or learning that took occurred.

A nurse is reinforcing teaching with a client who has been recently diagnosed with osteoporosis. Which of the following should be included? A.) Increase intake of dietary calcium b. Walking for one to two hours daily is recommended. c. Eliminate safety hazards in the home d. Long-term estrogen replacement therapy will be required.

ANSWER-->C.) Eliminate safety hazards in the home RATIONALE: Intake of calcium alone is not a treatment for osteoporosis, but calcium is an important part of a prevention program to promote bone health. Most people do not get enough calcium in their diet, and therefore calcium supplements are needed.

A client is discharged following a cardiac catheterization procedure. Which of the following should the nurse include in the discharge teaching? a. Tub baths the night following the procedure are acceptable. b. Notify provider if bruising is noted at the site. c. Remove dressing the evening of the procedure. d. Limit activity for several days after the procedure.

ANSWER-->D) limit activity for several days after the procedure RATIONALE: Mild bruising at the insertion site is not unusual and will resolve after several days.

A client is scheduled for surgery. Which of the following findings should the nurse report to the provider prior to surgery? A.) Serum potassium of 3.8 mEq/L B.) A missing identification band C.) Increased anxiety level D.) A decrease in BP

ANSWER-->D.) A decrease in BP RATIONALE: If a missing ID band is noted the nurse can recreate the band prior to proceeding to the operating room. The ID band is a method of properly identifying a pt & necessary for care

A nurse is evaluating placement of a nasogastric (NG) tube. Which of the following is the least reliable method to determine correct NG tube placement? a. Aspirate to collect gastric content. b. Test pH of gastric contents c. Ask the client to talk. d. Inject air into tube and listen over abdomen.

ANSWER-->D.) Inject air into tube and listen over abdomen RATIONALE: Other than X-ray, aspiration of gastric contents with pH testing is the most reliable method to determine correct NG tube placement. A pH of 4 or less is expected.

A nurse is reviewing the medical hx of a pt who has osteoarthirits. The pt aska the nurse about taking the supplement chondroitin w/glucosamine. The nurse hsould instuct the pt to use this supplement w/caution b/c of which of the following findings in the pts hx? A.) anticoagulant therapy B) hypotension C) hx of hypoglycemia D) allergy to eggs

ANSWER: A This supplement Chrondroitin w/glucosamine should be used with caution while on anticoag. therapy b/c it can increase the risk of bleeding. The nurse should advise the pt to monitor manifestations of bleeding such as bruisng and black tarry stools

A nurse is caring for a pt experiencing acute kidney failure after a surgical procedure. Telemetry monitoring shows a widened QRS, frequent premature ventricular contractions, and a HR of 55/min. Which of the following electrolyte imabalances should the nurse identify? A) Hyperkalemia B) Hypocalcemia C) Hypernatremia D) Hypophosphatemia

ANSWER: A A pt who has hyperkalemia can have ECG changes such as premature ventricular contractions, ventricular fibrillation, and widened QRS. This is a dangerous electrolyte distrurbance b/c it can cause cardiac dysrhythmias which can be life-threatening RATIONALE for B: Pt who has hypocalcemia=abdominal cramps, paresthesia of fingertips, muscle craps, tremors, irritability, confusion, and psychosis

A nurse is caring for a client diagnosed with hyperemesis gravidarum. Which of the following are expected findings for this client? Select all that apply Select one or more: a. Dehydration b. Weight loss c. Ketosis d. Persistent diarrhea e. Increased BP

ANSWER: A, B, C RATIONALE: Hyperemesis gravidarum is excessive nausea & vomiting (r/t elevated hCG levels) that is prolonged past 12 weeks of gestation & results in a 5% weight loss from pre-pregnancy weight, electrolyte imbalance, acetonuria, & ketosis. Dehydration would lead to an decrease in BP & increase in pulse.

A nurse is caring for a newborn client who is experiencing severe hyperbilirubinemia. Which of the following are symptoms of kernicterus? Select all that apply. Select one or more: a. Hypotonic b. Backward arching of the neck and trunk c. Lethargy d. Temperature instability e. Low birth weight

ANSWER: A, B, C RATIONALE: Kernicterus (bilirubin encephalopathy) can result from untreated hyperbilirubinemia w/bilirubin levels at or higher than 25 mg/dL. It is a neurological syndrome caused by bilirubin depositing in brain cells. Survivors may develop cerebral palsy, epilepsy, or mental retardation. They may have minor effects such as learning disorders or perceptual motor disabilities. Sx's can include lethargy, hypotonia, high-pitched cry and tonic motions such as backwards arching of the neck & trunk. Low birth weight & temp instability are not sx's assoc. w/kernicterus

What are characteristics of the fetus that are reviewed to determine the biophysical profile (BPP) during an ultrasound? Select all that apply. Select one or more: a. Fetal tone b. Qualitative amniotic fluid volume c. Reactive FHR d. Fetal tidal volume e. Fine body movements

ANSWER: A, B, C RATIONALE: Fetal tone, relative FHR, fetal breathing movements, gross body movements,and qualitative amniotic fluid volume are physical & physiological characteristics of the BPP

A nurse is educating a client on how to perform Kegel exercise therapy for urinary incontinence. Which of the following points should be included in teaching? Select all that apply. a.During exercises, tighten pelvic muscles for a count of 10 and then relax for a count of 10. b. Have a designated time and place for completing therapy. c. Complete exercises in only a sitting position. d. Improvement in incontinence may be seen after 6 weeks of exercise therapy. e. While sitting on the toilet, strain down to help identify pelvic muscles.

ANSWER: A, B, D RATIONALE: At first, it is helpful to have a designated time and place to do exercises because the client will need to concentrate to do them correctly. Although improvement may take several months, most clients notice a positive change after 6 weeks of exercises. The client should be educated to tighten pelvic muscles for a slow count of 10 and then relax for a slow count of 10. This exercise should be done 15 times while lying down, sitting up, and standing (a total of 45 exercises). The client should then repeat the exercises rapidly contracting and relaxing the pelvic muscles 10 times. This should take no longer than 10 to 12 minutes for all three positions, or 3 to 4 minutes for each set of 15 exercises.

A nurse is caring for a neonate who is 34 weeks gestation. The nurse correctly understands which of the following are consistent with prematurity? Select all that apply. a. Large amount of vernix present b. Mongolian spots on shoulders c. Inner eye canthus level with pina d. Abundant lanugo e. Prominent clitoris & labia minora

ANSWER: A, D, E RATIONALE: - Abundant lanugo is noted in abundant amounts w/a premature newborn - Prominent clitoris & labia minora are seen w/prematurity -Large amounts of vernix are noted w/prematurity

A nurse is providing preoperative teaching about stool cosnistency to a pt who will undergo a colectomy w/the placement of a ileostomy. Which of the following info about stool consistency should the nurse include in her teaching? A) stool will have a pasty texture B) stool will have a high volume of liquid C.) Stool will be solid & well-formed D) stool will appear bloody w/clots

ANSWER: B The nurse should include in teaching that when peristalsis returns, a pt can have an initial period of high-volume liquid stool output up to 1,800 mL/day. Later, as the proximal small bowel adapts, stool volume should drop to about 800 mL/day

A nurse is teaching a new mother breastfeeding techniques. Which of the following teaching tips are appropriate to discuss with a new mother who is breastfeeding? Select all that apply. a. Dark, firm stools are the norm. b. Avoid use of a pacifier to prevent nipple confusion. c. Burp the newborn between each breast. d. Avoid a specific length of time to breastfeed. e. Two to three wet diapers per day are the norm

ANSWER: B, C, D RATIONALE: Avoid educating mothers regarding the duration of newborn feedings. Mothers should be instructed to evaluate when the newborn has completed the feeding, including slowing of newborn suckling, a softened breast, or sleeping. Show the mother how to burp the newborn when she alternates breasts. The newborn should be burped either over the shoulder or in an upright position with his chin supported. The mother should gently pat the newborn on his back to elicit a burp. ell the mother to avoid nipple confusion in the newborn by not offering supplemental formula, pacifier, or soothers. Supplementation can be provided using a small feeding or syringe feeding, if needed.

A nurse is administering magnesium sulfate to a client diagnosed with preeclampsia. Which of the following signs and symptoms would indicate possible magnesium toxicity? Select all that apply. Select one or more: a. Hypertension b. Prolonged PR interval c. Hypotension d. Diminished tendon reflexes e. Hyperactive tendon reflexes

ANSWER: B, C, D RATIONALE: Magnesium Sulfate reduces striated muscle contractions due to a depressant effect on the CNS. It blocks neuromuscular transmission. Toxic signs of Magnesium sulfate include diminished tendon reflexes, hypotension and prolonged PR intervals.

A laboring client reports suddenly feeling something in her vagina. Upon assessment, the nurse identifies a prolapsed umbilical cord. Place the following interventions in the correct order that they should be performed for this client. A. Prepare the client for a cesarean birth. B. Administer oxygen at 8-10L via face mask. C. Notify primary care provider of the prolapsed cord. D. Reposition the client in either a knee-ches or Trendelenburg position. E. Using a sterile glove insert two fingers into the vagina to reduce pressure off the cord. Select one: a. B, C, D, A, E b. B, A, D, C, E c. C, D, E, B, A d. A, D, B, E, C

ANSWER: C RATIONALE: C. Notifying the health care provider and staff is the first priority and facilitates readiness for further interventions. D. Next step will be to remove pressure from the cord by repositioning client. E. Inserting fingers into the vagina and applying finger pressure to the fetal presenting part reduces pressure on the umbilical cord and provides oxygenation to the fetus. B. Administration of supplemental oxygen will further improve fetal oxygenation. A Emergent care of the client and fetus is priority and if all other measures fail, the client should be prepared for a cesarean birth.

A nurse is assessing a pt who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure? A) S3 gallop B) weak peripheral pulses C) increased abdominal girth D) Wheezing

ANSWER: C Increased abdominal girth is an expected finding of right-sided heart failure due to systemic congestion and an enlarged liver and spleen. Systemic congestion can lead to fluid retention and increased pressure in the venous system, which can manifest w/edema in the lower extremities

A nurse is caring for a pt who has nephrotic syndrome. The nurse should expect the pt to have which of the following clinical mainfestations? A) Decrease in glolmerular permeability B) Increase in serum protein levels C) Loss of immune fxn D) Hyperlipidemia

ANSWER: D Nephrotic syndrome can result in decreased liver fxn causing an increase in lipid production and hyyperlipidemia RATIONALE for B.) Nephrotic syndrome can result in a decrease of protein levels b/c large amounts of protein pass thru the glomerular membrane and into the pts urine

A nurse is providing D/C teaching to a pt who is starting PN therapy at home following a total gastrectomy. Which of the following statements should indicate to the nurse the pt understands the teaching? A) I will adjust the rate of infusion based on my urinary output B) I will need to have a 60 mL syring to administer my PN C) I will keep addtional solution bags @ room temp D) I will use asceptic technique when administering my PN

ANSWER: D The nurse should teach the pt asceptic tech when connecting the infusion to the catheoter hub to prevent microorganisms from entering the vascular system and causing a catheter-related bloodstream infection

A nurse is caring for a pt who is 24 hours postoperative following a total hip arthroplasty, which of the following actions should the nurse take? A.) Place the affected leg in external rotation B) Encourgae the pt to use incentive spirometry every shift C) Instruct the pt to lean forward when rising form a chair D) Maintain abduction of the affected extremity

ANSWER: D-->Nurse should ensure affected extremity is in aposition of abduction to prevent dislocation. Abduction of affected extremity is maintained by placing an abductor pillow or several pillows b/w the pts legs while in bed RATIONALES: A) Nurse should maintain affected extremity in a netural position to prevent dislocation; manifestations of dislocation of the hip=affected leg rotates in an inward position, pt has sudden severe pain, and the surgical extremity is shorter B) Nurse should encourage pt to cough, deep breathe, & use incentive spirometry q 2 hours to prevent pneumonia, atelectasis, which is the collapse of alveoli. Atelectasis can lead to poor O2 exchange and pneumonia C.) TO prevent disslocation the pt should not flex the hip more than 90 degrees at a time. Leaning forward when rising from a chair flexes the hip more than 90 degrees

A nurse is caring for a client diagnosed with osteomyelitis. The nurse would expect which of the following findings during the assessment? Select all that apply. Select one or more: a. Positive wound cultures b. Coolness upon palpation c. Elevated erythrocyte sedimentation rate d. Leukocytosis e. Sharp bone pain

ANSWER= A, C, D RATIONALE: With osteomyelitis the client will experience an increase in the WBC count (leukocytosis) due to infection. Positive wound cultures are found in osteomyelitis as it is an infectious process. ESR elevates in the presence of infection/inflammation.

An 8-year-old child was admitted to the hospital for possible shunt malfunction. The child has been diagnosed with hydrocephalus since birth. The nurse understands which of the following are symptoms of increased intracranial pressure? Select all that apply. Select one or more: a. High-pitched cry b. Increased clumsiness c. Vomiting d. Hypotonic deep tendon reflexes e. Headache

ANSWER= B, C, E RATIONALE: Headaches, increased clumsiness and vomiting may indicate increased ICP in a school-aged child. High pitched crying would be a manifestation in an infant, but not for an 8 year old child. High pitched crying would be a manifestation in an infant, but not for an 8 year old child

A nurse is caring for a client who has MRSA in a wound. Which of the following infection control precautions should be initiated? Select all that apply. Select one or more: a. Wear a particulate respirator mask when administering medications to the client. b. Wear a protective gown when entering the client's room c. Don clean gloves when delivering the clients meal tray d. Wear sterile gloves when removing the client's wound dressing e. Use a face shield when irrigating the client's wound

ANSWER= B, C, E RATIONALE: Contact precautions should be used for a client with MRSA. Contact precautions require a private room with other clients with the same infection, gown and gloves, and disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag. Clean gloves are used when removing a dirty dressing. Using sterile gloves for removal of a dressing is not necessary.

During a group therapy session on a psychiatric unit, the nurse leader observes that one of the clients frequently interrupts the session. Which of the following nursing actions is the most appropriate for this situation? Select one: a. Ask the client to speak privately with a nurse after the meeting. b. Encourage another group member to reprimand the client. c. Discuss this observation during the post-meeting evaluation. d. Tell the client that the interrupting behavior must be discontinued.

ANSWER=A RATIONALE: A therapeutic milieu group aims to help increase self-esteem, decrease social isolation, encourage appropriate social behaviors, and educate pts in basic living skills. Confronting the pt during the meeting could negatively affect self-esteem and increase social isolation. The behavior needs to be addressed, but not in an openly confrontational way

The nurse is assessing the family dynamics of a widow with end stage terminal cancer. Which statement made between the adult children would best indicate the need for further teaching? Select one: a. "It does not matter what we think, the living will says 'do not resuscitate'." b. "The doctors have told us that it is time for us to make some tough decisions." c. "Since you are the oldest child, you have the responsibility to decide." d. "If daddy were alive, he would be making these hard decisions, not us."

ANSWER=A RATIONALE: In the legal hierarchy (order of importance), when the pt is unable to make decisions and there is no spouse to decide, the next decision-maker is the oldest adult child

A nurse is caring for a client of the Buddhist faith who has just given birth to a stillborn infant. Which of the following interventions is most appropriate? Select one: a. Inquire about any rituals the parents would like to perform at this time. b. Gently inform the parents about the hospital procedures for handling a stillborn infant. c. Remove the infant from the room and allow the parents a period of time to grieve. d. Remain in the room and answer any questions the parents may have about the stillbirth.

ANSWER=A RATIONALE: The nurse should remain in the room unless asked to leave. However, the nurse may not be prepared to answer detailed questions or provide detailed explanations

A 3-month-old infant has just undergone a cheiloplasty. The nurse is conducting an assessment following the procedure and needs to complete a pain assessment. Which of the following pain assessment tools will the nurse use to conduct this pain assessment? Select one: a. FLACC b. FACES c. Numeric scale d. Oucher

ANSWER=A RATIONALE: The Oucher pain assessment tool is recommended for children b/w 3-13 yoa. Pain is rated on a scale of 0-5 using a diagram of 6 photographs

A nurse has provided discharge education to a school age client and his parents following a radius fracture with cast application. Which of the following statements by the client's parent indicates a need for additional teaching? Select one: a. "When we get home we will use a hair dryer to finish drying the cast." b. "We will notify the provider if his fingers become swollen and dark." c. "We will keep the cast elevated about his heart for the next 24 hours." d. "We will reposition him every 2 hours until the cast is dry."

ANSWER=A RATIONALE: The pt should be repositioned every 2 hours so that dry air circulates around & under the cast for faster drying. This also will prevent pressure from changing the shape of the cast

A nurse is working in the Emergency Department (ED). In which order should the following clients be triaged? A. 30 year old male reporting shortness of breath. B. 18 year old male with a possible fractured tibia. C. 24 year old female with a swollen and bruised ankle. D. 40 year old female with high fever and productive cough. Select one: a. B, C, A, D b. A, D, B, C c. C, B, A, D d. A, B, D, C

ANSWER=B RATIONALE: Order A. Shortness of breath is considered an emergent triage category and implies that a condition exists that poses an immediate threat to life or limb. This client would be seen first. D. High fever and productive cough would raise suspicion of pneumonia. New onset of pneumonia is considered an urgent triage category. This implies that the client should be treated quickly, as long as respiratory failure does not appear imminent. B. A possible fractured tibia is considered an urgent triage category. This implies that the client should be treated quickly. C. A swollen and bruised ankle is considered non-urgent. The client can generally wait for several hours without a significant risk of clinical deterioration.

A nurse is caring for a child who has leukemia. What discharge teaching would be provided to the parents prior to discharge? a. Side effects of radiation therapy b. How to properly use vascular access devices. c. Encourage parents not to palpate the stomach. d. Report developmental delays to the provider.

ANSWER=B RATIONALE: Children who have Leukemia will not go thru radiation tx therapy. Depending on the type of Leukemia will determine the chemotherapy tx

Place in order of priority, which clients the nurse will visit first to last. A. A client receiving IV chemotherapy and the infusion pump is alarming. B. A client who is ordered to be discharged. C. A client who is one day post chest tube insertion for pneumothorax. D. A client in wrist restraints who has a sitter in the room. E. A client admitted via the Emergency Department three hours ago with the diagnosis of "acute abdomen". Select one: a. B, C, D, E, A b. A, E, C, D, B c. D, E, B, C, A d. A, B, D, E, C

ANSWER=B RATIONALES: A. The client receiving chemotherapy is the first order of priority because the chemo therapeutic drug may be infiltrating or the line may be occluded. If the infusion site has infiltrated, it could cause tissue damage. If the line has occluded, measures to regain patency must be carried out quickly or the line will be lost. E. The next client is a new admission from the emergency department and current baseline status needs to be assessed rapidly. C. Next the status of the chest tube must be assessed. The purpose of the chest tube is to provide for lung re-expansion. If the tube is not functioning properly, the client will be in respiratory distress and will require rapid intervention. D. This client is in wrist restraints and the nurse must assess circulation and check in with the sitter. B. The client being discharged today would be considered the most stable of the clients.

The family of a 14-year-old client with Attention-Deficit Hyperactivity Disorder (ADHD) is requesting the nurse's assistance in implementing strategies in the client's management of ADHD. Which of the following strategies should be discussed in the management of ADHD for an adolescent client? Select all that apply. Select one or more: a. Plan structured activities in the afternoon. b. Use charts to assist with organization. c. Introduce new situations slowly d. Model positive behaviors e. Offer verbal instruction combined w/visual cues

ANSWER=B, D, E RATIONALES: - Offer verbal instruction w/visual cues can help the pt better focus on the request or task -Using charts in staying organized is a good measure -Parents, teachers, & role models should model positive behavior to help the pt cope w/appropriate behavioral outcomes in all different situations

A nurse is preparing to discharge an older adult client to the home of a family member while recovering from hip surgery. Which of the following may negatively affect the client's adjustment to living with family members? Select one: a. Older clients often recover more quickly when encouraged to interact with family. b. The family is actively involved in the discharge plans. c. The family is insisting on maintaining financial control for the client. d. The client is unable to complete all ADLs

ANSWER=C RATIONALE: While gaining independence is very important, the inability to complete all the ADLs would not necessarily interfere w/an adaptation to living w/family

A nurse is helping parent's select appropriate independent activities for their 8-year-old child. Which of the following would be an appropriate activity? a. Allowing the child to play video games b. Encouraging the child to assume care of the family pet c. Providing frequent trips to the library d. Playing touch football

ANSWER=C RATIONALE: While video games can be stimulating, its important for parents to monitor selection of games for violence & obscenity

A distracted 7-year-old student is sent to the school nurse by his teacher. When the nurse checks his hair and scalp, the nurse notes the evidence of pediculosis capitis. What are recognizable signs of this form of skin infestation? Select one: a. Flaking of the scalp with pink, irritated skin exposed b. Multiple tiny pustules on the scalp with no abnormal findings on the hair shafts. c. Scaly, circumscribed patches on the scalp, w/mild alopecia in these areas d. Small white spots that adhere to the hair shaft, close to the scalp

ANSWER=D

The nurse is assisting the parents of a school-aged child with a plan to prepare him for the impending death of a family member. What would be the potential behavior of the school-aged child when faced with this stressor? a. Believe that death is temporary b. Accepting behavior of this situation c. Same emotional demonstration as his parents d. Uncooperative behavior

ANSWER=D RATIONALE: Preschool-aged children view death as temporary due to the lack of understanding or concept of time

A nurse is providing instructions for car seat safety to parents of an infant. The nurse should include which of the following? Select all that apply. Select one or more: a. Used car seats should be inspected by the health deparment. b. When placing the infant in the front seat, the air bag should be off. c. The infant should be rear facing until 6 months of age. d. Infants should be rear facing until they weigh 9.1kg (20 lbs). e. A 5 point restraint system is recommended for car seats

ANSWER=D, E RATIONALE: Infants should be place in the rear facing position until they weigh 9.1 kg (20lbs). five point restraint system or a T-shield should be part of the convertible restraint system. It is recommended never to use a second-hand car seat.

A nurse is aware that priorities need to be continuously set and reset in order to meet the needs of multiple clients. Which principles of client care should the nurse use for prioritization when giving report? Select all that apply. (SELECT 1 OR MORE): a.) Prioritize systmeic before local b.) Listen carefully and dont assume c.) Prioritize acute before chronic d.) Recognize & respond to transient findings e.) Prioritize potential problems before actual

ANSWERS--->A, C, B RATIONALE(S): Prioritizing systemic before local ("life before limb") is a prioritization principle in client care. Examples include prioritizing interventions for a client in shock over interventions for a client with a localized limb injury. Prioritizing acute (less opportunity for physical adaptation) before chronic (greater opportunity for physical adaptation) is a prioritization principle in client care. Examples include prioritizing the care of a client with a new injury/illness (e.g., mental confusion, chest pain) or an acute exacerbation of a previous illness over the care of a client with a long-term chronic illness. Listen carefully and don't assume is a prioritization principle used in client care. Recognizing that a postoperative client's report of pain could be due to pain in another location rather than expected surgical pain.

A nurse is providing pin site care for a client with skeletal traction for a tibia-fibula fracture. Which of the following findings should the nurse report to the provider? Select all that apply. Select one or more: a. Loosening of the pins b. 1+ edema of skin at the pin sites c. Muscle spasms d. Purulent drainage at the insertion sites e. Crusting at the pin sites

ANSWERS--->A, C, D RATIONALES: Loosening of the pins should be reported to prevent failure of traction device. Purulent drainage is a finding related to infection and needs to be reported. Muscle spasms unrelieved by medication/repositioning should be report to the provider as it is a sign of potential complications.

A nurse is caring for a client who has difficulty swallowing following a cerebrovascular accident (CVA). Which of the following interventions should the nurse implement? Select all that apply. Select one or more: a. Encourage client to place food in the front of the mouth. b. Assess swallowing Reflexes before feeding c. Encourage pt to flex head and neck back when swallowing d. Elevate the HOB 90 degrees before feeding e. Maintain suction equipment at the bedside

ANSWERS--->B, D, E RATIONALE: Suction equipment must be maintained at the bedside of client at risk for aspiration to aid in clearing the airway. To assist with safe feeding, the nurse should review the clients swallowing reflexes before feeding. Gag and cough reflexes should also be assessed. Elevating the head of the bed 90 degrees will facilitate swallowing and prevent aspiration.

A nurse is transferring a client with a diagnosis of CVA. Which of the following safety measures should be implemented? Select all that apply. Select one or more: a. Detach arm and foot rests from wheelchair. b. Engage locks on wheelchair and bed c. Assist client to move toward the weaker side. d. Pull on the arm of the client for stabilization. e. Utilize an assistive device to facilitate transfer.

ANSWERS-->A, B, E RATIONALE: The nurse should ensure that the client's wheelchair and bed are locked before transferring begins. Detachable arm and foot rests are removed from wheelchairs to make getting in and out of the chair easier. An assistive device, such as a rope, attached to the headboard of the bed enables the client to pull themselves toward the center of the bed, facilitating a safe transfer.

A nurse is caring for an intraoperative client. Which of the following are basic principles of sterile technique? Select all that apply. Select one or more: a. Sterile surfaces may touch other sterile surfaces b. A six-inch perimeter should be maintained around the sterile field. c. Once a sterile package is opened, the edges are considered unsterile. d. Hands must stay below waist level once sterile gloves are applied. e. Surgical gowns are sterile from the chest to the level of the sterile field

ANSWERS-->A, C, E RATIONALE: All materials in contact with the surgical wound or used within the sterile field must be sterile. Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile; contact with unsterile objects at any point renders a sterile area contaminated. After a sterile package is opened, the edges are considered unsterile. Gowns of the surgical team are considered sterile in front from the chest to the level of the sterile field. The sleeves are also considered sterile from 2 inches above the elbow to the stockinette.

Which of the following diseases should the nurse anticipate using droplet precautions? Select all that apply. Select one or more: a. Mumps b. Varicella c. Tuberculosis d. Pertussis e. Scarlet Fever

ANSWERS-->A, D, E RATIONALE: Mumps, Pertussis, Rubella, and Scarlet Fever can generate droplets from coughing, sneezing, and talking, as well as during certain procedures such as suctioning and bronchoscopy. Transmission via large droplets requires close contact (within 3 feet or less) between the source patient and the susceptible individual. Droplets (due to their large size) do not remain suspended in air and travel short distances - three feet or less. Thus, Droplet Precautions require the use of a standard surgical mask within three feet of the patient. However, it is prudent to wear a mask upon entering the room of a patient on Droplet Precautions to avoid any inadvertent exposure. All require droplet precautions. The droplet nuclei are greater than 5 microns and a regular surgical mask can filter out the organisms.

A nurse is feeding a client with dysphagia. Which of the following should the nurse do to prevent aspiration? Select all that apply. Select one or more: a. Consult with a speech pathologist for evaluation b. Provide a brief rest period before eating c. Place food on the weaker side of the mouth. d. Position the client in an upright, seated position in a chair. e. Assist the pt to flex the head to a chin-down position

ANSWERS-->A, D, E RATIONALE: A speech language pathologist identifies clients at risk and provides recommendations for therapy. The client should be positioned in an upright, seated position in a chair, or raise the head of the bed to 90 degrees. The client should slightly flex the head to a chin-down position to help prevent aspiration.

The nurse will need to wear a standard mask when caring for a client with which of the following disorders? Select all that apply. Select one or more: a. Hepatitis A Virus b. Pharyngeal diphtheria c. Meningococcal pneumonia d. Respiratory viral influenza e. Tuberculosis

ANSWERS-->B, C, D RATIONALE: A standard mask is used for droplet precautions, which should be utilized for organisms that can be spread through the air but are unable to remain in the air farther than 3 feet. Pharyngeal diphtheria, respiratory viral influenza, and meningococcal pneumonia are such disorders

TONICITY OF TYPICAL IV SOLUTIONS:

ISOTONIC: - Same osmolality as normal plasma; no osmotic pressure difference is created so fluids remain primarily in ECF -Isotonic IV fluids replace ECF losses and expand vascular volume quickly - Examples: 0.9% sodium chloride (normal saline); Ringer's solution; Lactated ringers solution (LR); 5 % Dextrose in water (D5W)-->D5W Is isotonic in bag but has hypotonic effect in body after dextrose i metabolized; two-thirds of water goes to body cells HYPOTONIC: - Provides free water & small amounts of sodium and chloride to cells (used to influx water into ICF) Examples: 0.45% sodium chloride (1/2 NS); 0.225% sodium chloride (1/4 NS) HYPERTONIC: - EXAMPLES: 5 %dextrose in 0.45% sodium chloride (D5 1/2 NS); 5% dextrsoe in 0.225% sodium chloride (D5 1/4 NS); 5% dextrose in 0.9% sodium chloride (D5NS); 3% sodium chloride (3% NaCl); 5% sodium chloride (5% NaCl); 10% dextrose; 50% dextrose - D5 1/2 NS & D5 1/4 NS--are hypertonic in IV bag and provide dextrose and some water to cells - D5 NS is isotonic after dextrose is metabolized 3% & 5% NaCl: used to treat specific problems; administered in carefully controlled, limited doses to avoid vascular volume overload and cell dehydration; also used to pull excess fluid from cels and promote osmotic diuresis